MS HESI
Which client should the nurse recognize as most likely to experience sleep apnea? a. Middle-aged female who takes a diuretic nightly. b. Obese older male client with a short, thick neck. c. Adolescent female with a history of tonsillectomy. d. School-aged male with a history of hyperactivity disorder.
b. Obese older male client with a short, thick neck.
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? a. Maintain the residual limb on three pillows at all times. b. Place a large tourniquet at the client's bedside. c. Apply constant, direct pressure to the residual limb. d. Do not allow the client to lie in the prone position.
b. Place a large tourniquet at the client's bedside.
A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? a. Assess neurovascular status. b. Change the client's position. c. Inspect the traction equipment. d. Review pain medication orders.
a. Assess neurovascular status.
A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? a. Bilateral lower leg stasis dermatitis. b. Clubbing of fingers and toes. c. Intermittent claudication. d. Peripheral cyanosis.
a. Bilateral lower leg stasis dermatitis.
A client is admitted to the emergency department after falling from a high roof. Which finding should the nurse report immediately? a. Clear, watery drainage from the ear. b. Dried blood around the ear and neck. c. Tenderness on palpation of the ear. d. Pearly appearance of the tympanic membrane.
a. Clear, watery drainage from the ear.
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? a. Cyanosis of the fingertips. b. Bradycardia and bradypnea. c. Presence of S3 and S4 heart sounds. d. 3+ pitting edema of the lower extremities.
a. Cyanosis of the fingertips.
The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? a. Diabetes mellitus. b. Hypothyroidism. c. Parkinson's disease. d. Recurring pneumonia.
a. Diabetes mellitus.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? a. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." b. "Alopecia is a common side effect you will experience during long-term steroid therapy." c. "Your hair will grow back completely after your course of chemotherapy is completed." d. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."
a. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide? a. Estrogen deficiency causes the vaginal tissues to become dry and thinner. b. Infrequent intercourse results in the vaginal tissues losing their elasticity. c. Dehydration from inadequate fluid intake causes vulva tissue dryness. d. Lack of adequate stimulation is the most common reason for dyspareunia.
a. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? a. He visits his diabetic brother who just had surgery to amputate an infected foot. b. He is provided with the most current information about the dangers of untreated diabetes. c. He comments on the community service announcements about preventing complications associated with diabetes. d. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.
a. He visits his diabetic brother who just had surgery to amputate an infected foot.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. Which nursing intervention is indicated? a. Help the client to determine ways to increase his fluid intake. b. Obtain an appointment for the client to see an ear, nose, and throat specialist. c. Schedule an appointment with an allergist to determine if the client is allergic to the cat. d. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.
a. Help the client to determine ways to increase his fluid intake.
Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? a. Hoarseness. b. Dry mouth. c. Mouth ulcers. d. Weight loss.
a. Hoarseness.
Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? a. Horizontal white banding. b. Diffuse blue discoloration. c. Diffuse brown discoloration. d. Thin, dark red vertical lines.
a. Horizontal white banding.
Which statement made by a client with chronic pancreatitis indicates that further education is needed? a. I will cut back on smoking cigarettes daily. b. I will avoid drinking caffeinated beverages. c. I will rest frequently and avoid vigorous exercise. d. I will eat a bland, low-fat, high-protein diet.
a. I will cut back on smoking cigarettes daily.
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the priority nursing diagnosis for this client? a. Impaired communication related to paralysis of skeletal muscles. b. High risk for infection related to increased intracranial pressure. c. Potential for injury related to impaired lung expansion. d. Social isolation related to inability to communicate.
a. Impaired communication related to paralysis of skeletal muscles.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client? a. Information about smoking cessation. b. Diet instructions for a low-residue diet. c. Instructions on a weight-loss program. d. The importance of increasing milk in the diet.
a. Information about smoking cessation.
A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? a. Jewish European ancestry. b. H. pylori bowel infection. c. Family history of irritable bowel syndrome. d. Age between 25 and 55 years.
a. Jewish European ancestry.
Which description of pain is consistent with a diagnosis of rheumatoid arthritis? a. Joint pain is worse in the morning and involves symmetric joints. b. Joint pain is better in the morning and worsens throughout the day. c. Joint pain is consistent throughout the day and is relieved by pain medication. d. Joint pain is worse during the day and involves unilateral joints.
a. Joint pain is worse in the morning and involves symmetric joints.
A client receiving cholestyramine for hyperlipidemia should be evaluated for which vitamin deficiency? a. K. b. B12. c. B6. d. C.
a. K.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? a. Lower left quadrant pain and a low-grade fever. b. Severe pain at McBurney's point and nausea. c. Abdominal pain and intermittent tenesmus. d. Exacerbations of severe diarrhea.
a. Lower left quadrant pain and a low-grade fever.
A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? a. Lung tissue biopsy. b. Positive blood cultures. c. Magnetic resonance imaging (MRI). d. Computerized tomography (CT) of the thorax.
a. Lung tissue biopsy.
Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? a. Newly retracted nipple. b. A thickened area where the skin folds under the breast. c. Whitish nipple discharge. d. Tender lumpiness noted bilaterally throughout the breasts.
a. Newly retracted nipple.
Which condition should the nurse suspect when a client reports vaginal dryness during intercourse? a. Obstructed Bartholin's glands. b. Hyperactive sebaceous glands. c. Infected bulbourethral glands. d. Strangulated prostate gland.
a. Obstructed Bartholin's glands.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? a. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. b. Purse the lips while inhaling as deeply as possible and then exhale through the nose. c. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. d. Place one hand on the chest, one hand the abdomen and make both hands move outward.
a. Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? a. Potassium 6.0 mEq. b. Daily urine output of 400 ml. c. Peripheral neuropathy. d. Uremic fetor.
a. Potassium 6.0 mEq.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? a. Prevention of deformities. b. Avoidance of joint trauma. c. Relief of joint inflammation. d. Improvement in joint strength.
a. Prevention of deformities.
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? a. Propanolol. b. Captopril. c. Furosemide. d. Dobutamine.
a. Propanolol.
A young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond? a. Propose sperm banking before RT then artificial insemination is an option. b. Suggest adoption when the client is in remission or ready for parenting. c. Tell the client that infertility is a non-reversible side effect of radiotherapy. d. Explain that sperm production will be suppressed after radiotherapy is over.
a. Propose sperm banking before RT then artificial insemination is an option.
An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further assess the client for which condition? a. Pulmonary embolism. b. Heart failure. c. Tuberculosis. d. Bronchitis.
a. Pulmonary embolism.
Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.) a. Quality of the pain. b. Signs of inflammation. c. Ankle range of motion. d. Muscle strength testing. e. Visible deformities of the joint.
a. Quality of the pain. b. Signs of inflammation. c. Ankle range of motion. e. Visible deformities of the joint.
An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, which should the nurse remember about full-thickness burns? a. Regenerative function of the skin is absent because the dermal layer has been destroyed. b. Tissue regeneration will begin several days following return of normal circulation. c. Debridement of eschar will delay the body's ability to regenerate normal tissue. d. Normal tissue formation will be preceded by scar formation for the first year.
a. Regenerative function of the skin is absent because the dermal layer has been destroyed.
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? a. Report the findings to the surgeon. b. Irrigate the indwelling urinary catheter. c. Apply manual pressure to the bladder. d. Increase the IV flow rate for 15 minutes.
a. Report the findings to the surgeon.
A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? a. Serum creatinine. b. Blood Urea Nitrogen (BUN). c. Sedimentation rate. d. Urine specific gravity.
a. Serum creatinine.
In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.) a. Set the infusion pump to infuse the albumin within four hours. b. Compare the client's blood type with the label on the albumin. c. Assign a UAP to monitor blood pressure q15 minutes. d. Administer through a large gauge catheter. e. Monitor hemoglobin and hematocrit levels. f. Assess for increased bleeding after administration.
a. Set the infusion pump to infuse the albumin within four hours. d. Administer through a large gauge catheter. e. Monitor hemoglobin and hematocrit levels. f. Assess for increased bleeding after administration.
Small bowel obstruction is a condition characterized by which finding? a. Severe fluid and electrolyte imbalances. b. Metabolic acidosis. c. Ribbon-like stools. d. Intermittent lower abdominal cramping.
a. Severe fluid and electrolyte imbalances.
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? a. She sustained an insect bite to her left arm yesterday. b. She has lost twenty pounds since the surgery. c. Her healthcare provider now prescribes a calcium channel blocker for hypertension. d. Her hobby is playing classical music on the piano.
a. She sustained an insect bite to her left arm yesterday.
The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which laboratory test result should the nurse expect an increase in the serum level? a. Sodium. b. Antidiuretic hormone. c. Potassium. d. Glucose.
a. Sodium.
A female client receiving IV vasopressin for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? a. Start an IV nitroglycerin infusion. b. Nasogastric lavage with cool saline. c. Increase the vasopressin infusion. d. Prepare for endotracheal intubation.
a. Start an IV nitroglycerin infusion.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? a. Sweating, trembling, tachycardia. b. Polyuria, polydipsia, polyphagia. c. Nausea, vomiting, anorexia. d. Fruity breath, tachypnea, chest pain.
a. Sweating, trembling, tachycardia.
The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? a. Teach the client techniques of intermittent self-catheterization. b. Decrease fluid intake to prevent over distention of the bladder. c. Use incontinence briefs to maintain hygiene with urinary dribbling. d. Explain that anticholinergic drugs will decrease muscle spasticity.
a. Teach the client techniques of intermittent self-catheterization.
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? a. Two weeks before menstruation. b. Vaginal mucous discharge is thick. c. Low basal temperature. d. First thing in the morning.
a. Two weeks before menstruation.
A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? a. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). b. Getting pregnant while using an IUD is common and is not the best contraceptive choice. c. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. d. Selecting a contraceptive device should consider choosing a successful method used in the past.
a. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).
During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? a. muscle weakness. b. Urinary frequency. c. Abnormal involuntary movements. d. A decline in cognitive function.
a. muscle weakness
The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis? a. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L. b. pH 7.45 , pCO 2 37 mmHg, HCO 3 24 mEq/L. c. pH 7.34, pCO 2 36 mmHg, HCO 3 21 mEq/L. d. pH 7.46, pCO 2 35 mmHg, HCO 3 28 mEq/L.
a. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L.
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? a. "Check it again in one month, and if it is still there schedule an appointment." b. "Most lumps are benign, but it is always best to come in for an examination." c. "Try not to worry too much about it, because usually, most lumps are benign." d. "If you are in your menstrual period it is not a good time to check for lumps."
b. "Most lumps are benign, but it is always best to come in for an examination."
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? a. A 35-year-old multipara who never breastfed. b. A 50-year-old whose mother had unilateral breast cancer. c. A 55-year-old whose mother-in-law had bilateral breast cancer. d. A 20-year-old whose menarche occurred at age 9.
b. A 50-year-old whose mother had unilateral breast cancer.
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) a. Marijuana cigarettes do not affect sperm count. b. Alcohol consumption can cause erectile dysfunction. c. Low testosterone levels affect sperm production. d. Cessation of smoking improves general health and fertility. e. Obesity has no effect on sperm production.
b. Alcohol consumption can cause erectile dysfunction. c. Low testosterone levels affect sperm production. d. Cessation of smoking improves general health and fertility.
A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? a. Amount of weight gain or weight loss during the previous year. b. An accurate menstrual cycle diary for the past 6 to 12 months. c. Skin pigmentation and hair texture for evidence of hormonal changes. d. Previous birth-control methods and beliefs about the calendar method.
b. An accurate menstrual cycle diary for the past 6 to 12 months.
The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? a. A history of obesity. b. An allergy to sulfa drugs. c. Cessation of smoking three years ago. d. Numbness in the soles of the feet.
b. An allergy to sulfa drugs.
During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? a. Notify the healthcare provider for reinsertion. b. Attempt to reinsert the tracheostomy tube. c. Position the client in a lateral position with the neck extended. d. Ventilate client's tracheostomy stoma with a manual bag-mask.
b. Attempt to reinsert the tracheostomy tube.
A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? a. Osteoporosis is a progressive genetic disease with no effective treatment. b. Calcium loss from bones can be slowed by increasing calcium intake and exercise. c. Estrogen replacement therapy should be started to prevent the progression osteoporosis. d. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.
b. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. Which nursing action is best for the nurse to implement? a. Ask the client what he means by "heart trouble." b. Call for an ECG to be performed immediately. c. Notify surgery that the ECG is over two years old. d. Notify the client's surgeon immediately.
b. Call for an ECG to be performed immediately.
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? a. Flush the tube with 50 ml of water q 8 hours. b. Check for tube placement and residual volume q4 hours. c. Obtain a daily x- ray to verify tube placement. d. Position on left side with head of bed elevated 45 degrees.
b. Check for tube placement and residual volume q4 hours.
A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? a. Dyspnea. b. Nocturia. c. Confusion. d. Stomatitis.
b. Nocturia.
Which milestone indicates to the nurse successful achievement of young adulthood? a. Demonstrates a conceptualization of death and dying. b. Completes education and becomes self-supporting. c. Creates a new definition of self and roles with others. d. Develops a strong need for parental support and approval.
b. Completes education and becomes self-supporting.
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? a. Situational low self-esteem related to functional impairment and change in role function. b. Disabled family coping related to dissonant coping style of significant person. c. Interrupted family processes related to shift in health status of family member. d. Risk for ineffective therapeutic regimen management related to complexity of care.
b. Disabled family coping related to dissonant coping style of significant person.
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? a. Explain the effect of the follicle-stimulating and luteinizing hormones. b. Discuss perimenopause and related comfort measures. c. Assess lung fields and for a cough productive of blood-tinged mucous. d. Ask if a fever above 101 F (38.3 C) has occurred in the last 24 hours.
b. Discuss perimenopause and related comfort measures.
Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? a. Describe proper administration of vaginal suppositories and cream. b. Encourage the client to perform Kegel exercises 10 times daily. c. Explain the importance of using condoms when having sexual intercourse. d. Discuss the importance of keeping a diary of daily temperature and menstrual cycle events.
b. Encourage the client to perform Kegel exercises 10 times daily.
A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? a. Determine the client is anxious and allow him to sleep. b. Evaluate his blood pressure, pulse, and respiratory status. c. Review the client's pre-operative history for alcohol abuse. d. Continue to monitor the client for reactivity to anesthesia.
b. Evaluate his blood pressure, pulse, and respiratory status.
A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? a. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. b. Gram-negative organisms are more resistant to antibiotic therapy. c. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. d. Gram-negative pneumonias usually affect infants and small children.
b. Gram-negative organisms are more resistant to antibiotic therapy.
Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? a. Numbness, tingling, and cramps in the extremities. b. Headache, diaphoresis, and palpitations. c. Cyanosis, fever, and classic signs of shock. d. Nausea, vomiting, and muscular weakness.
b. Headache, diaphoresis, and palpitations.
A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? a. Frequent urinary tract infections. b. Inability to get pregnant. c. Premenstrual syndrome. d. Chronic use of laxatives.
b. Inability to get pregnant.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? a. Limit dietary selection of cholesterol to 300 mg per day. b. Increase intake of soluble fiber to 10 to 25 grams per day. c. Decrease plant stanols and sterols to less than 2 grams/day. d. Ensure saturated fat is less than 30% of total caloric intake.
b. Increase intake of soluble fiber to 10 to 25 grams per day.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement? a. Give 20 mEq of potassium chloride. b. Initiate continuous cardiac monitoring. c. Arrange a consultation with the dietician. d. Teach about the side effects of diuretics.
b. Initiate continuous cardiac monitoring.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. Which action should the nurse take first? a. Use a laryngoscope to check for a foreign body lodged in the esophagus. b. Reposition the head to validate that the head is in the proper position to open the airway. c. Turn the client to the side and administer three back blows. d. Perform a finger sweep of the mouth to remove any vomitus.
b. Reposition the head to validate that the head is in the proper position to open the airway.
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? a. Serum PTT of 10 seconds. b. Serum calcium of 5 mg/dL. c. Oxygen saturation of 90%. d. Hemoglobin of 10 g/dL.
b. Serum calcium of 5 mg/dL.
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement? a. Prepare the client for transcutaneous pacemaker. b. Shock the client with 200 joules per hospital policy. c. Use a magnet to deactivate the implanted pacemaker. d. Observe the monitor until the onset of ventricular fibrillation.
b. Shock the client with 200 joules per hospital policy.
The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit? a. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. b. Shuffling gait, masklike facial expression, and tremors of the head. c. Extreme muscular weakness, easy fatigability, and ptosis. d. Numbness of the extremities, loss of balance, and visual disturbances.
b. Shuffling gait, masklike facial expression, and tremors of the head.
The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? a. Exercise bicycle. b. Sphygmomanometer. c. Blood glucose monitor. d. Weekly medication box.
b. Sphygmomanometer.
Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? a. Tinnitus, vertigo, and hearing difficulties. b. Sudden, stabbing, severe pain over the lip and chin. c. Facial weakness and paralysis. d. Difficulty in chewing, talking, and swallowing.
b. Sudden, stabbing, severe pain over the lip and chin.
A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? a. The vaccine is given annually before the flu season to those over 50 years of age. b. The immunization is administered once to older adults or persons with a history of chronic illness. c. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. d. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years.
b. The immunization is administered once to older adults or persons with a history of chronic illness.
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? a. Place HIV positive clients in strict isolation and limit visitors. b. Wear gloves when coming in contact with the blood or body fluids of any client. c. Conduct mandatory HIV testing of those who work with AIDS clients. d. Freeze HIV blood specimens at -70 F to kill the virus.
b. Wear gloves when coming in contact with the blood or body fluids of any client.
The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? a. "Have you ever experienced any paralysis of your arms or legs?" b. "Have you ever sustained a severe head injury?" c. "Have you ever been 'frozen' in one spot, unable to move?" d. "Do you have headaches, especially ones with throbbing pain?"
c. "Have you ever been 'frozen' in one spot, unable to move?"
Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? a. Hematuria. b. 2 pounds weight gain. c. 3+ bacteria in urine. d. Steady, dull flank pain.
c. 3+ bacteria in urine.
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? a. The dosage of the diuretic will be decreased. b. The diuretic will be discontinued. c. A potassium supplement will be prescribed. d. The dosage of the diuretic will be increased.
c. A potassium supplement will be prescribed.
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement? a. Determine if the client has also experienced breast tenderness and weight gain. b. Encourage the client to begin a regular, daily program of walking and exercise. c. Advise the client to notify the healthcare provider for immediate medical attention. d. Tell the client to stop taking the medication for a week to see if symptoms subside.
c. Advise the client to notify the healthcare provider for immediate medical attention.
The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension? a. Opague color of the sclera. b. Transparency of the cornea. c. Amount of retinal vessel damage that has occurred. d. Constriction and dilatation of the pupils.
c. Amount of retinal vessel damage that has occurred.
During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? a. Neither plan allows selections of healthcare providers or hospitals. b. There are fewer healthcare providers to choose from than in an HMO plan. c. An individual may select healthcare providers from outside of the PPO network. d. An individual can become a member of a PPO without belonging to a group.
c. An individual may select healthcare providers from outside of the PPO network.
The nurse is initiating the client's fourth dose of gentamycin sulfate IV. The health care provider (HCP) has prescribed peak and trough levels. Which is the most important action for the nurse to implement next? a. Draw the peak 15 minutes before and the trough 15 minutes after the next dose. b. Draw the peak one hour before and one hour after the next dose. c. Draw the trough 5 minutes before and the peak 30 minutes after the next dose. d. Draw the trough 30 minutes before and 30 minutes after the next dose.
c. Draw the trough 5 minutes before and the peak 30 minutes after the next dose.
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit? a. Elevated LDH. b. Elevated serum amylase. c. Elevated CK-MB. d. Elevated hematocrit.
c. Elevated CK-MB.
Which postmenopausal client's complaint should the nurse refer to the healthcare provider? a. Breasts feel lumpy when palpated. b. History of white nipple discharge. c. Episodes of vaginal bleeding. d. Excessive diaphoresis occurs at night.
c. Episodes of vaginal bleeding.
While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? a. Immediately after the exposure. b. Within one week of the exposure. c. Four to six weeks after the exposure. d. Three months after the exposure.
c. Four to six weeks after the exposure.
The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? a. Increased WBC, decreased RBC. b. Increased serum bilirubin, slightly increased liver enzymes. c. Increased protein in the urine, slightly increased serum glucose levels. d. Decreased serum sodium, an increased urine specific gravity.
c. Increased protein in the urine, slightly increased serum glucose levels.
The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which recommendation should the nurse make that is most beneficial in protecting the client's joints? a. Increase the amount of calcium intake in the diet. b. Apply alternating heat and cold therapies. c. Initiate a weight-reduction diet to achieve a healthy body weight. d. Use a walker for ambulation to lessen weight-bearing on the hips.
c. Initiate a weight-reduction diet to achieve a healthy body weight.
Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? a. Faint pedal pulses. b. Decrease in blood pressure. c. Lethargy. d. Slow breathing.
c. Lethargy.
The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include? a. Safety precautions during activity. b. Assess for changes in size of lymph nodes. c. Maintain a fluid intake of 3 to 4 L per day. d. Administer narcotic analgesic around the clock.
c. Maintain a fluid intake of 3 to 4 L per day.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? a. This is a normal auscultatory finding. b. May indicate pneumothorax. c. May indicate pneumonia. d. May indicate severe emphysema.
c. May indicate pneumonia.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? a. A decreased total lung capacity. b. Normal arterial blood gases. c. Normal skin coloring. d. An absence of sputum.
c. Normal skin coloring.
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? a. Failing eyesight resulting in an unsafe environment. b. Renal osteodystrophy resulting from chronic renal failure. c. Osteoporosis resulting from hormonal changes. d. Cardiovascular changes resulting in small strokes which impair mental acuity.
c. Osteoporosis resulting from hormonal changes.
An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? a. Pain in the calf awakening him from a sound sleep. b. Calf pain on exertion which stops when standing in one place. c. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. d. Pain upon arising in the morning which is relieved after some stretching and exercise.
c. Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? a. Sodium. b. Antidiuretic hormone. c. Potassium. d. Glucose.
c. Potassium.
A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? a. Release the traction q4h to provide skin care. b. Turn the client for back care while suspending traction. c. Provide back and skin care while maintaining the traction. d. Give back care after the client is released from traction.
c. Provide back and skin care while maintaining the traction.
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? a. White blood count of 10,000 mm3. b. Serum glucose of 115 mg/dl. c. Purulent sputum. d. Excessive hunger.
c. Purulent sputum.
A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? a. Stay out of direct sunlight. b. Restrict intake of high protein foods. c. Schedule extra rest periods. d. Go to the emergency room immediately.
c. Schedule extra rest periods.
When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching? a. Recommend that the client carry suction equipment at all times. b. Instruct the client to have writing materials with him at all times. c. Tell the client to carry a medic alert card stating that he is a total neck breather. d. Tell the client not to travel alone.
c. Tell the client to carry a medic alert card stating that he is a total neck breather.
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? a. Lymph node involvement is not significant. b. Small tumors are aggressive and indicate poor prognosis. c. The tumor's estrogen receptor guides treatment options. d. Stage I indicates metastasis.
c. The tumor's estrogen receptor guides treatment options.
Which discharge instruction is most important for a client after a kidney transplant? a. Weigh weekly. b. Report symptoms of secondary Candidiasis. c. Use daily reminders to take immunosuppressants. d. Stop cigarette smoking.
c. Use daily reminders to take immunosuppressants.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? a. Present knowledge related to the skill of injection. b. Intelligence and developmental level of the client. c. Willingness of the client to learn injection sites. d. Financial resources available for the equipment.
c. Willingness of the client to learn injection sites.
Which information about mammograms is most important to provide a post-menopausal female client? a. Breast self-examinations are not needed if annual mammograms are obtained. b. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. c. Yearly mammograms should be done regardless of previous normal x-rays. d. Women at high risk should have annual routine and ultrasound mammograms.
c. Yearly mammograms should be done regardless of previous normal x-rays.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment? a. serum digoxin level is 1.5. b. blood pressure is 104/68. c. serum potassium level is 3. d. apical pulse is 68/min.
c. serum potassium level is 3.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client? a. pulse rate, both apically and radially. b. blood pressure, both standing and sitting. c. temperature. d. skin color and turgor.
c. temperature.
A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? a. "Diagnosis of AIDS is made when you have 2 positive ELISA test results." b. "Diagnosis is made when both the ELISA and the Western Blot tests are positive." c. "I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister?" d. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual."
d. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual."
A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client? a. "What dose of medication are you taking?" b. "Are you eating foods rich in potassium?" c. "Have you lost weight recently?" d. "At what time do you take your medication?"
d. "At what time do you take your medication?"
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? a. "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight." b. "I will let you have one cracker, but that is all you can have for the rest of tonight." c. "What did the healthcare provider tell you about the test you are having tomorrow?" d. "The test you are having tomorrow requires that you have nothing by mouth tonight."
d. "The test you are having tomorrow requires that you have nothing by mouth tonight."
A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? a. Fluid and electrolyte balance. b. Prevention of water toxicity. c. Reduced glucose in the urine. d. Adequate cellular nourishment.
d. Adequate cellular nourishment.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client? a. Apply sequential compression devices (SCDs) bilaterally. b. Assess for a positive Homan's sign in each leg. c. Pad all bony prominences on the affected leg. d. Advise the client to remain in bed with the leg elevated.
d. Advise the client to remain in bed with the leg elevated.
The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? a. Place a chair at a right angle to the bedside. b. Encourage deep breathing prior to standing. c. Help the client to sit and dangle legs on the side of the bed. d. Allow the client to sit with the bed in a high Fowler's position.
d. Allow the client to sit with the bed in a high Fowler's position.
What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? a. Vasodilators and hormones. b. Analgesics and sedatives. c. Anticoagulants and expectorants. d. Bronchodilators and steroids.
d. Bronchodilators and steroids.
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? a. Listen to bilateral lung and bowel sounds. b. Obtain the client's pulse and blood pressure. c. Assist the client to the bathroom to void. d. Check the client's gag and swallow reflexes.
d. Check the client's gag and swallow reflexes.
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula? a. Over use of laxatives for bowel regularity result in loss of peristaltic tone. b. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. c. Diverticulosis is the result of high fiber diet and sedentary life style. d. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
d. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. Which action should the nurse implement? a. Notify social services immediately of suspected elderly abuse. b. Discuss the need for mental health counseling with the daughter. c. Explain to the client that she needs to take better care of herself. d. Collect further data to determine whether self-neglect is occurring.
d. Collect further data to determine whether self-neglect is occurring.
An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? a. Abominal distention. b. Undue fatigue. c. Cyanosis of the lips. d. Confusion and tachycardia.
d. Confusion and tachycardia.
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? a. An increase in abdominal girth. b. Hypertension and a bounding pulse. c. Decreased bowel sounds. d. Difficulty in handwriting.
d. Difficulty in handwriting.
A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client? a. Xylocaine. b. Procainamide. c. Phenytoin. d. Digoxin.
d. Digoxin.
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) a. Remove the diaphragm immediately after intercourse. b. Wash the diaphragm with an alcohol solution. c. Use the diaphragm to prevent conception during the menstrual cycle. d. Do not leave the diaphragm in place longer than 8 hours after intercourse. e. Replace the old diaphragm every 3 months.
d. Do not leave the diaphragm in place longer than 8 hours after intercourse. e. Replace the old diaphragm every 3 months.
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? a. A diet low in phosphates. b. Skin inspection for bruising. c. Exercise regimen, including swimming. d. Elimination of hazards to home safety.
d. Elimination of hazards to home safety.
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? a. Facial flushing. b. Fever. c. Pounding headache. d. Feelings of dizziness.
d. Feelings of dizziness.
A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? a. Position the head of the bed (HOB) flat. b. Withhold intravenous fluids. c. Administer a bolus of IV fluids. d. Give an antihypertensive medication.
d. Give an antihypertensive medication.
The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? a. If suctioning will be needed for drainage of the wound. b. If the family would prefer a private or semi-private room. c. Prescription for removal of the drain. d. If the client's wound is infected.
d. If the client's wound is infected.
A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? a. Stage II. b. Invasive infiltrating ductal carcinoma. c. T1N0M0. d. Inflammatory with peau d'orange.
d. Inflammatory with peau d'orange.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? a. Black. b. White. c. Light green. d. Medium yellow.
d. Medium yellow.
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? a. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. b. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. c. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. d. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
d. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? a. Observe cyst size fluctuations as a sign of malignancy. b. Use estrogen supplements to reduce breast discomfort. c. Notify the healthcare provider if whitish nipple discharge occurs. d. Perform a breast self-exam (BSE) procedure monthly.
d. Perform a breast self-exam (BSE) procedure monthly.
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? a. Racing pulse with exertion. b. Clubbing of the fingers. c. An increased chest diameter. d. Productive cough with grayish-white sputum.
d. Productive cough with grayish-white sputum.
The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? a. Administer 30 minutes before eating. b. Evaluate the effectiveness 1 hour after administration. c. Instruct the client to swallow the tablet whole. d. Question the healthcare provider's prescription.
d. Question the healthcare provider's prescription.
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? a. Losing weight. b. Decreasing caffeine intake. c. Avoiding large meals. d. Raising the head of the bed on blocks.
d. Raising the head of the bed on blocks.
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? a. Avoid high carbohydrate foods. b. Decrease intake of fat soluble vitamins. c. Decrease caloric intake. d. Restrict salt and fluid intake.
d. Restrict salt and fluid intake.
In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? a. Genetic counseling. b. Twelve-step recovery program. c. Clinical nutritionist. d. Smoking cessation program.
d. Smoking cessation program.
A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding? a. Wearing dentures. b. Use of aspirin prior to admit. c. Prescribed nitroglycerin for chest pain. d. Takes digitalis.
d. Takes digitalis.
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? a. The length of time each group member has resided at the nursing home. b. A brief description of each resident's family life. c. The age of each group member. d. The usual activity patterns of each member of the group.
d. The usual activity patterns of each member of the group.
The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? a. Irritable bowel syndrome. b. Diverticulitis. c. Crohn's disease. d. Ulcerative colitis.
d. Ulcerative colitis.
