AH 3 prep u
a
A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated? a. The left leg is internally rotated. b. The leg length is the same as the right leg. c. The client has discomfort when moving in bed. d. There are diminished peripheral pulses on the affected extremity.
a
A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication? a. Bone fracture b. Loss of estrogen c. Negative calcium balance d. Dowager's hump
b
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? a. Have the patient extend both hands while the nurse compares the volume of both radial pulses. b. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. c. Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes. d. Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength.
b
The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is: a. Anorexia. b. Chronic diarrhea. c. Nausea and vomiting. d. Oral candida.
b, c, d
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) a. Capillary refill less than 3 seconds b. Decreased sensory function c. Excruciating pain d. Loss of motion e. 2+ peripheral pulses in the affected distal pulse
d
A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because: a. The three drugs can be given at lower doses. b. The second and third drugs increase the effectiveness of the first drug. c. The first two drugs are toxic to cancer cells, and the third drug promotes cell growth. d. The three drugs have a synergistic effect and act on the cancer cells with different mechanisms.
c
A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate? a. "Most clients need to use the drops for only about a few months." b. "If the drops don't work, surgery may be needed to cure your condition." c. "You'll need to use the drops for the rest of your life to control the glaucoma." d. "These drops are just the first step to make sure that your vision doesn't get worse."
c
A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? a. "Your child does not have AIDS but this condition puts your child at risk for it later in life." b. "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal." c. "Although AIDS is an immune deficiency, your child's condition is different from AIDS." d. "We need to do some more testing before we will know if your child's condition is AIDS."
b, c, d, e
A client asks a nurse, "What can I use to decrease my risk of exposure to HIV?" What will the nurse include as effective in reducing the risk of HIV exposure? Select all that apply. a. Lambskin condoms b. Sexual abstinence c. Latex male condoms d. Polyurethane female condoms e. Dental dams
d
A client asks the nurse what is causing the fatigue following radiotherapy. What is the nurse's best response? a. The cancer is spreading to other parts of the body. b. The cancer cells are dying in large numbers. c. Fighting off infection is an exhausting venture. d. Substances are released when tumor cells are destroyed.
a
A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client? a. Posterior iliac crest b. Sternum c. Femur d. Ankle
b
A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication? a. Amoxicillin b. Aluminum hydroxide c. Prednisone d. Tegretol
d
A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? a. Perform a cardiovascular assessment every 4 hours. b. Check the client's history for a congenital link to thrombocytopenia. c. Monitor daily platelet counts. d. Closely observe the client's skin for petechiae and bruising.
c
A client diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. What is the best response by the nurse? a. "CTS is a neuropathy that is characterized by bursitis and tendinitis." b. "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers." c. "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist." d. "CTS is a neuropathy that is characterized by pannus formation in the shoulder."
c
A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. What complication would you suspect in this client? a. Stroke b. Tissue infarction c. Congestive heart failure d. Pulmonary embolus
c
A client has Paget's disease. An appropriate nursing diagnosis for this client is: a. Risk for infection b. Delayed wound healing c. Risk for falls d. Fatigue
b
A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"? a. injury resulting from a blow or blunt trauma b. stretched or pulled beyond its capacity c. injuries to ligaments surrounding a joint d. subluxation of a joint
d
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma? a. Polycythemia vera b. Decreased serum protein c. Decreased calcium level d. Increased urinary protein
a
A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? a. immobilization b. surgical repair c. external rotation d. enhancing complications
tmj
A client has been treated for migraine headaches for several months and comes to the clinic stating he is getting no better. The nurse is talking with the client and hears an audible click when the client is moving his jaw. What does the nurse suspect may be happening
d
A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? a. Address issues of negative body image. b. Place the client in reverse isolation. c. Administer pain medication. d. Maintain nutrition.
optic nerve
A client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend?
d
A client has hereditary hemochromatosis. Laboratory test results indicate an elevated serum iron level, high transferrin saturation, and normal complete blood count (CBC). What is most important action for the nurse to take? a. Instruct the client to limit iron intake in the diet. b. Inform the client to limit ingestion of alcohol. c. Educate about precautions to follow after a liver biopsy. d. Remove the prescribed one unit of blood.
hyperopia
A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?
d
A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal? a. 10 mm Hg b. 15 mm Hg c. 20 mm Hg d. 25 mm Hg
d
A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? a. Questions the administration of both medications b. Ensures the client has completed dialysis treatment c. Holds the epoetin alfa if the BUN is elevated d. Assesses the hemoglobin level
d
A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? a. Greenstick b. Oblique c. Spiral d. Compound
b
A client is being evaluated for a diagnosis of chronic myeloid leukemia (CML). What diagnostic indicator will the nurse assess? a. An enlarged liver b. A leukocyte count >100,000/mm3 c. Lymphadenopathy d. Increased number of blast cells
cones
A client is color blind. The nurse understands that this client has a problem with:
a
A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate? a. "You have some fluid that has collected in your middle ear but no infection." b. "It has resulted from the several recurrent episodes of acute otitis media you've had." c. "You have a common infection in one of the bones of your face." d. "Your eardrum has ruptured because of the extreme pressure in your middle ear from the infection."
c, d, e
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. a. Infection b. Blood loss c. Abnormal erythrocyte production d. Destruction of normally formed red blood cells e. Inadequate formed white blood cells
a
A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching? a. Take 1 hour before breakfast b. Take with dairy products c. Decrease intake of fruits and juices d. Decrease intake of dietary fiber
b (n and v due to chemo can cause electrolyte issues)
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? a. Urine output of 400 ml in 8 hours b. Serum potassium level of 2.6 mEq/L c. Blood pressure of 120/64 to 130/72 mm Hg d. Sodium level of 142 mEq/L
d (avoid gum lacerations)
A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include? a. Gargle after each meal. b. Floss before going to bed. c. Treat cavities immediately. d. Use a soft toothbrush and allow it to air dry before storing.
b
A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of activity limitations when stating that a brace must be worn for which length of time? a. 2 to 4 weeks b. 6 to 8 weeks c. 10 to 12 weeks d. 14 to 16 weeks
a
A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? a. There is a strong correlation between iron stores and hemoglobin levels. b. There is a strong correlation between iron stores and hemoglobin characteristics. c. There is an inverse relationship between iron stores and hemoglobin levels. d. There is a weak correlation between iron stores and hemoglobin levels.
a
A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the bestaction by the nurse? a. Assess the tympanic membrane. b. Educate the client on the therapeutic effects of medications. c. Document the effectiveness of medications. d. Irrigate the ear.
a
A client presents to the ED reporting a chemical burn to both eyes. Which is the priority nursing intervention? a. Irrigate both eyes. b. Obtain the Material Safety Data Sheet (MSDS). c. Assess visual acuity. d. Assess the pH of the corneal surface.
c
A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention? a. Elevate the client's legs. b. Encourage ambulation. c. Assess for signs of injury. d. Keep the feet cool.
a (dont put anything on it and let it air dry)
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity.Which intervention should be part of this client's care plan? a. Avoiding using soap on the irradiated areas b. Applying talcum powder to the irradiated areas daily after bathing c. Wearing a lead apron during direct contact with the client d. Removing thoracic skin markings after each radiation treatment
c
A client sprains an ankle while playing tennis and is brought to the emergency department. What is the priority action by the nurse? a. Heat, compression, analgesics, and exercise b. Rest, heat, compression, and elevation c. Rest, ice, compression, and elevation d. Exercise, ice, compression, and elevation
a
A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states that he cannot feel or move his fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? a. Compartment syndrome b. Dislocation c. Muscle spasms d. Subluxation
b
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis c. Can't assess tumor or regional lymph nodes and no evidence of metastasis d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
d (shouldnt bend down that much anyhow)
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a. "I'll need to keep several pillows between my legs at night." b. "I need to remember not to cross my legs. It's such a habit." c. "The occupational therapist is showing me how to use a sock puller to help me get dressed." d. "I don't know if I'll be able to get off that low toilet seat at home by myself."
b
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a. Performing passive range-of-motion (ROM) exercises on the client's legs once each shift b. Keeping a pillow between the client's legs at all times c. Turning the client from side to side every 2 hours d. Maintaining the client in semi-Fowler's position
d
A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks? a. C3, C4, and L1 b. L1, L2, and L4 c. L2, L3, and L5 d. L4, L5, and S1
d
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? a. Hemolytic anemia b. Polycythemia vera c. Leukemia d. Multiple myeloma
c
A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client? a. Chest strapping b. Mechanical ventilation c. Coughing and deep breathing with pillow splinting d. Thoracentesis
d
A client who had a corneal transplant a few months ago arrives at the emergency department reporting eye discomfort. When assessing the client, which of the following would lead the nurse to suspect graft failure? a. Pale conjunctiva b. Reduced tearing c. Halos around lights d. Blurred vision
c
A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician to perform? a. analgesia and immobilization b. heat and immobilization c. joint manipulation and immobilization d. ice and immobilization
a
A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate? a. "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." b. "You may discuss your prescriptions with your physician at your follow-up appointment." c. "If your temperature is normal for 48 hours, you may discontinue the medication." d. "The antibiotics will help the bone to heal."
a, d
A client who plays tennis is experiencing elbow discomfort. Following assessment, the client receives a diagnosis of tendinitis, epicondylitis, or tennis elbow. a. pain radiating down the dorsal surface of the forearm weak grasp b. pain or burning in one or both hands c. pain more prominent at night d. What symptoms and signs did the client have? Select all that apply.
2-3 weeks
A client who wears soft contact lenses opts for laser correction surgery. The nurse would instruct the client to discontinue using the contact lenses for which time period before surgery?
c
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? a. Urine specimen for culture and sensitivity b. Blood specimen for electrolyte studies c. Stool specimen for ova and parasites d. Sputum specimen for acid fast bacillus
c
A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about? a. Protease inhibitor b. Integrase inhibitors c. Reverse transcriptase inhibitors d. Hydroxyurea
d
A client with a brain tumor is undergoing radiation and chemotherapy for treatment of cancer. The client has recently reported swelling in the gums, tongue, and lips. Which is the most likely cause of these symptoms? a. Neutropenia b. Extravasation c. Nadir d. Stomatitis
d
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." b. "Try to ambulate independently after about 24 hours." c. "Shampoo your hair every day for 10 days to help prevent ear infection." d. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
b
A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? a. Loss of vibratory and position senses b. Neurologic involvement c. Severity of the disease d. Insufficient intake of dietary nutrients
a
A client with disseminated intravascular coagulation (DIC) has a critically low fibrinogen level and is beginning to hemorrhage. To increase the amount of fibrinogen in the body, the nurse anticipates administering which blood product? a. Cryoprecipitate b. Fresh frozen plasma c. Albumin d. Packed red blood cells
a
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms? a. "Eat small amounts of bland, soft foods frequently." b. "Eat larger amounts of bland, soft foods less frequently." c. "Eat cold, bland foods with a large amount of water." d. "Eat low-fiber blended foods only."
perimetry test
A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:
d
A client with pernicious anemia is receiving parenteral vitamin B12therapy. Which client statement indicates effective teaching about this therapy? a. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." b. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." c. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." d. "I will receive parenteral vitamin B12 therapy for the rest of my life."
c
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? a. Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients b. Risk for falls related to complaints of dizziness c. Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit d. Fatigue related to decreased hemoglobin and hematocrit
a
A client with sickle cell anemia has a a. low hematocrit. b. high hematocrit. c. normal hematocrit. d. normal blood smear.
a
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? a. "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." b. "DIC occurs when the immune system attacks platelets and causes massive bleeding." c. "DIC is a complication of an autoimmune disease that attacks the body's own cells." d. "DIC is caused when hemolytic processes destroy erythrocytes."
d
A client's vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse? a. "You see an object from 200 feet away that a person with normal vision sees from 20 feet away." b. "You see an object from 20 feet away just like a person with normal vision." c. "You see an object from 200 feet away just like a person with normal vision." d. "You see an object from 20 feet away that a person with normal vision sees from 200 feet away."
a
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving: a. A-positive blood to an A-negative client. b. O-negative blood to an O-positive client. c. O-positive blood to an A-positive client. d. B-positive blood to an AB-positive client.
leukopenia
A decrease in circulating white blood cells (WBCs) is referred to as
d
A female client is at risk for developing osteoporosis. Which action will reduce the client's risk? a. Living a sedentary lifestyle to reduce the incidence of injury b. Stopping estrogen therapy c. Taking a 300-mg calcium supplement to meet dietary guidelines d. Initiating weight-bearing exercise routines
a
A female patient has a hemoglobin of 6.4 g/dL and is preparing to have a blood transfusion. Why would it be important for the nurse to obtain information about the patient's history of pregnancy prior to the transfusion? a. A high number of pregnancies can increase the risk of reaction. b. If the patient has never been pregnant, it increases the risk of reaction. c. Obtaining information about gravidity and parity is routine information for all female patients. d. If the patient has been pregnant, she may have developed allergies.
c
A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her parent that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur? a. 1 to 2 months b. 3 to 5 months c. 6 to 12 months d. Longer than 12 months
c (if numbness, pain, or tingling felt is indicative of CTS)
A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment? a. Have the client make a fist and open the hand against resistance. b. Have the client stretch the fingers around a ball and squeeze with force. c. Have the client hold the palm of the hand up while the nurse percusses over the median nerve. d. Have the client pronate the hand while the nurse palpates the radial nerve.
c
A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of? a. Keep all follow-up appointments. b. Keep a record of eye pressure measurements. c. Adhere to the medication regimen. d. Participate in the decision-making process.
b
A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would mostlikely decrease the pain associated with stomatitis? a. Recommend that the client discontinue chemotherapy. b. Provide a solution of viscous lidocaine for use as a mouth rinse. c. Monitor the client's platelet and leukocyte counts. d. Check regularly for signs and symptoms of stomatit
b
A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this? a. Women rarely manifest the gene expression b. Women lose iron through menstrual cycles c. Women have lower hemoglobin levels d. Women require grater folic acid supplementation
a
A nurse caring for a client with myeloma prepares to administer dexamethasone to the client. What is the nurse's best understanding of how this medication is an effective treatment option for this client? a. It kills affected cells. b. It decreases immune response. c. It decreases tumor necrosis factor. d. It kills affected bone marrow.
b
A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing: a. Opacity in the lens. b. Loss of accommodative power in the lens. c. Shrinkage of the vitreous body. d. Decreased eye muscle tone.
a
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately a. Stops the chemotherapeutic infusion b. Administers diphenhydramine c. Gives prednisolone IV d. Places the client on oxygen by nasal cannula
c
A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for? a. chronic liver failure. b. acute heart failure. c. pathologic bone fractures. d. hypoxemia.
b
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a. Pallor, bradycardia, and reduced pulse pressure b. Pallor, tachycardia, and a sore tongue c. Sore tongue, dyspnea, and weight gain d. Angina pectoris, double vision, and anorexia
b
A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? a. Monitor the client's toilet patterns. b. Monitor the client to prevent sepsis. c. Monitor the client's physical condition. d. Monitor the client's heart rate.
b
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? a. White blood cell (WBC) count of 9,000 cells/mm3 b. Stage 3 pressure ulcer on the left heel c. Temperature of 98.3° F (36.8° C) d. Ate 75% of all meals during the day
a
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? a. Wear disposable gloves and protective clothing. b. Break needles after the infusion is discontinued. c. Disconnect I.V. tubing with gloved hands. d. Throw I.V. tubing in the trash after the infusion is stopped.
c
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? a. Keep the affected leg in a position of adduction. b. Use measures other than turning to prevent pressure ulcers. c. Prevent internal rotation of the affected leg. d. Keep the hip flexed by placing pillows under the client's knee.
b (antihistamine)
A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? a. Dexamethasone b. Chlorpheniramine c. Dicloxacillin d. Bupivacaine
b
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? a. Hyperkalemia b. Hypercalcemia c. Hypernatremia d. Hypermagnesemia
d
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? a. respiratory status b. Balancing rest and activity c. Restricting fluid intake d. Preventing bone injury
c (risk for bleeding)
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? a. Limit visits by family members. b. Encourage the client to use a wheelchair. c. Use the smallest needle possible for injections. d. Maintain accurate fluid intake and output records.
a
A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse? a. To detect the abnormal sounds suggestive of acute chest syndrome and heart failure b. To detect the evidence of infection such as fever and tachycardia c. To detect the evidence of dehydration that might have triggered a sickle cell crisis d. To detect the motor strength and stroke-related signs and symptoms
a
A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described? a. open angle b. angle closure c. congenital d. secondary
b
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? a. Umbo in the center of the tympanic membrane b. External auditory canal erythema c. Tympanic membrane pearly gray d. Manubrium superior to the umbo
d
A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? a. "Use your continuous passive motion machine for 2 hours each day." b. "You need to perform weight-bearing exercises twice a week." c. "You need to limit the amount of protein and calcium in your diet." d. "You will receive IV antibiotics for 3 to 6 weeks."
b
A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest? a. Yoga b. Walking c. Bicycling d. Swimming
a, b, e
A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. a. Flank pain b. Shaking chills c. Hunger d. Fatigue e. Tightness in the chest
c
A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? a. Stand at a position diagonal to the client. b. Have the client use a finger to occlude the ear to be tested. c. Stand about 1 to 2 feet away from the ear to be tested. d. Speak a phrase in a low normal tone of voice.
d
A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? a. "This condition is associated with various sports." b. "Surgery is the only sure way to manage this condition." c. "Using arm splints will prevent hyperflexion of the wrist." d. "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."
a
A nurse working with clients diagnosed with sickle cell disease notices that sickle cell crisis cases increase in the winter months. What is the primary pathophysiological reason for this? a. Colder temperatures slows the blood flow. b. Colder temperatures worsens sickling. c. Colder temperatures increases vessel pressures. d. Colder temperatures impairs oxygen uptake.
a
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? a. Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential b. Monitoring the client's breathing and reviewing the client's arterial blood gases c. Monitoring the client's heart rate and reviewing the client's hemoglobin d. Monitoring the client's blood pressure and reviewing the client's hematocrit
b
A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain? a. A dull, deep, boring ache b. Sharp and piercing c. Similar to "muscle cramps" d. Sore and aching
d
A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? a. Changing the dressing b. Applying a cock-up splint and immobilization c. Having the patient exercise the fingers to avoid future contractures d. Performing hourly neurovascular assessments for the first 24 hours
a, b, c
A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.) a. Apply an emollient lotion to soften the skin. b. Control swelling with elastic bandages, as directed. c. Gradually resume activities and exercise. d. Use friction to remove dead surface skin by rubbing the area with a towel. e. Use a razor to shave the dead skin off.
c
A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following? a. Streptococcus pneumonia b. Hemophilus influenzae c. Chlamydia trachomatis d. Staphylococcus aureus
b
A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last? a. Less than 24 hours b. Between 24 and 48 hours c. About 72 hours d. At least 1 week
a
A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern for this patient? a. Hypovolemic shock b. Infection c. Knee and hip dislocation d. Pain resulting from muscle spasm
c
A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation? a. Magnesium level b. Potassium level c. Alkaline phosphatase d. Troponin levels
b
A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? a. High-Fowler's to allow for maximum hip flexion b. Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees c. Prone, with a pillow under the shoulders d. Supine, with the bed flat and a firm mattress in place
b
A patient is scheduled for cryoablation for cervical cancer and tells the nurse, "I am not exactly sure what the surgeon is going to do." What is the best response by the nurse? a. "The surgeon is going to use medication to inject the area." b. "The surgeon is going to use liquid nitrogen to freeze the area." c. "The surgeon is going to use a laser to remove the area." d. "The surgeon is going to use radiofrequency to ablate the area."
a
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? a. BUN and creatinine b. AST and ALT c. Hemoglobin and hematocrit d. Platelet count
d
A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign? a. A significant loss of central vision b. Diminished acuity c. Pain associated with a purulent discharge d. The presence of halos around lights
a
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue? a. Excisional biopsy b. Incisional biopsy c. Needle biopsy d. Punch biopsy
c
A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? a. Potassium level b. Creatinine level c. Hemoglobin level d. Folate levels
b
A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with a. anorexia. b. seizure. c. weight gain. d. myalgia.
a
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should: a. Encourage fluid intake, if possible, to dilute the urine. b. Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. c. Limit fluids to 1,000 mL/day to minimize stress on the renal tubules. d. Modify the diet to acidify the urine, thus preventing uric acid crystallizatio
a
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? a. Employs the Z-track technique b. Uses a 23-gauge needle c. Injects into the deltoid muscle d. Rubs the site vigorously
a
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? a. osteomyelitis b. hematoma c. hemorrhage d. infection
a (dont know if will be able to get pregnant, dont want to when going thru chemo)
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is a. "You will need to practice birth control measures." b. "You will continue having your menses every month." c. "You will experience menopause now." d. "You will be unable to have children."
a
According to the tumor-node-metastasis (TNM) classification system, T0 means there is a. No evidence of primary tumor b. No regional lymph node metastasis c. No distant metastasis d. Distant metastasis
a, b, c, d
Acute myeloid leukemia (AML) results from a defect in the hematopoietic stem cell that differentiates into which of the following myeloid cells? Select all that apply. a. Monocytes b. Granulocytes c. Erythrocytes d. Platelets e, Islet cells
c
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? a. Anemia b. Leukopenia c. Thrombocytopenia d. Neutropenia
b
An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as? a. Volkmann's contracture b. Subluxation c. Compartment syndrome d. Sprain
a
An client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults? a. dementia b. stomatitis c. glossitis d. ataxia
communited
An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?
myopia
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?
Volkmann's contracture
Condition in which the muscles in the palm side of the forearm shorten, causing the fingers to form a fist and the wrist to bend
b
During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? a. "After age 40, height may show a gradual decrease as a result of spinal compression" b. "After menopause, the body's bone density declines, resulting in a gradual loss of height." c. "There may be some slight discrepancy between the measuring tools used." d. "The posture begins to stoop after middle age."
c
During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ? a. Blurred vision b. Elevated intraocular pressure c. Mucopurulent ocular discharge d. Severe pain
c
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? a. Elevated hematocrit concentration b. Enlarged mean corpuscular volume (MCV) c. Low ferritin level concentration d. Elevated red blood cell (RBC) count
d
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior? a. Promotion b. Initiation c. Prolongation d. Progression
b
Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which of the following is the best response from the nurse? a. "It is nothing serious." b. "It means corrective lenses are required." c. "Simple surgery can fix this problem." d. "This is normal for anyone your age."
a, c
Following bone marrow aspiration of a client, analysis reveals more than 20% immature blast cells. Platelet counts are 9000/mm³. What nursing interventions should the nurse employ for the care of this client? Select all that apply. a. Administer prescribed docusate daily. b. Discuss the withholding of oral contraceptives. c. Assess for mental state changes. d. Recommend taking ibuprofen for mild aches and pains. e. Apply pressure to venipuncture sites for 1 to 2 minutes.
b
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? a. Administering aspirin if the temperature exceeds 102° F (38.8° C) b. Inspecting the skin for petechiae once every shift c. Providing for frequent rest periods d. Placing the client in strict isolation
dramamine
Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs?
a
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing a. facial nerve paralysis. b. nystagmus. c. motor impairment. d. diplopia.
d
In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? a. Wound packing b. Wound irrigation c. Vitamin supplements d. Surgical debridement
mitosis
In which phase of the cell cycle does cell division occur?
20/200
It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?
d
Lifestyle risk factors for osteoporosis include a. lack of aerobic exercise. b. a low-protein, high-fat diet. c. an estrogen deficiency or menopause. d. lack of exposure to sunshine.
bed rest
Nursing management of the client with acute symptoms of benign paroxysmal positional vertigo includes
c
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: a. Chronic open-angle. b. Normal tension. c. Acute angle-closure. d. Chronic angle-closure.
c
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? a. "Most likely, the father is the carrier of the gene." b. "The trait is passed down through the mother." c. "The child must inherit two defective genes, one from each parent." d. "It is an acquired, not a hereditary disorder."
a, c
Phagocytic dysfunction is characterized by the following. Choose all that apply. a. Increased incidence of bacterial infections b. Immunity to infection with herpes simplex c. Chronic eczematoid dermatitis d. Manifestation of underlying disease processes e. Rapid heartbeat
viral set point
The balance between the amount of HIV in the body and the immune response is the:
d
The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis? a. Frequency of a headache b. Pain in the outer ear c. Hearing ability fluctuations d. A sensation of things moving
b
The client is having a Weber test. During a Weber test, where should the tuning fork be placed? a. On the mastoid process behind the ear b. In the midline of the client's skull or in the center of the forehead c. Near the external meatus of each ear d. Under the bridge of the nose
a
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? a. Extravasation b. Stomatitis c. Nausea and vomiting d. Bone pain
c
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has? a. Too many erythrocytes b. A decrease in granulocytes c. A general reduction in all white blood cells d. A general reduction in neutrophils and basophils
b
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? a. Use contact precautions with this client. b. Perform a neurologic assessment with vital signs. c. Request a prescription of diphenoxylate and atropine for loose stools. d. Teach the client to vigorously floss the teeth to prevent infections.
b
The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately? a. Chalazion b. Acute angle-closure glaucoma c. Hordeolum d. Blepharitis
a (prevent teeth staining)
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? a. Drink liquid iron preparations with a straw. b. Take iron with an antacid to avoid stomach upset. c. Avoid vitamin C as it prevents absorption. d. Taking iron pills with milk aids in absorption.
b
The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following? a. Pupillary reaction b. Extraocular muscle function c. Eyelid drooping d. Eyeball oscillation movements
b
The nurse cares for a client with acute myeloid leukemia with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain? a. Abnormal blood cells deposit in small vessels. b. Bone marrow expands. c. Lymph nodes expand. d. Abnormal blood cells crystalize.
c
The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? a. "I will lie prone with my legs slightly elevated." b. "I will bend at the waist when I am lifting objects from the floor." c. "I will avoid prolonged sitting or walking." d. "Instead of turning around to grasp an object, I will twist at the waist."
b
The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions? a. Creatinine and blood urea nitrogen (BUN) levels b. Iron levels c. Magnesium levels d. Potassium levels
a
The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? a. Decrease in estrogen b. Increase in calcitonin c. Decrease in parathyroid hormone d. Increase of vitamin D
d
The nurse is assessing a client with leukemia. How would the nurse assess for enlargement and tenderness over the liver and spleen? a. By reviewing laboratory test results b. By calculating the absolute neutrophil count c. By looking for evidence of bruising d. By palpating the abdomen
d
The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do? a. Bind the toes so that they will straighten. b. Do active range of motion on the toes. c. Have surgery to fix them. d. Wear properly fitting shoes.
c
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? a. Ultrasonography b. Retinal Imaging c. Retinal Angiography d. Retinoscopy
c
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy? a. It is used to remove cancerous cells using a needle. b. It removes an entire lesion and the surrounding tissue. c. It removes a wedge of tissue for diagnosis. d. It treats cancer with lymph node involvement.
b
The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? a. Raloxifene b. alendrondate c. Teriparatide d. Denosumab
canal of shclemm
The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?
b
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a. Osteopathic tumors destroy bone causing fractures. b. Osteoclasts break down bone cells so pathologic fractures occur. c. Osteolytic activating factor weakens bones producing fractures. d. Osteosarcomas form producing pathologic fractures.
b12
The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?
a
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack? a. Meclizine (Antivert) b. Furosemide (Lasix) c. Cortisporin otic solution d. Gentamicin (Garamycin) intravenously
b
The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important? a. Shield your throat area when near others. b. Flush the toilet twice after every use. c. Prepare food separately from family members. d. Use disposable utensils for the next month.
d
The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit? a. Excessive consumption of coffee or tea b. Elimination of iron by the body c. Decrease in the total body iron stores with age d. Blood loss from the gastrointestinal or genitourinary tract
b
The nurse is conducting a community education program using the American Cancer Society's colorectal screening and prevention guidelines. The nurse determines that the participants understand the teaching when they identify that people over the age of 50 should have which screening test every 10 years? a. Fecal occult blood test b. Colonoscopy c. Prostate-specific antigen (PSA) d. Papanicolaou (Pap)
a
The nurse is discussing disorders of the hematopoietic system when a client asked about erythrocytosis. What disease will the nurse mention with a primary characteristic of erythrocytosis? a. polycythemia vera b. sickle cell disease c. aplastic anemia d. pernicious anemia
d
The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client? a. To minimize the adverse effects of drug therapy b. To reduce the magnitude of the hearing deficit c. To minimize the risk of a tumor that involves the vestibulocochlear nerve d. To reduce the production of fluid in the inner ear
a
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? a. Eating calf's liver with a glass of orange juice b. Eating leafy green vegetables with a glass of water c. Eating apple slices with carrots d. Eating a steak with mushrooms
c
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? a. Do not take medication with orange juice because it will delay absorption of the iron. b. Iron may cause indigestion and should be taken with an antacid such as Mylanta. c. Dilute the liquid preparation with another liquid such as juice and drink with a straw. d. Discontinue the use of iron if your stool turns black.
c
The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? a. WBC count of 4,200 cells/uL b. Hematocrit of 38% c. Platelet count of 9,000/mm3 d. Creatinine level of 1.0 mg/dL
arthroscopy
The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for?
b
The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? a. Has a history of viral hepatitis as a teenager 10 years ago b. Reports having a cold 1 month ago that resolved quickly c. Received a blood transfusion within 1 year d. Had a dental extraction 2 days ago for caries in a tooth
b
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis? a. The client being distressed in the mornings b. A progressive, bilateral loss of hearing c. A red and swollen ear drum d. The client describing a recent upper respiratory infection
b
The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? a. "Acute leukemia develops slowly." b. "Chronic leukemia develops slowly." c. "In chronic leukemia, the minority of leukocytes are mature." d. "In acute leukemia there are not many undifferentiated cells."
b
The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? a. "Treatment is simple and consists of single-drug therapy." b. "Intrathecal chemotherapy is used primarily as preventive therapy." c. "The goal of therapy is palliation." d. "Side effects are rare with therapy."
a
The nurse is teaching the client about consolidation. What statement should be included in the teaching plan? a. "Consolidation therapy is administered to reduce the chance of leukemia recurrence." b. "Consolidation occurs as a side effect of chemotherapy." c. "Consolidation of the lungs is an expected effect of induction therapy." d. "Consolidation is the term used when a client does not tolerate chemotherapy."
b
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of a. nadir. b. graft-versus-host disease. c. metastasis. d. acute leukopenia.
b
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? a. Erythrocytes that are macrocytic and hyperchromic b. Erythrocytes that are microcytic and hypochromic c. Clustering of platelets with sickled red blood cells d. An increased number of erythrocytes
c
The nurse should monitor for which manifestation in a client who has had LASIK surgery? a. Excessive tearing b. Cataract formation c. Halos and glare d. Stye formation
b
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? a. Debilitating fatigue b. Bone pain in the back of the ribs c. Gradual muscle paralysis d. Severe thrombocytopenia
over 21 mmhg
The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of:
b
The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? a. To remove the tumor from the brain b. To prevent the formation of new cancer cells c. To analyze the lymph nodes involved d. To destroy marginal tissues
a
There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? a. avascular necrosis b. fat embolism c. pulmonary embolism d. shock
b
There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for: a. Tonometry. b. Ophthalmoscopy. c. Gonioscopy. d. Perimetry
nsaids
To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes?
a
Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? a. Compartment syndrome. b. Phlebitis. c. Infection. d. Chronic venous insufficiency.
a (common and expected)
Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate? a. Administer medication, as ordered, for the reported discomfort. b. Contact the health care provider. c. Initiate a consult with a psychologist. d. Do nothing because it isn't possible to have pain in a missing limb.
a
What action should be taken when there is an insect in the ear? a. Instillation of mineral oil b. Instillation of carbamide peroxide c. Instillation of hot water d. Use of a small forceps
a
What assessment finding best indicates that the client has recovered from induction therapy? a. Neutrophil and platelet counts within normal limits b. Vital signs within normal ranges c. No evidence of edema d. Absence of bone pain
b
What food can the nurse suggest to the client at risk for osteoporosis? a. Carrots b. Broccoli c. Chicken d. Bananas
c
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action? a. Eggs and milk b. Fish and poultry c. Ham and bacon d. Green, leafy vegetables
a (takes 4-6 mos post tx)
What should the nurse tell a client who is about to begin chemotherapy and is anxious about hair loss? a. The client should consider getting a wig or cap prior to beginning treatment. b. Alopecia related to chemotherapy is relatively uncommon. c. The hair will grow back within 2 months post therapy. d. The hair will grow back the same as it was before treatment.
a
When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: a. light flashes and floaters in front of the eye. b. a recent driving accident while changing lanes. c. headaches, nausea, and redness of the eyes. d. frequent episodes of double vision.
c
When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following? a. 20/20 + 30 b. 20/20/50 c. 20/50-3 d. 20/50
c
Which action should the nurse recommend to a client with blepharitis? a. Soak the area in warm water b. Incision and drainage c. Keep lid margins clean d. Sleep with the face parallel to the floor
a
Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? a. Lower lumbar b. Upper lumbar c. Thoracic d. Cervical
b, c, e
Which client(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply. a. The client who sustained a clavicle fracture b. The client with elevated pressure within the muscles c. The client with hemorrhage in the site of injury d. The client using ice to control pain in the extremity e. The client with a plaster cast applied immediately after injury
presbycusis
Which condition refers to hearing loss associated with degenerative changes?
c
Which does a nurse thoroughly evaluate before a hematopoietic stem cell transplant (HSCT) procedure? a. Family history b. Drug history c. Blood studies d. Allergy history
b
Which general nursing measure is used for a client with a fracture reduction? a. Promote intake of omega-3 fatty acids b. Encourage participation in ADLs c. Examine the abdomen for enlarged liver or spleen d. Assist with intake of immune-enhancing tube feeding formulas
b
Which group of medications causes pupillary constriction? a. Mydriatics b. Miotics c. Beta-blockers d. Adrenergic agonists
b
Which is a correct rationale for encouraging a client with otitis externa to eat soft foods? a. Chewy foods, such as red meat, may react with prescribed analgesics and antibiotics. b. Chewing may cause discomfort. c. Chewing may lead to further complications, such as otitis media. d. Chewing may cause excessive drainage.
c
Which is a growth-based classification of tumors? a. Sarcoma b. Carcinoma c. Malignancy d. Leukemia
a
Which is a symptom of hemochromatosis? a. Bronzing of the skin b. Inflammation of the mouth c. Inflammation of the tongue d. Weight gain
a
Which is not a risk factor for osteoporosis? a. being male b. small-framed, thin White or Asian women c. being postmenopausal d. family history
vertigo
Which manifestation is the most problematic for the client diagnosed with Ménière disease
b
Which may occur if a client experiences compartment syndrome in an upper extremity? a. Whiplash injury b. Volkmann's contracture c. Callus d. Subluxation
a
Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)? a. Calcitonin b. Raloxifene c. Teriparatide d. Vitamin D
vitamin k
Which medication is the antidote to warfarin?
c
Which nursing intervention is essential in caring for a client with compartment syndrome? a. Keeping the affected extremity below the level of the heart b. Wrapping the affected extremity with a compression dressing to help decrease the swelling c. Removing all external sources of pressure, such as clothing and jewelry d. Starting an I.V. line in the affected extremity in anticipation of venogram studies
c
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? a. Implement neutropenic precautions b. Eliminate direct contact with others who are infectious c. Apply prolonged pressure to needle sites or other sources of external bleeding d. Monitor temperature at least once per shift
b, c, d, e
Which of the following are complications related to polycythemia vera (PV)? Select all that apply. a. Splenomegaly b. CVA c. MI d. Ulcers e. Hematuria
d
Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? a. Normocytic b. Microcytic c. Hyperchromic d. Hypochromic
a
Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? a. Disseminated intravascular coagulation (DIC) b. Avascular necrosis (AVN) c. Complex regional pain syndrome (CRPS) d. Fat embolism syndrome (FES)
c
Which of the following inhibits bone resorption and promotes bone formation? a. Estrogen b. Parathyroid hormone c. Calcitonin d. Corticosteroids
anemia
Which of the following is the most common hematologic condition affecting elderly patients
a
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? a. Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss b. Conducting various tests to determine the function and the structure of the eyes c. Determining if further action is warranted d. Advising the patient on the diet and exercise regimen to be followed
surgery
Which of the following is the treatment of choice for acoustic neuromas?
d
Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain? a. Epicondylitis b. Heterotopic ossification c. Acute compartment syndrome d. Rotator cuff tears
a
Which of the following precautions should the nurse take when a patient is at risk of injury secondary to vertigo and probable imbalance? a. Have the patient sit in a wheelchair when moving. b. Recommend that the patient keep his or her eyes closed. c. Restrict the patient from looking at one place. d. Allow the patient to move the head slowly.
a
Which of the following presents with an onset of heel pain with the first steps of the morning? a. Plantar fasciitis b. Hallux valgus c. Morton's neuroma d. Ganglion
a
Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? a. Scleral buckle b. Pars plana vitrectomy c. Pneumatic retinopexy d. Phacoemulsification
viral
Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?
a
Which of the following was formerly called a bunion? a. Hallux valgus b. Plantar fasciitis c. Morton's neuroma d. Ganglion
b
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? a. Increased ability to stretch arm over the head b. Difficulty lying on affected side c. Pain worse in the morning d. Minimal pain with movement
d
Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? a. A 24-year-old female taking oral contraceptives b. A 40-year-old patient with a history of hypertension c. A 52-year-old patient with acute kidney injury d. A 72-year-old patient with a history of cancer
eustachian tube
Which portion of the middle ear equalizes pressure?
c
Which should a nurse thoroughly evaluate before a bone marrow transplant (BMT) procedure? a. Family history b. Drug history c. Blood studies d. Allergy history
c
Which statement best describes the function of stem cells in the bone marrow? a. They are active against hypersensitivity reactions. b. They defend against bacterial infection. c. They produce all blood cells. d. They produce antibodies against foreign antigens.
a
Which statement describes benign paroxysmal positional vertigo (BPPV)? a. The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. b. The onset of BPPV is gradual. c. BPPV is caused by tympanic membrane infection. d. BPPV is stimulated by the use of certain medications, such as acetaminophen.
LASIK
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?
d
Which symptoms may a client with Ménière disease report before an attack? a. Nystagmus b. Low blood pressure c. Photosensitivity d. A full feeling in the ear
radiculopathy
Which term refers to a disease of a nerve root?
d
Which term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a. Callus b. Hammertoe c. Hallux valgus d. Dupuytren's contracture
greenstick
Which term refers to a fracture in which one side of a bone is broken and the other side is bent?
a
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a. Pancytopenia b. Anemia c. Leukopenia d. Thrombocytopenia
sprain
Which term refers to an injury to ligaments and other soft tissues surrounding a joint?
tympanoplasty
Which term refers to surgical repair of the tympanic membrane?
aphakia
Which term refers to the absence of the natural lens?
nonunion
Which term refers to the failure of fragments of a fractured bone to heal together
d
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry red in color? a. Molluscum contagiosum b. Milia c. Xanthelasma d. Hemangioma
impacted
Which type of fracture occurs when a bone fragment is driven into another bone fragment?
b
Which type of sickle crisis occurs as a result of infection with the human parvovirus? a. Sequestration crisis b. Aplastic crisis c. Sickle cell crisis d. Acute chest syndrome
d
While doing a health history, a client tells the nurse that her mother, her grandmother, and her sister died of breast cancer. The client asks what she can do to keep from getting cancer. What is the bestresponse by the nurse? a. "If you eat right, exercise, and get enough rest, you can always prevent breast cancer." b. "With your family history, there is nothing you can do to prevent getting cancer, so be mindful of your family risk factors." c. "Cancer often skips a generation, so don't worry about it." d. "Cancer prevention and detection can be done with blood analysis for tumor markers to measure your risk level."
a
With fractures of the femoral neck, the leg is a. shortened, adducted, and externally rotated. b. shortened, abducted, and internally rotated. c. adducted and internally rotated. d. abducted and externally rotated.
c
complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels b. Low levels of urine constituents normally excreted in the urine c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels d. Electrolyte imbalance that could affect the blood's ability to coagulate properly
angiogenesis
formation of new blood vessels
hereditary cancer syndrome
include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.
blepharitis
inflammation of the glands and eyelash follicles along the margin of the eyelids
fat embolism syndrome
is characterized by fever, tachycardia, tachypnea, and hypoxia. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.
total arthroplasty
replacement of both articular surfaces within one joint.
closed reduction
the bone is restored to its normal position by external manipulation.
open reduction
the correction and alignment of the fracture after surgical dissection and exposure of the fracture.
b
A client comes to the clinic complaining of low back pain radiating down the left leg. After diagnostic studies rule out any pathology, the health care provider orders a serotonin-norepinephrine reuptake inhibitor (SNRI). Which medication does the nurse anticipate educating the client about? a. Amitriptyline b. Duloxetine c. Gabapentin d. Cyclobenzaprine
b
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client? a. Cutting of a bivalve cast b. Cutting a cast window c. Removal of the cast d. Insertion of an external fixator
a
A client has undergone an external fixation. Which actions would be the priority for this client? a. Maintaining pin care. b. Planning the client's diet. c. Monitoring the client's urine output. d. Monitoring the client's blood pressure.
c
A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate? a. "Only your male children are at risk for developing this disease." b. "Your female children will be carriers for the disease, but only male children will develop the disease." c. "All of your children will be carriers of the recessive gene but may not develop the disease." d. "All of your children will develop the disease."
d
A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? a. Wound packing b. Wound irrigation c. Vitamin supplements d. Surgical debridement
b
A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? a. Gastric ulcer b. Pernicious anemia c. Hyperthyroidism d. Sickle cell anemia
b
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? a. Antibiotic therapy b. Immunosuppressive agents c. Chest physiotherapy d. Anticoagulation
c
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem? a. Consult a skin specialist. b. Scrub the area vigorously to remove the crust. c. Apply lotions and take warm baths or soaks. d. Avoid exposure to direct sunlight.
d
A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as? a. Buck's traction b. Skeletal traction c. Internal fixation d. Open reduction
c
A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction? a. Crutchfield tongs b. Thomas splint c. Buck's d. Balanced suspension
a
Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? a. "CPM increases range of motion of the joint." b. "CPM strengthens the muscles of the leg." c. "CPM delivers analgesic agents directly into the joint." d. "CPM prevents injury by limiting flexion of the knee."
b
More than 50% of individuals with this disease develop pernicious anemia: a. Bruton disease b. Common variable immunodeficiency (CVID) c. DiGeorge syndrome d. Nezelof syndrome
b
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? a. An open reduction b. A fasciotomy c. A total hip replacement d. A total knee replacement
b
The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication? a. Osteomyelitis b. Hypovolemic shock c. Urinary retention d. Atelectasis
b
The lower the client's viral load, a. the shorter the time to AIDS diagnosis. b. the longer the survival time. c. the shorter the survival time. d. the longer the time immunity.
a
The majority of patient with primary immunodeficiency are in which age group? a. Younger than 20 b. 20 to 40 c. 41 to 50 d. 51 to 60
a
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is a. Malnutrition b. Neutropenia c. Hypocalcemia d. Chronic diarrhea
a
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: a. Risk for ineffective therapeutic regimen management b. Disturbed body image c. Situational low self-esteem d. Risk for avascular necrosis of the joint
a (normal is 3k-7k)
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment? a. Assessing the client for signs and symptoms of infection b. Assessing the client's activity level and functional status c. Assessing the client for indications of internal or external hemorrhage d. Assessing the client for signs of venous thromboembolism
b
The nurse is caring for a client with a spica cast. What is the nurse's priority intervention? a. Position the client on the affected side. b. Keep the cast clean and dry. c. Promote elimination with a regular bedpan. d. Keep the legs in abduction.
c
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? a. Atelectasis b. Hypovolemia c. Pulmonary embolism d. Urinary tract infection
d
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? a. Apply the traction straps snugly. b. Assess the client's level of consciousness. c. Remove the traction at least every 8 hours. d. Teach the client how to prevent problems caused by immobility.
b
Kaposi sarcoma (KS) is diagnosed through a. skin scraping. b. biopsy. c. visual assessment. d. computed tomography.
b
Morton neuroma is exhibited by which clinical manifestation? a. High arm and a fixed equinus deformity b. Swelling of the third (lateral) branch of the median plantar nerve c. Longitudinal arch of the foot is diminished d. Inflammation of the foot-supporting fascia
b
The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? a. "The client probably has a case of the flu and you should give acetaminophen." b. "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." c. "This is one of the side effects from antiretroviral therapy and will require changing the medication." d. "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider."
hip spica
Which type of cast encloses the trunk and a lower extremity?
c
To prepare a client who has a fractured femur for ambulation, the nurse teaches the client how to do quadriceps setting exercises. Which instruction is the most accurate? a. "Contract and relax your buttocks." b. "Try to lift your legs up when I press against your feet." c. "Press the back of your knee against the bed." d. "Flex and extend your toes."
b
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? a. means of transmission b. HIV-1 is more prevalent than HIV-2 subtypes c. the fact that it is a mutated virus originally thought to be bovine in nature d. cure rate
a
When the nurse administers intravenous gamma-globulin infusion, she recognizes that which symptom, if reported by the client, may indicate an adverse effect of the infusion? a. Tightness in the chest b. Nasal stuffiness c. Increased thirst d. Burning urination
b
Which action would be most important postoperatively for a client who has had a knee or hip replacement? a. Providing crutches to the client. b. Assisting in early ambulation. c. Using a continuous passive motion (CPM) machine. d. Encouraging expressions of anxiety.
b
Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy? a. Depression, memory impairment, and coma b. Respiratory or urinary system infections c. Rheumatoid arthritis d. Cardiac dysrhythmias and heart failure
splint
Which device is designed specifically to support and immobilize a body part in a desired position?
b
Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery? a. It provides active range of motion. b. It promotes healing by increasing circulation and movement of the knee joint. c. It promotes healing by immobilizing the knee joint. d. It prevents infection and controls edema and bleeding.
d
Which is an inaccurate principle of traction? a. The weights are not removed unless intermittent treatment is prescribed. b. The weights must hang freely. c. The client must be in good alignment in the center of the bed. d. Skeletal traction is interrupted to turn and reposition the client.
a (never flex them)
Which is not a guideline for avoiding hip dislocation after replacement surgery. a. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. b. Keep the knees apart at all times. c. Put a pillow between the legs when sleeping. d. Never cross the legs when seated.
a
Which is usually the most important consideration in the decision to initiate antiretroviral therapy? a. CD4+ counts b. HIV RNA c. Western blotting assay d. ELISA
d
Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture? a. Arthrodesis b. Joint arthroplasty c. Total joint arthroplasty d. Open reduction
b
Which principle applies to the client in traction? a. Weights should rest on the bed. b. Skeletal traction is never interrupted. c. Knots in the ropes should touch the pulley. d. Weights are removed routinely.
c
A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority? a. Deficient knowledge related to the effects of the disease b. Risk for infection related to the immune system dysfunction c. Disturbed body image related to loss of fat in the face and arms d. Risk for impaired liver function related to drug therapy effects
c
A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? a. Distal sensory polyneuropathy (DSP) b. Candidiasis c. HIV encephalopathy d. Cytomegalovirus (CMV)
c
On a visit to the family health care provider, a client is diagnosed with a bunion on the lateral side of the great toe at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? a. "Bunions are congenital and can't be prevented." b. "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." c. "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." d. "Bunions are caused by a metabolic condition called gout."
c
The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care? a. Maintain the client in a supine or side-lying position. b. Encourage client to ambulate frequently in the halls. c. Assist with chest physiotherapy every 2 to 4 hours. d. Limit fluid intake to 1 1/2 to 2 liters per day.
b (must be freely hanging)
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? a. Body aligned opposite to line of traction pull b. Weights hanging and touching the floor c. Pulleys without evidence of the obstruction d. Ropes freely moving over pulleys
a
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? a. "Metal pins will go through my skin to the bone." b. "I will wear a boot with weights attached." c. "A belt will go around my pelvis and weights will be attached." d. "The traction can be removed once a day so I can shower."
a, c, d, e
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. a. semen b. urine c. breast milk d. blood e. vaginal secretions
a
Which statement describes external fixation? a. The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. b. The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. c. The bone is restored to its normal position by external manipulation. d. The bone is surgically exposed and realigned.
c
Which statement is accurate regarding care of a plaster cast? a. The cast must be covered with a blanket to keep it moist during the first 24 hours. b. The cast will dry in about 12 hours. c. The cast can be dented while it is damp. d. A dry plaster cast is dull and gray.
a, b, c, e
A nurse is caring for a client in skeletal leg traction. Which nursing assessment findings indicate the client has met expected outcomes? Select all that apply. a. Capillary refill less than 3 seconds b. Repositions self with trapeze c. Peripheral pulses +2 bilaterally d. Right calf warm and swollen e. Elbows are free of skin breakdown
d
A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan? a. Keeping the casted arm warm by covering it with a light blanket b. Avoiding handling the cast for 24 hours or until it is dry c. Evaluating pedal and posterior tibial pulses every 2 hours d. Assessing movement and sensation in the fingers of the right hand
d
A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy? a. Reverse the HIV+ status to a negative status. b. Treat mycobacterium avium complex. c. Eliminate the risk of AIDS. d. Bring the viral load to a virtually undetectable level
c
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? a. Arthrodesis b. Hemiarthroplasty c. Total arthroplasty d. Osteotomy
b
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? a. "You would have to stay here much longer because it takes a cast longer to dry." b. "A splint is applied when more swelling is expected at the site of injury." c. "It is best if an orthopedic doctor applies the cast." d. "Not all fractures require a cast."
a (retested in 2-8 weeks)
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? a. 6 weeks b. 12 weeks c. 18 weeks d. 24 weeks
c
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? a. "You should take the drug with an antacid." b. "It doesn't matter if you take this drug with or without food." c. "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." d. "When you take this drug, eat a high-fat meal immediately afterwards."
a
A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain? a. Elevate the affected extremity and use cold applications. b. Breathe deeply and cough every 2 hours until ambulation is possible. c. Do ROM exercises as indicated. d. Apply antiembolism stockings as indicated.
d (steroids and condition make more susceptible to serious infection)
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? a. If the client experiences nausea, omit the dose. b. The client should be alert for joint aches. c. This medication is commonly used for many inflammatory reactions and is relatively safe. d. Be alert for signs and symptoms of infection and report them immediately to the physician.
b
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client? a. Sign a refusal of blood transfusion form so the client will not receive the transfusion. b. Bank autologous blood. c. Ask people to donate blood. d. Using volume expanders in case blood is needed.
ELISA
A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?
c
A client taking fosamprenavir reports "getting fat." What is the nurse's best action? a. Have the client increase exercise. b. Assess the client's diet. c. Teach the client about medication side effects. d. Arrange for a psychological counseling.
d
A client that is HIV+ has been diagnosed with Pneumocystispneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection? a. Nystatin b. Amphotericin B c. Fluconazole d. Trimethoprim-sulfamethoxazole
b
A client was playing softball and dislocated four of his fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as? a. Open reduction b. Closed reduction c. Open reduction with internal fixation d. External fixation
b
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise? a. Consume large, high-fat meals. b. Avoid fibrous foods, lactose, fat, and caffeine c. Reduce food intake. d. Increase intake of iron and zinc.
b
A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client? a. Assisting with range-of-motion and isometric exercises. b. Changing the client's position within prescribed limits. c. Administering prescribed analgesics. d. Applying warm compresses.
a
A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? a. Explain that the sensation being felt is normal and will not burn the client. b. Remove the cast immediately, notifying the physician. c. Administer antianxiety and pain medication. d. Call for assistance to hold the client in the required position until the cast has dried.
a
A client with acquired immune deficiency syndrome (AIDS) comes to the clinic reporting difficulty swallowing. The client says, "It hurts so much when I swallow." Inspection reveals creamy white patches in the client's mouth. What will the nurse suspect? a. Candidiasis b. Wasting syndrome c. Cryptococcus neoformans d. Clostridium difficile diarrhea
b (done after two positive ELISA tests)
A client with suspected human immunodeficiency virus (HIV) has had two positive enzyme-linked immunosorbent assay (ELISA) tests. What diagnostic test would be run next? a. ELISA b. Western Blot c. T4/T8 ratio d. Polymerase chain reaction
a
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding? a. testing the client for the presence of HIV b. instructing the client to wear cotton underwear c. having the client abstain from sexual activity for 6 weeks while the medication is working d. using a medicated douche in order to keep the vaginal pH normal
a
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? a. Better molding to the client b. Quicker drying c. Longer lasting d. More breathable
c
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection? a. Limit interactions with people who are not HIV infected. b. Limit interactions with people who are already HIV infected. c. Follow the same sexual precautions as someone who has been diagnosed with AIDS. d. Quit their job and get admitted to a hospital or a cancer treatment center.
d
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? a. DAF b. CVID c. SCID d. AIDS
c
A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has a. vascular lesions caused by dilated blood vessels. b. an inability to understand the spoken word. c. uncoordinated muscle movements. d. difficulty swallowing.
a
A nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). The client wants to know when medication for the disease will begin. What is the nurse's best response? a. If the client has a CD4 T-cell count less than 350 cells/mm3. b. When the client is coinfected with hepatitis C. c. If the client is diagnosed with HIV-associated liver disease. d. After the client has been cured of Kaposi's sarcoma.
d
A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? a. Examine the surgical dressing every hour. b. Administer pain medication per client request. c. Monitor vital signs every 4 hours. d. Perform neuromuscular assessment every hour.
a
A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? a. Assessing the extremity for neurovascular integrity b. Keeping the client from sliding to the foot of the bed c. Keeping the ropes over the center of the pulley d. Ensuring that the weights hang free at all times
b
A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching? a. "Girls are diagnosed with primary immunodeficiencies more often than boys." b. "The majority of primary immunodeficiencies are diagnosed in infancy." c. "My baby cannot survive into childhood with a diagnosis of primary immunodeficiency." d. "The primary immunodeficiency will disappear with age."
a
Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction? a. IgA deficiency b. Ataxia-telangiectasia c. Wiskott-Aldrich syndrome d. Hyperimmunoglobulinemia E syndrome
d
The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication? a. Re-fracture of the hip b. Contracture of the hip c. Avascular necrosis of the hip d. Dislocation of the hip
a (only use water based lubricant)
The nurse is instructing a male client about safer sexual behaviors. Which client statement indicates a need for additional instruction? a. "I will apply baby oil to lubricate the condom." b. "I should use a new condom each time I have sex." c. "My partner and I should avoid manual-anal intercourse." d. "After having sex, I should hold onto the condom when pulling out."
d
The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond? a. "Your child may die without proper medication and treatment." b. "Selective immunoglobulin A deficiency is the term used to describe the early stages of AIDS." c. "If left untreated, selective immunoglobulin A deficiency can cause uncontrolled muscle movements with progressive neurologic deterioration." d. "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."
a (causes condensation and damp skin)
Which would be contraindicated as a component of self-care activities for the client with a cast? a. Cover the cast with plastic to insulate it b. Cushioning rough edges of the cast with tape c. Elevate the casted extremity to heart level frequently d. Do not attempt to scratch the skin under a cast
c
While the nurse is performing a physical assessment, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. What should this assessment indicate to the nurse? a. Morton's neuroma b. Dupuytren's contracture c. Carpal tunnel syndrome d. Impingement syndrome
