final medsurg
Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply. 1 Turgor of tissue 2 Edema of the ankles 3 Specific gravity of urine 4 Amount of urinary output 5 Texture of mucous membranes
1 Turgor of tissue 5 Texture of mucous membranes
Which client is observed for hemorrhage and infection as a nursing safety priority? 1 Client A 2 Client B 3 Client C 4 Client D
1 Client A
A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Tomato juice, raisin bran cereal, and tea 3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee
3 Applesauce, cream of wheat, and apple juice
A client is diagnosed with a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report what kind of stools? 1 Frothy 2 Ribbon shaped 3 Pale or clay colored 4 Dark brown or black
4 Dark brown or black
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? 1 Nervousness and tachycardia 2 Erythema toxicum rash and pruritus 3 Diaphoresis and altered mental state 4 Deep respirations and fruity odor to the breath
4 Deep respirations and fruity odor to the breath
A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question? 1 Malignant growth 2 Pocket of undigested food particles 3 Sac filled with pus from necrotic pancreatic tissue 4 Walled-off space of pancreatic enzymes and exudate
4 Walled-off space of pancreatic enzymes and exudate
A client with colon cancer is receiving hospice care at home. What is the focus of hospice care? 1 To ease the pain from illness 2 To provide curative treatment 3 To assist with activities of daily living 4 To adapt to the limitations due to illness
1 To ease the pain from illness
The nurse reviews the thyroid profiles of four clients. Which client's finding indicates the possibility of a thyroid tumor? 1 Client A 2 Client B 3 Client C 4 Client D
2 Client B
After a teaching session, the nurse evaluates the client's understanding of hypoparathyroidism. Which statement made by the client indicates the need for further education? 1 "I should eat an orange a day." 2 "I should include yogurt in my diet." 3 "I should perform mild exercises daily." 4 "I should sit outside in the sun."
2 "I should include yogurt in my diet."
A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition? 1 Everolimus 2 Azathioprine 3 Mycophenolate acid 4 Methylprednisolone
4 Methylprednisolone
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. 1 These seizures are associated with amnesia. 2 These seizures increase the risk of injuries due to fall. 3 These seizures are most resistant to drug therapy. 4 These seizures are preceded by perception of an offensive smell. 5 These seizures cause one sided movement of extremities in the client.
2 These seizures increase the risk of injuries due to fall. 3 These seizures are most resistant to drug therapy.
A nurse is reviewing the laboratory reports of four clients. Which client most likely has rheumatoid arthritis? 1 Client A 2 Client B 3 Client C 4 Client D
4 Client D
A client climbing a mountain experiences symptoms of acute mountain sickness. What is the priority nursing action performed by the nurse as prehospital care? 1 Administering acetazolamide 2 Administering dexamethasone 3 Providing oxygen mask to the client 4 Having the client descend to lower altitude
4 Having the client descend to lower altitude
Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? 1 Delayed reaction 2 Cytotoxic reaction 3 Immediate reaction 4 Immune complex-mediated reaction
4 Immune complex-mediated reaction
A nurse is reviewing the laboratory reports of four clients. Which client may have peptic ulcer disease? 1 A 2 B 3 C 4 D
2 B
The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition? 1 Drinking lots of water 2 Eating high-fiber foods 3 Bending over at the waist 4 Bending knees when lowering body
3 Bending over at the waist
Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? 1 Pulse rate 2 Blood pressure 3 Respiratory rate 4 Body temperature
3 Respiratory rate
The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? 1 Positive Kernig sign 2 Glasgow coma score: 10 3 Absence of nuchal rigidity 4 Negative Brudzinski sign
1 Positive Kernig sign
A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority? 1 Stop administration of meperidine. 2 Administer transdermal scopolamine. 3 Administer oxygen through facial mask. 4 Monitor respiratory status and sedation level.
1 Stop administration of meperidine.
A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? 1 Constipation 2 Muscle spasms 3 Hypoactive reflexes 4 Increased specific gravity
2 Muscle spasms
The nurse is caring for four clients with hypersensitivity reactions. Which client should the nurse suspect to have a type IV hypersensitive reaction? 1 Client A 2 Client B 3 Client C 4 Client D
4 Client D
For two months a client has been taking nonprescription medications and has made dietary changes for symptoms of gastritis. Following assessment by a primary healthcare provider, a diagnosis of extensive carcinoma of the stomach is made. The client asks how the disease got so advanced. On which information about carcinoma of the stomach should the nurse base a response? 1 Presents symptoms of severe pain for the client when in the early stages of the disease process 2 Is a risk factor for clients who have an absence of pylori in the stomach 3 Usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4 Often is diagnosed late because symptoms are nonspecific during the early stages
4 Often is diagnosed late because symptoms are nonspecific during the early stages
Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. 1 Impaired memory 2 Intolerance to cold 3 Difficulty breathing 4 Decreased blood pressure 5 Decreased body temperature
2 Intolerance to cold 5 Decreased body temperature
A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply. 1 High fat 2 Low sodium 3 High vitamins 4 Moderate protein 5 Low carbohydrates
2 Low sodium 3 High vitamins 4 Moderate protein
What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply. 1 Cytokines 2 Mast cells 3 Histamines 4 Neutrophils 5 Leukotrienes
2 Mast cells 3 Histamines 5 Leukotrienes
A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply. 1 Nausea A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply. 1 Nausea 2 Melena 3 Purpura 4 Diarrhea 5 Hematuria
2 Melena 3 Purpura 5 Hematuria
The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? 1 Prolonged exhalation to decrease air trapping 2 Shortened inhalation to reduce bronchial swelling 3 Increased respiratory rate to improve arterial oxygenation 4 Decreased use of diaphragm to increase amount of inspired air
Prolonged exhalation to decrease air trapping
A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1 "When was your last drink of vodka?" 2 "What prompts your drinking episodes?" 3 "Do you also eat when you drink?" 4 "Why do you mix the vodka with orange juice?"
1 "When was your last drink of vodka?"
One week after being hospitalized for an acute myocardial infarction, a client reports loss of appetite and feeling nauseated. Which of the client's prescribed medications should be withheld and the healthcare provider notified? 1 Digoxin 2 Propranolol 3Furosemide 4 Spironolactone
1 Digoxin
A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide and digoxin. What does the nurse determine is the cause of the depletion? 1 Diuretic therapy 2 Sodium restriction 3 Continuous dyspnea 4 Inadequate oral intake
1 Diuretic therapy
A client with a parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the client's clinical manifestations? 1 Hypercalcemia 2 Hypernatremia 3 Hypermagnesemia 4 Hyperphosphatemia
1 Hypercalcemia
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? 1 Intravenous administration of regular insulin 2 Administer insulin glargine subcutaneously at hour of sleep 3 Maintain nothing prescribed orally (NPO) status 4 Intravenous administration of 10% dextrose
1 Intravenous administration of regular insulin
A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? 1 Preventing falls 2 Monitoring electrolytes 3 Administering antiemetics 4 Adjusting the diuretic therapy
1 Preventing falls
Which electrolyte deficiency triggers the secretion of renin? 1 Sodium 2 Calcium 3 Chloride 4 Potassium
1 Sodium
What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. 1 The test involves the administration of a contrast medium. 2 Clients should have their hydration levels assessed. 3 Clients are instructed to lie still on a hard table. 4 Clients are served shellfish before the test. 5 A client's serum creatinine level is evaluated after the test.
1 The test involves the administration of a contrast medium. 2 Clients should have their hydration levels assessed. 3 Clients are instructed to lie still on a hard table.
After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. What will the urine specimen be tested for? 1 Specific gravity 2 Free hemoglobin 3 Carboxyhemoglobin 4 Disseminated intravascular coagulation (DIC)
2 Free hemoglobin
Which group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas? 1 Children 2 Older adults 3 Young adults 4 Middle-aged persons
2 Older adults
The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular
2 Wheezes
Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1 Serum sodium of 139 mEq/L (139 mmol/L) 2 Serum chloride of 100 mEq/L (100 mmol/L) 3 Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4 Serum potassium of 7.2 mEq/L (7.2 mmol/L)
4 Serum potassium of 7.2 mEq/L (7.2 mmol/L)
A client is diagnosed as having kidney failure. During the oliguric phase, what should the nurse assess for in this client? 1 Hypothermia 2 Hyperphosphatemia 3 Hypocalcemia 4 Hypernatremia
2 Hyperphosphatemia
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. 1 Vomiting 2 Irritability 3 Hypotension 4 Increased respirations 5 Decreased level of consciousness
1 Vomiting 2 Irritability 5 Decreased level of consciousness
During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. 1 Croup 2 Atelectasis 3 Cystic fibrosis 4 Bronchospasm 5 Pulmonary edema
2 Atelectasis 5 Pulmonary edema
A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply. 1 Taste 2 Breathing 3 Heart rate 4 Fluid balance 5 Voluntary movement
2 Breathing 3 Heart rate
A nurse is reviewing laboratory results from several clients. Based on the given data, which client will most likely have a diagnosis of hyperthyroidism documented in the medical record? 1 Client A 2 Client B 3 Client C 4 Client D
2 Client B
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? 1 Constriction of the superficial vessels dilates the deep vessels. 2 Constriction of the peripheral vessels increases the force of flow. 3 Dilation of the superficial vessels causes constriction of collateral circulation. 4 Dilation of the peripheral vessels causes reflex constriction of visceral vessels.
2 Constriction of the peripheral vessels increases the force of flow
A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? 1 Increased respiratory rate 2 Decreased workload of the heart 3 Reduced size of the clot blocking the coronary artery 4 Diminished metabolites within the ischemic heart muscle
2 Decreased workload of the heart
An older client who was found unconscious at home was admitted to the hospital with a fractured hip, renal failure, and dehydration. In the 24 hours since admission, the client has received 3 L of intravenous fluid. The client has also developed hyponatremia. Which element would the nurse conclude is the most likely to have contributed to the client developing hyponatremia? 1 Reduced dietary salt intake 2 Intravenous fluid infusion 3 Potassium reabsorption rate 4 Increased glomerular filtration
2 Intravenous fluid infusion
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia
2 Lethargy
A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. 1 Polyuria 2 Lethargy 3 Hypotension 4 Muscle twitching 5 Respiratory acidosis
2 Lethargy 4 Muscle twitching
What is the immediate nursing intervention for a client experiencing autonomic dysreflexia? 1 Administering an alpha blocker 2 Placing the client in a sitting position 3 Giving nifedipine or nitrate as prescribed 4 Monitoring blood pressure every 15 minutes
2 Placing the client in a sitting position
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? 1 Lessens the client's chest discomfort 2 Restores negative pressure in the pleural space 3 Drains accumulated fluid from the pleural cavity 4 Prevents subcutaneous emphysema in the chest wall
2 Restores negative pressure in the pleural space
A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? 1 The injury results in loss of the reflex arc. 2 The injury is above the sixth thoracic vertebra. 3 There has been a partial transection of the cord. 4 There is a flaccid paralysis of the lower extremities.
2 The injury is above the sixth thoracic vertebra.
A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. 1 Provide a low-fat diet 2Administer analgesics 3 Teach relaxation exercises 4 Encourage walking in the hall 5 Monitor cardiac rate and rhythm 6 Observe for signs of hypercalcemia
2Administer analgesics 3 Teach relaxation exercises 5 Monitor cardiac rate and rhythm
A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? 1 Atropine 2 Epinephrine 3 Amiodarone 4 Sodium bicarbonate
3 Amiodarone
A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis? 1 Client A 2 Client B 3 Client C 4 Client D
3 Client C
On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to? 1 Lymphadenopathy 2 Thrombocytopenia 3 Hypermetabolic status 4Hepatic encephalopathy
3 Hypermetabolic status
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness
3 Leg cramps 5 Muscle weakness
A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate? 1 Nasotracheal suction 2 Mechanical ventilation 3 Naloxone administration 4 Cardiopulmonary resuscitation
3 Naloxone administration
A client with C8 tetraplegia is admitted to the emergency room. The client develops a blood pressure of 80/40 mm Hg, pulse 48 beats/min, and respiratory rate (RR) of 18 breaths/min. The nurse suspects which condition? 1 Autonomic dysreflexia 2 Hemorrhagic shock 3 Neurogenic shock 4 Pulmonary embolism
3 Neurogenic shock
A client's body mass index (BMI) is 31. This client has a history of hyperinsulinemia caused by an intracranial tumor. Which treatment strategies would be beneficial? Select all that apply. 1 Leptin 2 Orlistat 3 Octreotide 4 Metformin 5 Sibutramine
3 Octreotide 4 Metformin
After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.
4 Determine the characteristics of the pain.
Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease? 1 Incisional pain 2 Popliteal pulse rate 3 Degree of hair growth 4 Lower extremity color
4 Lower extremity color
A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? 1 Mannitol 2 Dexamethasone 3 Chlorpromazine 4 Morphine
4 Morphine
While performing a respiratory assessment of a client with pneumonia, a nurse hears these sounds. What should the nurse document in the client's medical record? 00:00/00:16 1 Rhonchi 2 Fine crackles 3 Coarse crackles 4 Pleural friction rubs
4 Pleural friction rubs
Which carcinoma is the most common type of thyroid cancer and is most often found in younger women? 1 Papillary carcinoma 2 Follicular carcinoma 3 Medullary carcinoma 4 Anaplastic carcinoma
1 Papillary carcinoma
The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition? 1 1 mEq/L (1 mmol/L) serum lithium levels 2 3 mEq/L (3 mmol/L) serum lithium levels 3 135 mEq/L (135 mmol/L) serum sodium levels 4 140 mEq/L (140 mmol/L) serum sodium levels
2 3 mEq/L (3 mmol/L) serum lithium levels
To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? 1 A change in the respiratory rate 2 A tingling sensation in the hands 3 Periodic changes in the fetal heart rate 4 A pulse oximetry reading of less than 98%
2 A tingling sensation in the hands
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor
1 Mental confusion 4 Flapping hand tremors 5 Musty, sweet breath odor
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? 1 Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques 2 Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion 3 Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture 4 Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes
1 Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
After assessing a client with rheumatoid arthritis, the nurse suspects Sjögren's syndrome. Which manifestations are consistent with Sjögren's syndrome? Select all that apply. 1 Iritis 2 Scleritis 3 Xerostomia 4 Baker's cyst 5 Keratoconjunctivitis sicca
3 Xerostomia 5 Keratoconjunctivitis sicca
The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply. 1 "I should assess for low blood pressure." 2 "I should assess for increased digitalis toxicity." 3 "I should assess for a decreased rate of ventilation in respiratory alkalosis." 4 "I should assess for an increased depth of ventilation in respiratory alkalosis." 5 "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."
1 "I should assess for low blood pressure." 2 "I should assess for increased digitalis toxicity." 3 "I should assess for a decreased rate of ventilation in respiratory alkalosis."
A nurse is caring for four clients. Which client is at a risk of meningitis, hearing loss, and generalized paresis? 1 A 2 B 3 C 4 D
1 A
Which neurologic manifestation in a client is associated with hyperthyroidism? 1 Confusion 2 Hearing loss 3 Tremors 4 Slowness of speech
3 Tremors
A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? 1 Encourage the client to slow the breathing rate. 2 Auscultate the client's lungs and suction if indicated. 3Advise the healthcare provider that the client needs supplemental oxygen. 4 Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.
4 Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.
A healthcare provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? 1 Only at bedtime, when famotidine is not taken 2 Only if famotidine is ineffective 3 At the same time as famotidine, with a full glass of water 4 One hour before or 2 hours after famotidine
4 One hour before or 2 hours after famotidine
Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1 Flaccid paralysis and numbness 2 Absence of sweating and pyrexia 3 Escalating tachycardia and shock 4 Paroxysmal hypertension and bradycardia
4 Paroxysmal hypertension and bradycardia
Which concentration of a client's serum calcium level will stimulate the release of parathyroid hormone? 1 8.5 mg/dL (0.47 mmol/L) 2 9.0 mg/dL (0.5 mmol/L) 3 9.5 mg/dL (0.53 mmol/L) 4 10.0 mg/dL (0.56 mmol/L)
1 8.5 mg/dL (0.47 mmol/L)
A client is seen in the clinic with sickle cell crisis. Which hemoglobin range will the nurse expect to find? 1 6-8 g/100 mL (60-80 mmol/L) 2 10-12 g/100 mL (100-120 mmol/L) 3 12-14 g/100 mL (120-140 mmol/L) 4 16-18 g/100 mL (160-180 mmol/L)
1 6-8 g/100 mL (60-80 mmol/L)
The nurse is assessing four clients in a healthcare setting who have respiratory disorders. Which client's findings indicate possible metabolic acidosis? 1 Client 1 2 Client 2 3 Client 3 4 Client 4
3 Client 3
A client who is suspected of having leukemia has a bone marrow aspiration. What should the nurse do Immediately after the procedure? 1 Apply brief pressure to the site. 2 Have the client lie on the affected side. 3 Swab the site with an antiseptic solution. 4 Monitor vital signs every hour for 4 hours.
1 Apply brief pressure to the site.
The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply. 1 Chills 2 Urticaria 3 Hypotension 4 Tachycardia 5 Bronchospasm 6 Sense of impending doom
1 Chills 3 Hypotension 4 Tachycardia
The registered nurse (RN) is caring for four different post-surgical clients. Which activity delegated to the licensed practical nurse (LPN) would be appropriate to achieve a suitable care outcome? Select all that apply. 1 Client 1 2 Client 2 3 Client 3 4 Client 4 5 Client 5
1 Client 1 2 Client 2 5 Client 5
A client with hypertension is scheduled for a scan and electrolyte studies. During an interview with the nurse, the client exclaims, "I don't know why I just can't get a prescription for high blood pressure pills; that probably is all it is. I'm missing work by being here." Which is the best response by the nurse? 1 "It might not be high blood pressure. We have to be sure." 2 "It's frustrating to miss work and not know for sure what's wrong." 3 "I know it's frustrating, but you need to have a diagnostic workup." 4 "Maybe you could ask your primary healthcare provider if the tests could be done on separate days."
2 "It's frustrating to miss work and not know for sure what's wrong."
A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mcg/L. Which action should the nurse take? 1 Hold the medication and notify the healthcare provider. 2 Administer the next dose of the medication as prescribed. 3 Hold the next dose and then resume administration as prescribed. 4 Call the healthcare provider to obtain a prescription with an increased dose.
2 Administer the next dose of the medication as prescribed.
The healthcare team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse? 1 Placing a Foley catheter 2 Assessing the respirations 3 Placing an intravenous (IV) catheter 4 Administering patient-controlled analgesia
2 Assessing the respirations
The parents of a school-aged child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse? 1 "Radiation retards the growth of cells in the bone marrow of the cranium." 2 "This therapy decreases cerebral edema and prevents increased intracranial pressure." 3 "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." 4 "Neoplastic drug therapy without radiation is effective in most cases, but this is a precautionary treatment."
3 "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain."
A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas? 1 Maintain the gastric pH at a level less than 3.5. 2 Encourage the resumption of activities of daily living. 3 Administer the histamine H2-receptor antagonist as prescribed. 4 Ensure that the nasogastric tube remains in the fundus of the stomach.
3 Administer the histamine H2-receptor antagonist as prescribed.
While caring for different clients with respiratory problems, the nurse assesses the different alterations in the breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration? 1 Client 1 2 Client 2 3 Client 3 4 Client 4
3 Client 3
A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is prescribed by the healthcare provider. Which response does the nurse expect when using a room temperature irrigating solution? 1 Coagulation of blood 2 Neutralization of acids 3 Constriction of blood vessels 4 Stimulation of the vagus nerve
3 Constriction of blood vessels
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? 1 "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2 "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3 "It decreases the need for immobility because it clears toxins in short and intermittent periods." 4 "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
4 "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? 1 Initiate pulmonary hygiene to clear air passages of trapped mucus 2 Instruct to deep breathe slowly with inhalation longer than exhalation 3 Encourage continuous rapid panting to promote respiratory exchange 4 Administer oxygen at a low concentration to maintain respiratory drive
4 Administer oxygen at a low concentration to maintain respiratory drive
The nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction? 1 Client A 2 Client B 3 Client C 4 Client D
1 Client A
Given below in the table are the conditions of four different clients.Which client's care should be delegated to unlicensed assistive personnel (UAP) to achieve effective outcomes in the care? 1 Client A 2 Client B 3 Client C 4 Client D
1 Client A
The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority? 1 Client A 2 Client B 3 Client C 4 Client D
1 Client A
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products
1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
The nurse is providing education to a client with systemic lupus erythematosus. Which education will the nurse consider as high priority? 1 Instructing about ways to protect the skin 2 Helping the client to identify coping strategies 3 Teaching methods to monitor body temperature 4 Teaching about the effects of the disease on lifestyle
1 Instructing about ways to protect the skin
Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? 1 Lowering of the T wave 2 Elevation of the ST segment 3 Shortening of the QRS complex 4 Increased deflection of the Q wave
1 Lowering of the T wave
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse's best response? 1 "They stimulate prothrombin production." 2 "They aid absorption of fat-soluble vitamins." 3 "They promote bilirubin secretion in the urine." 4 "They help the common bile duct contract stronger."
2 "They aid absorption of fat-soluble vitamins."
During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition? 1 Using stool softeners 2 Blowing the nose and sneezing 3 Performing deep-breathing exercises 4 Bending the knees and lowering the body to pick up objects
2 Blowing the nose and sneezing
The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1 Pruritus 2 Sedation 3 Constipation 4 Respiratory rate 5 Nausea and vomiting
2 Sedation 4 Respiratory rate
A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment? 1 Increased urinary output 2 Tender mass in the left upper abdomen 3 Elevated erythrocytes, platelets, and granulocytes 4 Polydipsia, increased appetite, and urinary frequency
2 Tender mass in the left upper abdomen
A client with type 1 diabetes of long duration takes NPH insulin 70% and regular insulin 30% every morning. At 11:30 am, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 pm, the client's serum glucose level drops to 30 mg/dL (1.7 mmol/L), and insulin coma is diagnosed. To what factor does the nurse attribute the reason for the development of acute hypoglycemia? 1 Because the client did not eat lunch, glycogenolysis increased after the client took the morning insulin. 2 Because of the stress brought on by the chest pain, the use of serum glucose available to the client increased. 3 Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly. 4 Because of long-term use of insulin, the client's body became sensitive to the insulin dose, causing blood glucose levels to drop erratically.
3 Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly.
A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? 1 Chronic pain 2 Risk for injury 3 Electrolyte imbalance 4 Inadequate gas exchange
3 Electrolyte imbalance
Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which should the nurse monitor for when assessing for this complication? 1 Pallor and cyanosis 2 Dyspnea on exertion 3 Elevated hemoglobin 4 Decreased hematocrit
3 Elevated hemoglobin
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. 1 Fever 2 Diarrhea 3 Headache 4 Hematuria 5 Ecchymosis
3 Headache 4 Hematuria 5 Ecchymosis
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed? 1 Traditional phenothiazine 2 Judicious use of antipsychotics 3 Intramuscular injections of thiamine 4 Oral administration of chlorpromazine
3 Intramuscular injections of thiamine
A client is admitted to the hospital for acute pancreatitis. The nurse obtains the client's vital signs, performs a physical assessment, and reviews the client's health history. What is the priority intervention by the nurse? 1 Reduce environmental stimuli. 2 Continue to monitor the client's vital signs. 3 Institute constant observation of the client. 4 Assess the client for alcohol withdrawal symptoms.
4 Assess the client for alcohol withdrawal symptoms.
The nurse is caring for a client who is diagnosed with diabetes insipidus and is on intranasal desmopressin acetate (DDAVP). The client develops an upper respiratory tract infection during a hospital stay. Which alteration does the nurse anticipate in the client's prescription? 1 Cessation of DDAVP administration 2 Reduced DDAVP dose via oral route 3 Reduced DDAVP dose via subcutaneous route 4 Continuation of DDAVP administration via nasal route
3 Reduced DDAVP dose via subcutaneous route
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Respiratory acidosis
A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine
3 Respiratory and urinary
Which joint surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)? 1 Osteotomy 2 Arthrodesis 3 Synovectomy 4 Debridement
3 Synovectomy
A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? 1 Omit the 9:00 AM dose of the drug. 2 Give the same dosage of the drug rectally. 3 Administer the drug with 30 mL of water at 9:00 AM. 4 Ask the healthcare provider to prescribe an alternate route of administration.
4 Ask the healthcare provider to prescribe an alternate route of administration.
The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition? 1 Potassium 8 mEq/L 2 Hemoglobin 10 g/dL 3 Phosphorous 7 mg/dL 4 Bicarbonate 15 mEq/L
4 Bicarbonate 15 mEq/L
