Med surg exam 3 practice questions

The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A. Sickle cell disease B. Hemophilia C. Megaloblastic anemia D. Thrombocytopenia

Megaloblastic anemia

A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care? A. Risk for disuse syndrome related to ineffective peripheral circulation B. Functional urinary incontinence related to urethral occlusion C. Ineffective tissue perfusion related to thrombosis D. Ineffective thermoregulation related to hypothalamic dysfunction

Ineffective tissue perfusion related to thrombosis

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation? A. Eosinophils B. Red blood cells C. Lymphocytes D. Neutrophils

Neutrophils

The public health nurse is presenting a health promotion class to a group at a local community center. Which intervention most directly addresses the leading cause of cancer deaths in North America? A. Monthly self-breast exams B. Smoking cessation C. Annual colonoscopies D. Monthly testicular exams

Smoking cessation

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? A. The client's next of kin B. The client's spouse C. The client D. The surgeon

The client

A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment? A. Hypovolemia B. Vitamin B 12 deficiency C. Thrombocytopenia D. Iron overload

Iron overload

A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location? A. Spleen B. Kidneys C. Bone marrow D. Liver

Bone marrow

A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. A. Facilitate lung function testing. B. Assess breath sounds. C. Measure the client's oxygen saturation by oximeter. D. Monitor the client's respiratory pattern. E. Assess the client's respiratory rate.

Assess breath sounds. Measure the client's oxygen saturation by oximeter. Monitor the client's respiratory pattern. Assess the client's respiratory rate.

A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate? A. Help the client to sit, with head lowered below knees. B. Administer supplementary oxygen by nasal prongs. C. Obtain a full set of vital signs. D. Inform a health care provider or other primary care provider.

Help the client to sit, with head lowered below knees

The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance? A. Plasminogen B. Hemoglobin C. Hematocrit D. Fibrin

Hemoglobin

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period? A. Hyperglycemia B. Azotemia C. Falls D. Infection

Infection

A client is being discharged home after mastoid surgery. What topic should the nurse address in the client's discharge education? A. Expected changes in facial nerve function B. The need for audiometry testing every 6 months following recovery C. Safe use of analgesics and antivertiginous agents D. Appropriate use of over-the-counter (OTC) ear drops

Safe use of analgesics and antivertiginous agents

A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A. Folic acid B. Vitamin B12 C. Lactulose D. Magnesium sulfate

Vitamin B12

The nurse should recognize the greatest risk for the development of blindness in which of the following clients? A. A 58-year-old Caucasian woman with macular degeneration B. A 28-year-old Caucasian man with astigmatism C. A 58-year-old black woman with hyperopia D. A 28-year-old black man with myopia

A 58-year-old Caucasian woman with macular degeneration

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? A. A 74-year-old client with a low body mass index B. A 17-year-old client with traumatic injuries C. A 45-year-old client having an abdominal hysterectomy D. A 13-year-old client undergoing craniofacial surgery

A 74-year-old client with a low body mass index

A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia? A. A 50-year-old black woman who is going through menopause B. An 81-year-old woman who has chronic heart failure C. A 48-year-old man who travels extensively and has a high-stress job D. A 13-year-old girl who has just experienced menarche

An 81-year-old woman who has chronic heart failure

A nurse is reviewing a client's medication administration record in an effort to identify drugs that may contribute to the client's recent immunosuppression. What drug is most likely to have this effect? A. An antibiotic B. A nonsteroidal anti-inflammatory drug (NSAID) C. An antineoplastic D. An antiretroviral

An antineoplastic

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? A. Specialized cells recognize and ingest cells that are recognized as foreign. B. T lymphocytes are assisted by cytokines to fight infection. C. Lymphocytes are stimulated to become cells that attack microbes directly. D. Antibodies are made by B lymphocytes in response to a specific antigen.

Antibodies are made by B lymphocytes in response to a specific antigen

A nurse is educating a client about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A. Stem cell differentiation B. Cytokine production C. Phagocytosis D. Antibody production

Antibody production

A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A. The cellular immune response B. Apoptosis C. Phagocytosis D. Opsonization

Apoptosis

A nurse is providing discharge education to a client who has recently been diagnosed with a bleeding disorder. Which topic should the nurse prioritize when teaching this client? A. Avoiding buses, subways, and other crowded, public sites B. Avoiding activities that carry a risk for injury C. Keeping immunizations current D. Avoiding foods high in vitamin K

Avoiding activities that carry a risk for injury

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A. Rinsing the ears with normal saline after swimming B. Avoiding loud environmental noises C. Instilling antibiotic ointments on a regular basis D. Avoiding the use of cotton swabs

Avoiding the use of cotton swabs

The nurse is performing an initial assessment of a 75-year-old client who has just relocated to the long-term care facility. During the nurse's interview with the client, the client admits drinking around 600 mL (20 oz) of vodka every evening. What types of cancer does this put the client at risk for? Select all that apply. A. Malignant melanoma B. Brain cancer C. Breast cancer D. Esophageal cancer E. Liver cancer

Breast cancer Esophageal cancer Liver cancer

A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed type (type IV)

Cytotoxic (type II)

A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by which cells? A. Suppressor T cells B. Memory T cells C. Cytotoxic T cells D. Complement T cells

Cytotoxic T cells

A nurse educator is developing a care plan concerning a risk of infection related to vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan? A. Transient ischemic attack (TIA) B. Major burns C. Chronic obstructive pulmonary disease (COPD) D. Diabetes

Diabetes

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. A. Establishing an IV line B. Verifying the surgical site with the client C. Taking measures to ensure the client's comfort D. Applying a grounding device to the client E. Preparing the medications to be given in the OR

Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort

The nurse is planning the care of a client who has type 1 diabetes and who will be undergoing knee replacement surgery. This client's care plan should reflect an increased risk of what postsurgical complication(s)? Select all that apply. A. Hypoglycemia B. Delirium C. Acidosis D. Glucosuria E. Fluid overload

Hypoglycemia Acidosis Glucosuria

The nurse is caring for a client who is to begin receiving external radiation for a malignant tumor of the neck. While providing client education, what potential adverse effects should the nurse discuss with the client? A. Impaired nutritional status B. Cognitive changes C. Diarrhea D. Alopecia

Impaired nutritional status

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? A. Teach the client strategies for distraction. B. Pair the client with another client who has better coping strategies. C. Incorporate cultural and religious considerations, as appropriate. D. Give the client antianxiety medication.

Incorporate cultural and religious considerations, as appropriate

A client's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client's immunity? A. Humoral immune function B. Antigen recognition C. Cell-mediated immune function D. Antibody production

Cell-mediated immune function

A client with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. Which immune response predominates in this situation? A. Humoral B. Nonspecific C. Cellular D. Antibody

Cellular

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this client be taught about this diagnosis? Select all that apply. A. Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B. Cholesteatomas are usually the result of metastasis from a distant tumor site. C. Cholesteatomas are often the result of chronic otitis media. D. Cholesteatomas, if left untreated, result in intractable neuropathic pain. E. Cholesteatomas usually must be removed surgically.

Cholesteatomas are often the result of chronic otitis media Cholesteatomas usually must be removed surgically

A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a fever and a new onset of fine crackles on lung auscultation. Which action by the nurse would be the most appropriate? A. Apply supplementary oxygen by nasal cannula. B. Administer bronchodilators by nebulizer. C. Liaise with the respiratory therapist and consider high-flow oxygen. D. Inform the health care provider that the client may have an infection.

Inform the health care provider that the client may have an infection

The operating room nurse will be caring for a client who will receive a transsacral block. The use of a transsacral block for pain control would be most appropriate for a client undergoing which procedure? A. Thoracotomy B. Inguinal hernia repair C. Reduction mammoplasty D. Closed reduction of a right humerus fracture

Inguinal hernia repair

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A. Ossiculoplasty B. Insertion of a cochlear implant C. Stapedectomy D. Insertion of a ventilation tube

Insertion of a ventilation tube

A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Instill the medication in the conjunctival sac. B. Maintain a supine position for 10 minutes after administration. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Apply the medication evenly to the sclera

Instill the medication in the conjunctival sac

A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. Which education should the nurse prioritize? A. Scheduling appointments for the same time each month B. Keeping appointments for desensitization procedures C. Avoiding antihistamines for the duration of treatment D. Keeping a diary of reactions to the immunotherapy

Keeping appointments for desensitization procedures

A nurse who works in an oncology clinic is assessing a client who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the client's skin appears yellow. Which blood tests should be done to further explore this clinical sign? A. Liver function tests (LFTs) B. Complete blood count (CBC) C. Platelet count D. Blood urea nitrogen and creatinine

Liver function tests (LFTs)

During a routine mammogram, a client asks the nurse whether breast cancer causes the most deaths. Which type of cancer is the leading cause of death in the United States? A. Colorectal B. Prostate C. Lung D. Breast

Lung

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? a. Encourage light ambulation. b. Place the bed in a low position with the side rails up. c. Tell the client that he will be asleep before he leaves for surgery. d. Take the client's vital signs every 15 minutes.

Place the bed in a low position with the side rails up

A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? A. Plasma cells B. Neutrophils C. Red blood cells D. Platelets

Plasma cells

A client's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A. Plasminogen B. Thrombin C. Prothrombin D. Plasmin

Plasmin

A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care? A. Reduced concentration related to stress B. Delayed growth and development due to a prolonged hospitalization C. Decision conflict related to discharge planning D. Pneumonia due to reduced respiratory reserve

Pneumonia due to reduced respiratory reserve

Which nursing action best demonstrates primary cancer prevention? A. Encouraging yearly Pap tests B. Teaching testicular self-examination C. Promoting and providing vaccines D. Facilitating screening mammograms

Promoting and providing vaccines

A woman with a family history of breast cancer received a positive result on a breast tumor marking test and is requesting a bilateral mastectomy. This surgery is an example of which type of oncologic surgery? A. Salvage surgery B. Palliative surgery C. Prophylactic surgery D. Reconstructive surgery

Prophylactic surgery

The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and the caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply. A. Provide all discharge instructions in writing. B. Provide the surgeon's contact information. C. Give prescriptions to the client. D. Irrigate the client's incision and perform a sterile dressing change. E. Administer a bolus dose of an opioid analgesic.

Provide all discharge instructions in writing Provide the surgeon's contact information Give prescriptions to the client

A surgical client has been given general anesthesia and is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? A. Rub the client's back. B. Provide for client safety. C. Encourage the client to express feelings. D. Stroke the client's hand.

Provide for client safety

The perioperative nurse knows that the National Client Safety Goals have the potential to improve client outcomes in a wide variety of health care settings. Which of these goals has the most direct relevance to the OR? A. Improve safety related to medication use. B. Reduce the risk of client harm resulting from falls. C. Reduce the incidence of health care-associated infections. D. Reduce the risk of fires.

Reduce the risk of fires

The nurse knows that older clients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A. A more angular bone structure than a younger person B. Reduced ability to adjust rapidly to emotional and physical stress C. Increase susceptibility to hyperthermia D. Impaired ability to decrease one's metabolic rate

Reduced ability to adjust rapidly to emotional and physical stress

A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, reporting the development of a rash shortly after taking the first dose of the drug. Which response by the nurse would be most appropriate? A. Encourage the client to continue with the medication while monitoring the skin condition closely. B. Refer the client to a primary care provider to have the medication changed. C. Arrange for the client to go to the nearest emergency department. D. Encourage the client to take an over-the-counter antihistamine with each dose of the antibiotic.

Refer the client to a primary care provider to have the medication changed

A client's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A. Risk for imbalanced fluid volume related to low albumin B. Risk for infection related to low albumin C. Ineffective tissue perfusion related to low albumin D. Impaired skin integrity related to low albumin

Risk for imbalanced fluid volume related to low albumin

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit? A. Recent completion of radiation therapy for treatment of thyroid cancer B. Routine use of quinine for management of leg cramps C. Allergy to hair coloring and hair spray D. Previous perforation of the eardrum

Routine use of quinine for management of leg cramps

A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity? A. Disease prophylaxis B. Risk reduction C. Secondary prevention D. Tertiary prevention

Secondary prevention

A client has been diagnosed with hearing loss related to damage of the cochlea. What term is used to describe this condition? A. Exostoses B. Otalgia C. Sensorineural hearing loss D. Presbycusis

Sensorineural hearing loss

A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The client has asked if they will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this client most likely undergo? A. Lymphadenectomy B. Needle biopsy C. Open biopsy D. Sentinel node biopsy

Sentinel node biopsy

A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common? A. Sudden change in level of consciousness (LOC) B. Recurrent infections C. Anaphylaxis D. Severe fatigue

Severe fatigue

Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education? A. Infection risks associated with FFP administration B. Physiologic functions of plasma C. Signs and symptoms of a transfusion reaction D. Strategies for managing transfusion-associated anxiety

Signs and symptoms of a transfusion reaction

A client with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A. Risk factors for postoperative cytomegalovirus (CMV) B. Compensating for vision loss for the next several weeks C. Nonpharmacologic pain management strategies D. Signs and symptoms of increased intraocular pressure

Signs and symptoms of increased intraocular pressure

The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A. Respiratory function B. Evidence of decreased tissue perfusion C. Signs and symptoms of infection D. Recent changes in activity tolerance

Signs and symptoms of infection

A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? A. Sit or stand in front of the client when speaking. B. Use exaggerated lip and mouth movements when talking. C. Stand in front of a light or window when speaking. D. Say the client's name loudly before starting to talk.

Sit or stand in front of the client when speaking

A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Spina bifida D. Hypogammaglobulinemia

Spina bifida

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? A. Thyroid gland B. Spleen C. Kidney D. Pancreas

Spleen

A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention? A. Hepatectomy B. Vitamin K administration C. Platelet transfusion D. Splenectomy

Splenectomy

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. A. Absence of pain B. Stable blood pressure C. Ability to tolerate oral fluids D. Sufficient oxygen saturation E. Adequate respiratory function

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention

Surgical intervention

The nurse is providing discharge education for a client with a new diagnosis of Ménière disease. What food should the client be instructed to limit or avoid? A. Sweet pickles B. Frozen yogurt C. Shellfish D. Red meat

Sweet pickles

A nurse is providing care for a client who has a rheumatic disorder. The nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. Which diagnosis is most likely for this client? A. Osteoarthritis (OA) B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Gout

Systemic lupus erythematosus (SLE)

The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. Which aspect of therapeutic communication should the nurse implement? A. Wait for the client to initiate dialogue. B. Avoid making eye contact. C. Give preoperative medications prior to discussion. D. Use a tone that decreases the client's anxiety.

Use a tone that decreases the client's anxiety

A nurse is planning client education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? A. Tinnitus B. Visual changes C. Stomatitis D. Hirsutism

Visual changes

A 5-year-old client has been diagnosed with a severe food allergy. Which instruction should the nurse include when educating the parents about this client's allergy and care? A. Wear a medical identification bracelet. B. Know how to use the antihistamine pen. C. Know how to give injections of lidocaine. D. Avoid live attenuated vaccinations.

Wear a medical identification bracelet

A child goes to the school nurse and reports being unable to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A. Audiometry B. Rinne test C. Whisper test D. Weber test

Whisper test

A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among which group? A. Young adults B. Native Americans/First Nations C. Women D. People of Hispanic descent

Women

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: A. acquired immunity. B. natural immunity. C. phagocytic immunity. D. humoral immunity.

acquired immunity

The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans? A. The nurse should administer a bolus of dextrose IV solution preoperatively. B. The nurse should keep the client NPO for at least 8 hours preoperatively. C. The nurse should initiate a subcutaneous infusion of long-acting insulin. D. The nurse should assess the client's blood glucose levels frequently.

The nurse should assess the client's blood glucose levels frequently

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment? A. Percussion of the client's abdomen B. Palpation of the client's liver C. Auscultation of the client's apical heart rate D. Palpation of the client's lymph nodes

Palpation of the client's lymph nodes

A client with a history of arthritis is being discharged to home after right wrist surgery, and the nurse reviews nonopioid pain relief measures. Which intervention(s) would best address the needs of this client? Select all that apply. A. Paraffin bath B. Nonsteroidal anti-inflammatory drugs (NSAIDs) C. Rolling walker D. Antiepileptic medications E. Splint or brace

Paraffin bath Nonsteroidal anti-inflammatory drugs (NSAIDs) Splint or brace

A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition? A. Natural immunity B. Passive acquired immunity C. Cellular immunity D. Mild hypersensitivity

Passive acquired immunity

The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible? A. Performing documentation B. Estimating the client's blood loss C. Setting up the sterile tables D. Gives the surgeon instruments during surgery

Performing documentation

A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? A. Dermatitis B. Petechiae C. Urticaria D. Alopecia

Petechiae

Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns? A. "All donated blood is treated with antiretroviral medications before it is used." B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C. "HIV was eradicated from the blood supply in the early 2000s." D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

"Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

The nurse is providing health education to the parents of a 3-year-old who has been diagnosed with food allergies. Which statement should the nurse make when teaching this family about the child's health problem? A. "Food allergies are a lifelong condition, but most families adjust well to the necessary lifestyle changes." B. "Consistent use of over-the-counter antihistamines can often help a child overcome food allergies." C. "Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants." D. "Many children outgrow their food allergies in a few years if they avoid the offending foods."

"Many children outgrow their food allergies in a few years if they avoid the offending foods."

A client with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on a medical unit. The nurse observes that the client expresses anger and irritation when the call bell isn't answered immediately. Which response would be the most appropriate? A. "You seem like you're feeling angry. Is that something that we could talk about?" B. "Try to remember that stress can make your symptoms worse." C. "Would you like to talk about the problem with the nursing supervisor?" D. "I can see you're angry. I'll come back when you've calmed down."

"You seem like you're feeling angry. Is that something that we could talk about?"

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? A. "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." B. "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." C. "The presence of food in the stomach interferes with the absorption of anesthetic agents." D. "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

"You will need to have food and fluid restricted before surgery so you are not at risk for aspiration."

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? A. 2 feet (60 cm) B. 18 inches (45 cm) C. 1 foot (30 cm) D. 6 inches (15 cm)

1 foot (30 cm)

The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)? A. Production of inadequate quantities of RBCs B. Premature release of immature RBCs C. Injury to the RBCs in circulation D. Abnormalities in the structure and function of RBCs

Abnormalities in the structure and function of RBCs

The nurse is creating the plan of care for a postoperative client for reduction of a femur fracture. Which goal is the most important short-term goal for this client? A. Relief of pain B. Adequate respiratory function C. Resumption of activities of daily living (ADLs) D. Unimpaired wound healing

Adequate respiratory function

An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A. Ask if the client has been using OTC vasoconstrictors. B. Instruct the client to repeat the test at different times of the day when at home. C. Arrange for the client to visit an ophthalmologist. D. Encourage the client to adhere to prescribed drug regimen.

Arrange for the client to visit an ophthalmologist

The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take? A. Have the client sign the informed consent and place it in the chart. B. Call the health care provider to review the procedure with the client. C. Explain the procedure clearly to the client and the family. D. Provide the client with a pamphlet explaining the procedure.

Call the health care provider to review the procedure with the client

A surgical nurse is preparing to enter the restricted zone of the operating room. Which surgical attire should this nurse wear? Select all that apply. A. Street clothes B. Cap C. Mask D. Shoe covers E. Scrub clothes

Cap Mask Shoe covers Scrub clothes

Following a motorcycle accident, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A. The malleus can be visualized during otoscopic examination. B. The tympanic membrane is pearly gray. C. Tenderness is reported by the client when the mastoid area is palpated. D. Clear, watery fluid is draining from the client's ear.

Clear, watery fluid is draining from the client's ear

Allopurinol has been prescribed for a client receiving treatment for gout. The nurse caring for this client knows to assess the client for bone marrow suppression, which may be manifested by what diagnostic finding? A. Hyperuricemia B. Increased erythrocyte sedimentation rate C. Elevated serum creatinine D. Decreased platelets

Decreased platelets

A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Position the client in high Fowler position B. Discontinue the transfusion. C. Auscultate the client's lungs. D. Obtain a blood specimen from the client.

Discontinue the transfusion

A client being treated for bacterial pneumonia initially experienced dyspnea and a high fever but now claims to be feeling better and is afebrile. The client is most likely in which stage of the immune response? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

Effector stage

A client is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. Which food items would the nurse inform the client are common allergens? A. Citrus fruits and rice B. Root vegetables and tomatoes C. Eggs and wheat D. Hard cheeses and vegetable oils

Eggs and wheat

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? A. The client must not have received an immunization within 7 days. B. The nurse should administer albuterol 30 to 45 minutes prior to the test. C. Prophylactic epinephrine should be given before the test. D. Emergency equipment should be readily available.

Emergency equipment should be readily available

The nurse in the ED is caring for a child brought in by the parents who state that the child will not stop crying and pulling at the child's ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A. External otitis is characterized by aural tenderness. B. External otitis is usually accompanied by a high fever. C. External otitis is usually related to an upper respiratory infection. D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.

External otitis is characterized by aural tenderness

When assessing a postsurgical client's risk for deep vein thrombosis, the nurse should prioritize what assessment parameter? A. Range of motion B. Family history C. Blood pressure D. Hydration status

Hydration status

The PACU nurse is caring for an adult client who had a left lobectomy. The nurse is assessing the client frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A. Hypotension B. Hypervolemia C. Heart murmurs D. Dysrhythmias E. Hypertension

Hypotension Dysrhythmias Hypertension

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? A. Hypothermia B. Pulmonary edema C. Cerebral ischemia D. Arthritis

Hypothermia

The nurse educating a client with anemia is describing the process of red blood cell production. When the client's kidneys sense a low level of oxygen in circulating blood, which physiologic response is initiated? A. Increased stem cell synthesis B. Decreased respiratory rate C. Arterial vasoconstriction D. Increased levels of erythropoietin

Increased levels of erythropoietin

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications the client takes, along with their dosage and frequency. What intervention provides the client with the most accurate information? A. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. B. Instruct the client to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C. Instruct the client to discontinue levothyroxine sodium due to its effect on blood coagulation and the potential for heart dysrhythmias. D. Instruct the client to continue any herbal supplements unless otherwise instructed, and inform the client that these supplements have a minimal effect on the surgical procedure.

Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents

A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse experiencing a sudden hearing loss. What would the nurse suspect the client's diagnosis will be? A. Ossiculitis B. Ménière disease C. Ototoxicity D. Labyrinthitis

Labyrinthitis

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit? A. Last bowel movement B. Latex allergy C. Number of pregnancies D. Difficulty falling asleep

Latex allergy

Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A. Leukocytes B. Natural killer cells C. Cytokines D. Platelets E. Erythrocytes

Leukocytes Platelets Erythrocytes

The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest nursing priority? A. Assessing for hemorrhage B. Maintaining a patent airway C. Managing the client's pain D. Assessing vital signs every 30 minutes

Maintaining a patent airway

The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment? A. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B. Confusion, restlessness, and agitation are expected postoperative findings in older adults, and they will diminish in time. C. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. D. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss

The nurse is caring for an 88-year-old client who is recovering from an iliac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that the client is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. Which complication should the nurse suspect? A. Postoperative delirium B. Postoperative dementia C. Senile dementia D. Senile confusion

Postoperative delirium

A nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. What goal should the nurse prioritize? A. Maximize range of motion while minimizing exertion. B. Increase joint size and strength. C. Limit energy output in order to preserve strength for healing. D. Preserve or increase range of motion while limiting joint stress.

Preserve or increase range of motion while limiting joint stress

The nurse is doing preoperative client education with a client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? A. Reduce smoking by 50% to prevent the development of pneumonia. B. Continue smoking so as to help manage stress levels before and after surgery. C. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications. D. Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection.

Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection

The nurse is caring for an unconscious trauma client who needs emergency surgery. The client has an adult child, is legally divorced, and is planning to marry a partner in a few weeks. The client's parents are at the hospital with the other family members. The health care provider has explained the need for surgery, the procedure to be done, and the risks to the child, the parents, and the partner. Who should be asked to sign the surgery consent form? A. The partner B. The child C. The health care provider, acting as a surrogate D. The client's father

The child

The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? A. The client may be experiencing presurgical anxiety. B. The client may be at risk for malignant hyperthermia. C. The grandparent's surgery has minimal relevance to the client's surgery. D. The client may be at risk for a sudden onset of postsurgical infection.

The client may be at risk for malignant hyperthermia

A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure? A. lacrimal apparatus B. sclera C. cornea D. pupil

lacrimal apparatus

A nurse is interviewing a middle-aged client at the clinic. During the interview, the client states, "I've noticed that I keep having to move the newspaper farther away to read it. Soon my arms will be too short!" The nurse interprets this finding as indicative of which age-related change? A. loss of accommodation B. shrinkage of the vitreous body C. meibomian gland dysfunction (MBG) D. loss of skin elasticity

loss of accommodation

A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: A. lymphocytes. B. cytoblasts. C. antibodies. D. capillaries.

lymphocytes

A client is being asked to choose between an ambulatory surgical center and a hospital-based surgical unit. What guidance should the nurse provide? A. "Clients who go to ambulatory surgery centers are more independent." B. "Clients admitted to the hospital for surgery usually have multiple health needs." C. "In most cases, only emergency and trauma clients are admitted to the hospital." D. "Clients who have surgery in the hospital are those who need to have anesthesia given."

"Clients admitted to the hospital for surgery usually have multiple health needs."

A nurse provides care on a bone marrow transplant unit and is preparing a client for a hematopoietic stem cell transplantation (HSCT) the following day. Which information should the nurse emphasize to the client's family and friends? A. "Your family should likely gather at the bedside in case there is a negative outcome." B. "Make sure the client doesn't eat any food in the 24 hours before the procedure." C. "Wear a hospital gown when you go into the client's room." D. "Do not visit if you've had a recent infection."

"Do not visit if you've had a recent infection."

The nurse is discharging a client home after mastoid surgery. What should the nurse include in discharge teaching? A. "Try to induce a sneeze every 4 hours to equalize pressure." B. "Be sure to exercise to reduce fatigue." C. "Avoid sleeping in a side-lying position." D. "Don't blow your nose for 2 to 3 weeks."

"Don't blow your nose for 2 to 3 weeks."

The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery? A. "Your nurse will use a pain assessment scale to help rate and treat your pain." B. "Wait to ask for pain medication until the pain becomes intolerable." C. "Lying still in bed will help control your pain." D. "Don't worry—most clients do not have much pain from this surgery."

"Your nurse will use a pain assessment scale to help rate and treat your pain."

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 1 minute C. 3 minutes D. 5 minutes

5 minutes

A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has which type of immune disorder? A. A primary immune deficiency B. A gammopathy C. An autoimmune disorder D. A rheumatic disorder

A primary immune deficiency

A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? A. An increased hemoglobin and decreased hematocrit B. A decreased hemoglobin and hematocrit C. A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) D. An increased mean corpuscular volume (MCV) and red cell distribution width (RDW)

A decreased hemoglobin and hematocrit

A client comes into the clinic reporting fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. Which condition should the nurse most suspect the client has? A. A hypoproliferative anemia B. A leukemia C. Thrombocytopenia D. A hemolytic anemia

A hemolytic anemia

The surgical nurse is caring for a client whose wound is classified as clean contaminated. Which type of wound is the nurse likely to assess? A. A sutured incision without inflammation B. A wound with a drainage system C. A traumatic wound D. An abdominal wound with spillage from intestine

A wound with a drainage system

A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause? A. infection B. otosclerosis C. Meniere disease D. cholesteatoma

infection

A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays reveal no fracture of the extremity. Which factor is the most likely cause of the client's continued swelling? A. Degradation of cartilage B. Aging C. An inflammation process D. Reinjury not seen on x-ray results

An inflammation process

The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? A. Administer the platelets as rapidly as the client can tolerate. B. Establish IV access as soon as the platelets arrive from the blood bank. C. Ensure that the client has a patent central venous catheter. D. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.

Administer the platelets as rapidly as the client can tolerate

An infection control nurse is presenting an in-service reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A. Agglutination B. Cellular immune response C. Humoral response D. Phagocytic immune response

Agglutination

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? A. Heart rate and rhythm B. Skin integrity C. Core body temperature D. Airway patency

Airway patency

The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A. Myocardial muscle tissue B. All body fluids C. Cerebral tissue D. Venous and arterial vessel walls

All body fluids

While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding? A. ptosis B. entropion C. ectropion D. presbyopia

ptosis

A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of which potential effect on the client's immune function? A. Bone marrow suppression B. Uncontrolled apoptosis C. Prostaglandin synthesis inhibition D. Immunosuppression

Bone marrow suppression

A client is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this client is that the client will stop taking the medication as soon as the client starts to feel better. The nurse must emphasize the need for continued adherence to the prescribed medication so that the client can avoid which complication? A. Venous thromboembolism B. Osteoporosis C. Degenerative joint disease D. Blindness

Blindness

A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia

Bone marrow suppression

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A. Consent must be freely given. B. Consent must be notarized. C. Consent must be signed on the day of surgery. D. Consent must be obtained by a health care provider. E. Signature must be witnessed by a professional staff member.

Consent must be freely given Consent must be obtained by a health care provider Signature must be witnessed by a professional staff member

Which intervention should the nurse teach a client who is at risk for hypercalcemia? A. Avoid the use of stool softeners. B. Take laxatives daily. C. Consume 2 to 4 L of fluid daily. D. Restrict calcium intake.

Consume 2 to 4 L of fluid daily

A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A. Ensure that the day nurse knows not to give the antiemetic. B. Contact the prescriber to have the subcutaneous option discontinued. C. Reassess the client's need for antiemetics. D. Remove the subcutaneous route from the client's MAR.

Contact the prescriber to have the subcutaneous option discontinued

The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? A. Constriction of small venules B. Contraction of bronchial smooth muscle C. Dilation of large blood vessels D. Decreased secretions from gastric and mucosal cells

Contraction of bronchial smooth muscle

A client's natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances natural immunity? A. Cell cytoplasm B. Interstitial fluid C. Gastric secretions D. Cerebrospinal fluid

Gastric secretions

A client who was just diagnosed with scleroderma will be undergoing tests to assess for systemic involvement. Which system should the nurse prioritize in assessment? A. Hepatic B. Gastrointestinal C. Genitourinary D. Neurologic

Gastrointestinal

A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor? A. An attack on the platelets by antibodies B. Decreased production of platelets C. Impaired communication between platelets D. An autoimmune process causing platelet malfunction

Decreased production of platelets

A client is undergoing testing to determine the overall function of the client's immune system. Which test will best identify the functioning of the client's cellular immune system? A. Immunoglobulin testing B. Delayed hypersensitivity skin test C. Specific antibody response D. Total serum globulin assessment

Delayed hypersensitivity skin test

A nurse has admitted a client who has been diagnosed with urosepsis. Which immune response predominates in sepsis? A. Mitigated B. Nonspecific C. Cellular D. Humoral

Humoral

A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? A. IgA B. IgM C. IgG D. IgE

IgE

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A. Monitoring the client's physiologic status B. Providing emotional support to family C. Maintaining the client's cognitive status D. Maintaining a clean environment

Monitoring the client's physiologic status

A nurse is planning a client's care and is relating it to normal immune response. During which stage of the immune response do sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

Proliferation stage

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication? A. Sepsis B. Infection C. Pulmonary embolism D. Hematoma

Pulmonary embolism

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? A. Severed blood vessels constrict. B. Thromboplastin is released. C. Prothrombin is converted to thrombin. D. Fibrin is lysed.

Severed blood vessels constrict

A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room? A. That a commode is always available at the bedside B. That all furniture remains in the same position C. That visitors do not leave items on the bedside table D. That the client's slippers stay under the bed

That all furniture remains in the same position

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the client is taken to the preoperative holding area? A. That preoperative teaching was performed B. That the family is aware of the length of the surgery C. That follow-up home care is not necessary D. That the family understands the client will be discharged immediately after surgery.

That preoperative teaching was performed

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days' postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change the dressing. What would indicate to the nurse the client's possible readiness to learn how to change the dressing? Select all that apply. A. The client wants the nurse to teach a family member to do dressing changes. B. The client expresses interest in the dressing change. C. The client is willing to look at the incision during a dressing change. D. The client expresses dislike of the surgical wound. E. The client assists in opening the packages of dressing material for the nurse.

The client expresses interest in the dressing change The client is willing to look at the incision during a dressing change The client assists in opening the packages of dressing material for the nurse

The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.

The client has diabetes

Which of the following circumstances would most clearly warrant autologous blood donation? A. The client has type-O blood. B. The client has sickle cell disease or a thalassemia. C. The client has elective surgery pending. D. The client has hepatitis C.

The client has elective surgery pending

A client underwent an open bowel resection 2 days ago, and the nurse's most recent assessment of the client's abdominal incision reveals that it is dehiscing. Which factor should the nurse suspect may have caused the dehiscence? A. The client's surgical dressing was changed yesterday and today. B. The client has vomited three times in the past 12 hours. C. The client has begun voiding on the commode instead of a bedpan. D. The client used client-controlled analgesia (PCA) until this morning.

The client has vomited three times in the past 12 hours

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should recognize which purpose as a valid reason for preadmission assessment? A. Verifies completion of preoperative diagnostic testing B. Discusses and reviews client's financial status C. Determines the client's suitability as a surgical candidate D. Informs the client of need for postoperative transportation

Verifies completion of preoperative diagnostic testing

The operating room nurse is providing care for a major trauma client who has been involved in a motorcycle accident. Which intraoperative change may suggest the presence of anesthesia awareness? A. Respiratory depression B. Sudden hypothermia and diaphoresis C. Vital sign changes and client movement D. Bleeding beyond what is anticipated

Vital sign changes and client movement

A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote? A. Intravenous immunoglobulins (IVIG) B. Factor IX C. Vitamin K D. Factor VIII

Vitamin K

A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A. When the client is returned to the room after surgery B. When a follow-up evaluation in the clinical or home setting is done C. When the client is fully recovered from all effects of the surgery D. When the family becomes partly responsible for the client's care

When a follow-up evaluation in the clinical or home setting is done

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the client leaves the ED for the OR, the client goes into cardiac arrest. The nurse assists in a successful resuscitation and proceeds to release the client to the OR staff. When can the ED nurse perform the preoperative assessment? A. When the nurse has the opportunity to review the client's electronic health record B. When the client arrives in the OR C. When assisting with the resuscitation D. Preoperative assessment is not necessary in this case

When assisting with the resuscitation

A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy. When conducting this examination, which structure would the nurse expect to be examined last? A. red reflex B. vasculature C. optic disc D. macula

macula

An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A. Stool for occult blood B. Bone marrow biopsy C. Lumbar puncture D. Urinalysis

stool for occult blood

A nurse is preparing a presentation for a group of elementary school parents about ways to promote the health of the ears and hearing in their children. When describing the structure and function of the ears, which structure would the nurse most likely include as part of the middle ear? Select all that apply. A. pinna B. tympanic membrane C. oval window D. cochlea E. organ of Corti

tympanic membrane oval window

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to: A. eat a balanced diet that is high in protein. B. limit activity for the first 72 hours. C. take medications as prescribed. D. use the incentive spirometer every 2 hours.

use the incentive spirometer every 2 hours

A older adult client comes to the clinic for an evaluation. The client says, "It just doesn't seem like I hear as well as I used to hear." As part of the assessment, the nurse evaluates the client's gross auditory acuity. Which test would the nurse most likely conduct? A. whisper test B. Weber test C. Rinne test D. audiometry

whisper test

A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best? A. "I can only imagine how you feel. Would you like to talk about it?" B. "Let's find a quiet spot, and I'll teach you a few coping strategies." C. "That's the same way that most clients who have a chronic illness feel." D. "Do you think that maybe you could be managing things more efficiently?"

"I can only imagine how you feel. Would you like to talk about it?"

A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? A. "I have this ringing in my ears that just won't go away." B. "I feel so foggy in the mornings and it takes me so long to wake up." C. "When I eat a meal that's high in fat, I get really nauseous." D. "I seem to have lost my appetite, which is unusual for me."

"I have this ringing in my ears that just won't go away."

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? A. "I need to call the doctor if I get nauseated." B. "I need to call the doctor if I have a light morning discharge." C. "I need to call the doctor if I get a scratchy feeling." D. "I need to call the doctor if I see flashing lights."

"I need to call the doctor if I see flashing lights."

While on spring break, a 22-year-old client was taken to the hospital for heat stroke and alcohol poisoning. The client is worried and states that a biopsy was taken and showed "some kind of benign condition." Which response by the nurse would be best? A. "I understand that you are worried. Benign conditions are noncancerous, but let's look at your chart to see your results." B. "You have every right to be upset; a benign condition means you may have cancerous cells. Let me call your health care provider to talk to you." C. "Are you sure a biopsy was done? Your admitting diagnosis would not prompt that kind of procedure." D. "Do not worry; if something was wrong, your primary health care provider would have told you and started treatment."

"I understand that you are worried. Benign conditions are noncancerous, but let's look at your chart to see your results."

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client? A. "The dressing change is often painful, so we will give you pain medication beforehand." B. "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." C. "The dressing change should not be painful, but you can never be sure, and infection is always a concern." D. "The best time for a dressing change is during lunch. I will provide privacy, and it should not be painful."

"I will provide privacy. The dressing change should not be painful; you may look at the incision and help."

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."

"I'll make sure to monitor my body temperature on a regular basis."

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A. "I'm planning to avoid exposure to direct sunlight on my next vacation." B. "I've never exercised regularly, but I'm going to start working out at the gym daily." C. "I'm planning to talk with my pharmacist to review my current medications." D. "I'm certainly going to keep a close eye on my blood pressure from now on."

"I'm certainly going to keep a close eye on my blood pressure from now on."

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond? A. "You have a great attitude. This will likely shorten the amount of time that you need medications." B. "In fact, glaucoma usually requires lifelong treatment with medications." C. "Most people are treated until their intraocular pressure goes below 50 mm Hg." D. "You can likely expect a minimum of 6 months of treatment."

"In fact, glaucoma usually requires lifelong treatment with medications."

A presurgical client asks, "Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit?" Which response by the nurse would be best? A. "It allows recovery from anesthesia in a stimulating environment to facilitate awakening and reorientation." B. "It allows us to observe you until you're oriented and have stable vital signs and no complications." C. "The medical-surgical unit is short of beds, and the PACU is an excellent place to triage clients." D. "The surgeon likely will need to reinforce or alter the your incision in the hours following surgery."

"It allows us to observe you until you're oriented and have stable vital signs and no complications."

A client has been scheduled for a bone marrow aspiration and admits to the nurse being worried about the pain involved with the procedure. Which statement by the nurse when providing client education would be most accurate? A. "You'll be given painkillers before the test, so there won't likely be any pain." B. "You'll feel some pain when the needle enters your skin, but none during the aspiration." C. "Most people feel some brief, sharp pain when the marrow is aspirated." D. "I'll be there with you, and I'll try to help you keep your mind off the pain."

"Most people feel some brief, sharp pain when the marrow is aspirated."

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."

"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A client got a sliver of glass in his/her eye when a glass container at work fell and shattered. The glass had to be surgically removed and the client is about to be discharged home. The client asks the nurse for a topical anesthetic for eye pain. What should the nurse respond? A. "Overuse of these drops could soften your cornea and damage your eye." B. "You could lose the peripheral vision in your eye if you used these drops too much." C. "I'm sorry, this medication is considered a controlled substance and clients cannot take it home." D. "I know these drops will make your eye feel better, but I can't let you take them home."

"Overuse of these drops could soften your cornea and damage your eye."

A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. Which response by the nurse educator would be best? A. "The faster the onset of symptoms, the more severe the reaction." B. "The reaction will be about one-third more severe than the client's last reaction to the same antigen." C. "There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past." D. "The reaction will generally be slightly less severe than the last reaction to the same antigen."

"The faster the onset of symptoms, the more severe the reaction."

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? A. "I know I'll be fine because the health care provider has done this procedure hundreds of times." B. "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." C. "The health care provider is going to remove my uterus and told me about the risk of bleeding." D. "Because the health care provider isn't taking my ovaries, I'll still be able to have children."

"The health care provider is going to remove my uterus and told me about the risk of bleeding."

A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young, I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? A. "Newer antihistamines are combined with a stimulant that offsets drowsiness." B. "Most people find that they develop a tolerance to sedation after a few months." C. "The newer antihistamines are different than in years past, and cause less sedation." D. "Have you considered taking them at bedtime instead of in the morning?"

"The newer antihistamines are different than in years past, and cause less sedation.

A 56-year-old client has come to the clinic for a routine eye examination and is told bifocals are needed. The client asks the nurse what change in the eyes has caused this need for bifocals. How should the nurse respond? A. "You know, you are getting older now and we change as we get older." B. "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." C. "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." D. "The eye gets shorter, back to front, as we age and it changes how we see things."

"There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."

The clinic nurse is caring for an adult oncology client who reports extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure this client? A. "These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory studies and test results." B. "These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer." C. "Try not to be concerned about these symptoms. Every client feels this way after having radiation therapy." D. "Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying."

"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory studies and test results."

A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." B. "A platelet transfusion often further blunts your body's own production of platelets." C. "Finding a matching donor for a platelet transfusion is exceedingly difficult." D. "A very small percentage of the platelets in a transfusion are actually functional."

"Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body."

A client with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this client's hematologic disorder? A. "When did you last have a blood transfusion?" B. "What medications have you taken recently?" C. "Have you been under significant stress lately?" D. "Have you suffered any recent injuries?"

"What medications have you taken recently?"

A clinic nurse is conducting a preoperative interview with an adult client who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the client's safety? A. "What prescription and nonprescription medications do you currently take?" B. "Have you previously been admitted to the hospital, either for surgery or for medical treatment?" C. "How long do you expect to be at home recovering after your surgery?" D. "Would you say that you tend to eat a fairly healthy diet?"

"What prescription and nonprescription medications do you currently take?"

A client has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray showed carcinoma. The client reports feeling anxious and asks to smoke. Which statement by the nurse would be most therapeutic? A. "Smoking is the reason you are here." B. "The doctor left orders for you not to smoke." C. "You are anxious about the surgery. Do you see smoking as helping?" D. "Smoking is OK right now, but after your surgery it is contraindicated."

"You are anxious about the surgery. Do you see smoking as helping?"

The nurse is performing wound care on a postsurgical client. Which practice violates the principles of surgical asepsis? A. Holding sterile objects at chest level B. Allowing a sterile instrument to touch a sterile drape C. A circulating nurse touching a sterile drape D. Considering an unopened sterile package to be sterile

A circulating nurse touching a sterile drape

A surgical client has just been admitted to an inpatient nursing unit from the postanesthesia care unit with client-controlled analgesia (PCA). What must the client require for safe and effective use of PCA? A. A clear understanding of the need to self-dose B. An understanding of how to adjust the medication dosage C. A caregiver who can administer the medication as prescribed D. An expectation of infrequent need for analgesia

A clear understanding of the need to self-dose

A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client? A. A client who has previously been treated for tuberculosis B. A client who is at 30 weeks' gestation C. A client who is on estrogen-replacement therapy D. A client with a severe allergy to eggs

A client who is at 30 weeks' gestation

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock

A client who is being treated for septic shock

A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood? A. A client who is 81 years of age B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago D. A client who has type 1 diabetes

A client whose blood pressure is 78/49 mm Hg

The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client with an anaphylactic reaction after a bee sting B. A client with a skin reaction resulting from adhesive tape C. A client with a diagnosis of myasthenia gravis D. A client with rheumatoid arthritis

A client with an anaphylactic reaction after a bee sting

Which of the following individuals would be the most appropriate candidate for immunotherapy? A. A client who had an anaphylactic reaction to an insect sting B. A child with allergies to eggs and dairy C. A client who has had a positive tuberculin skin test D. A client with severe allergies to grass and tree pollen

A client with severe allergies to grass and tree pollen

An adult client with leukemia will soon begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy? A. Administer an antiemetic. B. Administer an antimetabolite. C. Administer a tumor antibiotic. D. Administer an anticoagulant.

Administer an antiemetic

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. A. Absence of reflexes B. Diminished ability to communicate C. Loss of pain sensation D. Nausea resulting from anesthetic E. Reduced blood pressure

Absence of reflexes Diminished ability to communicate Loss of pain sensation

An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed-type (type IV)

Anaphylactic (type 1)

The client's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A. Hypothermia B. Anaphylaxis C. Infection D. Malignant hyperthermia

Anaphylaxis

A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? A. Cytotoxic reaction due to contact with the powder in the gloves B. Immune complex reaction due to contact with anesthetic gases C. Anaphylaxis due to a latex allergy D. Delayed reaction due to exposure to cleaning products

Anaphylaxis due to a latex allergy

A client's health history reveals daily consumption of two to three bottles of wine. The nurse would consider increased risk for which hematologic disorder when planning assessments and interventions for this client? A. Leukemia B. Anemia C. Thrombocytopenia D. Lymphoma

Anemia

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization, which will allow for the release of which type of substance? A. Antibodies B. Antigens C. Cytokines D. Phagocytes

Antibodies

A nurse is caring for a client who has had a severe antigen-antibody reaction. Which portion of the antigen is involved in binding with the antibody? A. Antibody agglutination B. Antigenic message C. Antigenic determinant D. Antibody response

Antigenic determinant

A client is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the client? Select all that apply. A. Application of topical antibiotic ointment B. Maintenance of a supine position for the first 48 hours' postoperative C. Fluid restriction to prevent orbital edema D. Administration of loop diuretics to prevent orbital edema E. Use of an ocular pressure dressing

Application of topical antibiotic ointment Use of an ocular pressure dressing

A client has informed the home health nurse that he/she has recently noticed distortions when looking at the Amsler grid that is mounted on the refrigerator. What is the nurse's most appropriate action? A. Reassure the client that this is an age-related change in vision. B. Arrange for the client to have his/her visual acuity assessed. C. Arrange for the client to be assessed for macular degeneration. D. Facilitate tonometry testing.

Arrange for the client to be assessed for macular degeneration

A client with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the client appears to have lost some ability to function since the last office visit. What is the nurse's most appropriate action? A. Arrange a family meeting in order to explore assisted living options. B. Refer the client to a support group. C. Arrange for the client to be assessed in the home environment. D. Refer the client to social work.

Arrange for the client to be assessed in the home environment

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A. Upon the client's admission to the postanesthesia care unit (PACU) B. When the client returns from the PACU C. During the intraoperative period D. As soon as possible, and before the surgical procedure

As soon as possible, and before the surgical procedure

During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene? A. Ask the social worker to investigate alternative housing arrangements. B. Ask the social worker to investigate community support agencies. C. Encourage the client to explore surgical corrections for the vision problem. D. Arrange for referral to a rehabilitation facility for vision training.

Ask the social worker to investigate community support agencies

A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the client's previous medication regimen may have contributed to the development of this disorder? A. Calcium carbonate B. Vitamin B12 C. Aspirin D. Vitamin D

Aspirin

A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate? A. Encourage the client to focus on use of other senses. B. Assess and promote the client's coping skills during interactions with the client. C. Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. D. Promote the client's hope for recovery.

Assess and promote the client's coping skills during interactions with the client.

A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse? A. Assess for signs and symptoms of anaphylaxis. B. Assess for erythema and urticaria. C. Administer an over-the-counter (OTC) antihistamine. D. Administer epinephrine.

Assess for signs and symptoms of anaphylaxis

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? A. Assess the client's oxygen levels. B. Administer antianxiety medications. C. Page the client's health care provider. D. Initiate a social work referral.

Assess the client's oxygen levels

A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform? A. Have the client identify the blood type in writing. B. Ensure that the client has granted verbal consent for transfusion. C. Assess the client's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

Assess the client's vital signs to establish baselines

A client has just arrived to the floor after an enucleation procedure following a workplace accident in which the client's left eye was irreparably damaged. Which of the following should the nurse prioritize during the client's immediate postoperative recovery? A. Teaching the client about options for eye prostheses B. Teaching the client to estimate depth and distance with the use of one eye C. Assessing and addressing the client's emotional needs D. Teaching the client about his postdischarge medication regimen

Assessing and addressing the client's emotional needs

A client with mastoiditis is admitted to the postsurgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A. Assessing for mouth droop and decreased lateral eye gaze B. Assessing for increased middle ear pressure and perforated ear drum C. Assessing for gradual onset of conductive hearing loss and nystagmus D. Assessing for scar tissue and cerumen obstructing the auditory canal

Assessing for mouth droop and decreased lateral eye gaze

After mastoid surgery, an 81-year-old client has been identified as needing assistance in her home. What would be a primary focus of this client's home care? A. Preparation of nutritious meals and avoidance of contraindicated foods B. Ensuring the client receives adequate rest each day C. Helping the client adapt to temporary hearing loss D. Assisting the client with ambulation as needed to avoid falling

Assisting the client with ambulation as needed to avoid falling

A client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of which health problem? A. Bronchitis B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Asthma

Asthma

The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often? A. At least monthly B. At least once every 2 years C. At least once every 5 years D. At least once every 10 years

At least once every 2 years

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? A. Atelectasis B. Anemia C. Dehydration D. Peripheral edema

Atelectasis

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? A. Stay with the client and promptly notify the health care provider. B. Attempt to determine the cause of hemorrhage. C. Begin resuscitation. D. Put the client in the Trendelenburg position.

Attempt to determine the cause of hemorrhage

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing physical activity and taking OTC iron supplements C. Limiting psychosocial stress and eating a high-protein diet D. Avoiding cold temperatures and ensuring sufficient hydration

Avoiding cold temperatures and ensuring sufficient hydration

The nurse is conducting a health education about cancer prevention to a group of adults. What menu best demonstrates dietary choices for potentially reducing the risks of cancer? A. Smoked salmon and green beans B. Pork chops and fried green tomatoes C. Baked apricot chicken and steamed broccoli D. Liver, onions, and steamed peas

Baked apricot chicken and steamed broccoli

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A. Ensure that clients understand the differences between sensory hearing loss and conductive hearing loss. B. Educate clients about expected age-related changes in hearing perception. C. Educate clients about the risks associated with prolonged exposure to environmental noise. D. Be aware of clients' medication regimens and collaborate with other professionals accordingly.

Be aware of clients' medication regimens and collaborate with other professionals accordingly

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A. Ensure that blood components are never infused at a rate greater than 125 mL/h. B. Administer prophylactic antihistamines prior to all blood transfusions. C. Establish baseline vital signs for all clients receiving transfusions. D. Be vigilant in identifying the client and the blood component.

Be vigilant in identifying the client and the blood component

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A. Salmon accompanied by whole milk B. Mixed vegetables and brown rice C. Beef liver accompanied by orange juice D. Yogurt, almonds, and whole grain oats

Beef liver accompanied by orange juice

Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action? A. Protect the body against viral infection. B. Mark the parameters of the immune response. C. Bridge natural and acquired immunity. D. Collect immune complexes during inflammation.

Bridge natural and acquired immunity

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? A. By encouraging the client to perform deep breathing preoperatively B. By limiting the client's contact with family members preoperatively C. By maintaining the privacy of each client D. By eliciting informed consent from clients

By maintaining the privacy of each client

An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply? A. Reassure the client that modern surgery is free of significant risks. B. Describe the surgery to the client in as much detail as possible. C. Clearly explain any information that the client seeks. D. Remind the client that the anesthetic will render the client unconscious.

Clearly explain any information that the client seeks

A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? A. Note the corticosteroid use in the electronic health record and continue with the test. B. Modify the skin test to check for grass, mold, or dust allergies only. C. Administer sodium valproate to reverse the effects of corticosteroid usage. D. Cancel and reschedule the skin test when the client stops taking the corticosteroid.

Cancel and reschedule the skin test when the client stops taking the corticosteroid

The hospice nurse has just admitted a new client to the program. What principle guides hospice care? A. Care addresses the needs of the client as well as the needs of the family. B. Care is focused on the client centrally and the family peripherally. C. The focus of all aspects of care is solely on the client. D. The care team prioritizes the client's physical needs and the family is responsible for the client's emotional needs.

Care addresses the needs of the client as well as the needs of the family

A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? A. Beginning immunotherapy B. Carrying an epinephrine pen C. Maintaining the child's immunization status D. Avoiding all foods that have a high potential for allergies

Carrying an epinephrine pen

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Potassium-sparing diuretics B. Cholinergics C. Antibiotics D. Loop diuretics

Cholinergics

A hearing-impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client? A. Client is likely unable to hear the nurse during test. B. A person adept in sign language must be present during test. C. Lip reading will be the method of communication that is necessary. D. The nurse should interact with the client like any other client.

Client is likely unable to hear the nurse during test

The nurse just received a postoperative client from the postanesthesia care unit to the medical-surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit? A. Beginning early ambulation B. Maintaining clean dressings on the surgical site C. Closely monitoring neurologic status D. Resuming normal oral intake

Closely monitoring neurologic status

A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised? A. Lymphatic system B. Passive immunity C. Complement system D. Monoclonal antibodies

Complement system

A nurse should prioritize and closely monitor a client for a potentially severe anaphylactic reaction after the client has received which medical intervention? A. Measles-mumps-rubella vaccine B. Rapid administration of intravenous fluids C. Computed tomography with contrast solution D. Nebulized bronchodilator

Computed tomography with contrast solution

The nurse manager is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, which action should the nurse manager emphasize? A. Adjust the dose to the client's present symptoms. B. Wash hands with an alcohol-based cleanser following administration. C. Use gloves and a lab coat when preparing the medication. D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.

Dispose of the antineoplastic wastes in the hazardous waste receptacle

A client is being treated for cancer, and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which way? A. Causing apoptosis of cytokines B. Increasing interferon production C. Causing CD4+ cells to mutate D. Depressing antibody response

Depressing antibody response

The nurse's assessment of a client with significant visual losses reveals that the client cannot count fingers. How should the nurse proceed with assessment of the client's visual acuity? A. Assess the client's vision using a Snellen chart. B. Determine whether the client is able to see the nurse's hand motion. C. Perform a detailed examination of the client's external eye structures. D. Palpate the client's periocular regions.

Determine whether the client is able to see the nurse's hand motion.

A client is fighting an active infection. What function will cytokines perform in this immune response? A. Determining whether a cell is foreign B. Determining if lymphokines will be activated C. Determining whether the T cells will remain in the nodes and retain a memory of the antigen D. Determining whether the immune response will be the production of antibodies or a cell-mediated response

Determining whether the immune response will be the production of antibodies or a cell-mediated response

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common cause(s) of blindness and visual impairment among adults over the age of 40? Select all that apply. A. Diabetic retinopathy B. Trauma C. Macular degeneration D. Cytomegalovirus E. Glaucoma

Diabetic retinopathy Macular degeneration Glaucoma

When discussing with a client factors that distinguish malignant cells from benign cells of the same tissue type, which characteristic should the nurse mention? A. Slow rate of mitosis of cancer cells B. Different proteins in the cell membrane C. Differing size of the cells D. Different molecular structure in the cells

Different proteins in the cell membrane

The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A. Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B. Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C. Continue packing the wound and inform the health care provider that an antibiotic is needed. D. Discard the gauze packing and repack the wound with new Iodoform gauze.

Discard the gauze packing and repack the wound with new Iodoform gauze

A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. C. Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

Discontinue the remainder of the PRBC transfusion, and inform the health care provider

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? A. Ignore the comment because the client is unconscious. B. Discourage the colleague from making such comments. C. Report the comment immediately to a supervisor. D. Realize that humor is needed in the workplace.

Discourage the colleague from making such comments

A client with terminal small-cell lung cancer has been given a six-month prognosis and wants to die at home. The health care team believes the condition warrants inpatient care. The nurse might suggest which compromise? A. Discuss a referral for rehabilitation hospital. B. Panel the client for a personal care home. C. Discuss a referral for acute care. D. Discuss a referral for hospice care.

Discuss a referral for hospice care

A client's ocular tumor has necessitated enucleation and the client will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the client's discharge education? A. Disturbed body image B. Chronic pain C. Ineffective protection D. Unilateral neglect

Disturbed body image

The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthesia. Which instruction should the nurse give the client prior to the client leaving the hospital? A. Do not drive yourself home. B. Take an over-the-counter (OTC) sleeping pill for 2 nights. C. Attempt to eat a large meal at home to aid wound healing. D. Remain in bed for the first 48 hours' postoperative.

Do not drive yourself home

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is most important for the nurse to ask the client in preparation for this test? A. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B. Do you currently take any tranquilizers or stimulants on a regular basis? C. Do you have a history of falls or problems with loss of balance? D. Do you have a history of either high or low blood pressure?

Do you currently take any tranquilizers or stimulants on a regular basis?

A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations E. Quick decision making

Dropping of word endings Disinterest in conversations Social withdrawal Domination of conversations

The surgeon's preoperative assessment of a client finds that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? A. Maintain the head of the bed at 45 degrees or higher. B. Encourage early ambulation. C. Encourage oral fluid intake. D. Perform passive range-of-motion exercises every 8 hours.

Encourage early ambulation

A client with sickle cell disease is taking narcotic analgesics for pain control. Which intervention by the nurse would decrease the risk for narcotic substance abuse? A. Encourage the client to rely on complementary and alternative therapies. B. Encourage the client to seek care from a single provider for pain relief. C. Teach the client to accept chronic pain as an inevitable aspect of the disease. D. Limit the reporting of emergency department visits to the primary health care provider.

Encourage the client to seek care from a single provider for pain relief

A client is scheduled to undergo a bone marrow aspiration. When preparing the client for the procedure, which action would the nurse do first? A. Ensure informed consent has been obtained. B. Cleanse the skin with an antiseptic. C. Administer a local anesthetic. D. Cover the area with a sterile drape.

Ensure informed consent has been obtained

The operating room nurse is participating in the appendectomy of a client who has a dangerously low body mass index. The nurse recognizes the client's consequent risk for hypothermia. Which action should the nurse implement to prevent the development of hypothermia? A. Ensure that intravenous (IV) fluids are warmed to the client's body temperature. B. Transfuse packed red blood cells to increase oxygen-carrying capacity. C. Wrap the client in drape that has been soaked in hot water. D. Monitor the client's blood pressure and heart rate vigilantly.

Ensure that intravenous (IV) fluids are warmed to the client's body temperature

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? A. Prime IV tubing with a unit of blood and keep it on hold. B. Check that the client's electrolyte levels have been assessed preoperatively. C. Ensure that the client has had a current cross-match. D. Keep the blood on standby and warmed to body temperature.

Ensure that the client has had a current cross-match

A client on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in clients at risk for thrombocytopenia? A. Interrupted sleep pattern B. Hot flashes C. Epistaxis D. Increased weight

Epistaxis

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing

Erythematous rash

A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). Which laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A. Erythrocyte count B. Erythrocyte sedimentation rate C. Creatinine clearance D. C-reactive protein E. D-dimer

Erythrocyte sedimentation rate C-reactive protein

A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor? A. Recent blood donation B. Evidence of lung disease C. A history of venous thromboembolism D. Impaired renal function

Evidence of lung disease

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner? A. Historical precedent B. Client requests C. Health care providers' needs D. Evidence-based practice

Evidence-based practice

A client is vigilant in self-care but is frustrated by a recent history of upper respiratory infections and influenza. Which aspects of the client's lifestyle may have a negative effect on immune response? Select all that apply. A. Exercises at the gym twice a day B. Does not consume any red meat C. Takes over-the-counter daily vitamins D. Sleeps approximately seven hours daily E. Works as a medical researcher

Exercises at the gym twice a day Works as a medical researcher

A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A. Explain the location of items using clock cues. B. Explain that each of the items on the tray is clearly separated. C. Describe the location of items from the bottom of the plate to the top. D. Ask the client to describe the location of items before confirming their location.

Explain the location of items using clock cues

A client with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the client administers the pilocarpine, the client states that the client's vision is blurred. Which nursing action is most appropriate? A. Holding the next dose and notifying the health care provider B. Treating the client for an allergic reaction C. Suggesting that the client put on her glasses D. Explaining that this is an expected adverse effect

Explaining that this is an expected adverse effect

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client reports exercising two to three times daily, and the client's parent indicates that the client is being treated for anorexia nervosa. How should the nurse best follow up on these assessment data? A. Inform the postoperative team about the client's risk for wound dehiscence. B. Evaluate the client's ability to manage pain level. C. Facilitate a detailed analysis of the client's electrolyte levels. D. Instruct the client on the need for a high-sodium diet to promote healing.

Facilitate a detailed analysis of the client's electrolyte levels

A client with polymyositis is experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? A. Initiate a program of passive range of motion exercises B. Facilitate referrals to occupational and physical therapy C. Administer skeletal muscle relaxants as prescribed D. Encourage a progressive program of weight-bearing exercise

Facilitate referrals to occupational and physical therapy

An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? A. Risk for deficient fluid volume related to impaired erythropoiesis B. Risk for infection related to tissue hypoxia C. Acute pain related to uncontrolled hemolysis D. Fatigue related to decreased oxygen-carrying capacity

Fatigue related to decreased oxygen-carrying capacity

A clinic nurse is caring for a client newly diagnosed with fibromyalgia. When developing a care plan for this client, which nursing diagnosis should the nurse prioritize? A. Impaired urinary elimination related to neuropathy B. Altered nutrition related to impaired absorption C. Disturbed sleep pattern related to central nervous system stimulation D. Fatigue related to pain

Fatigue related to pain

The nurse's aide notifies the nurse that a client has decreased oxygen saturation levels. The nurse assesses the client and finds that the client is tachypneic, has crackles on auscultation, and has frothy and pink sputum. The nurse should suspect which complication? A. Pulmonary embolism B. Atelectasis C. Laryngospasm D. Flash pulmonary edema

Flash pulmonary edema

The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find? A. Flashing lights in the visual field B. Sudden eye pain C. Loss of color vision D. Colored halos around lights

Flashing lights in the visual field

A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do? A. Clarify the order with the surgeon. B. Follow the order because this bed position is correct. C. Reposition the client after the first dressing change. D. Ask the client to lie in a semi-Fowler position.

Follow the order because this bed position is correct

A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply. A. Foods B. Medications C. Insect stings D. Autoimmunity E. Environmental pollutants

Foods Medications Insect stings

A community health nurse is performing a visit to the home of a client who has a history of rheumatoid arthritis (RA). On which aspect of the client's health should the nurse focus most closely during the visit? A. Understanding of rheumatoid arthritis B. Risk for cardiopulmonary complications C. Social support system D. Functional status

Functional status

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in clients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis? A. Pilocarpine B. Penicillin C. Ganciclovir D. Gentamicin

Ganciclovir

A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? A. Generously flush the affected eye with a dilute antibiotic solution. B. Generously flush the affected eye with normal saline or water. C. Apply a patch to the affected eye. D. Apply direct pressure to the affected eye.

Generously flush the affected eye with normal saline or water

Upon examination via otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A. Acoustic tumor B. Cholesteatoma C. Facial nerve neuroma D. Glomus tympanicum

Glomus tympanicum

A 6-month-old infant is brought to the ED by the parents for inconsolable crying and pulling at the right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A. Yellowish-white B. Pink C. Gray D. Bluish-white

Gray

The nurse is caring for a client who has had spinal anesthesia. The client is under a health care provider's order to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages the client to adhere to the health care provider's order. Prevention of which outcome should the nurse include in the rationale for complying with this order? A. Hypotension B. Respiratory depression C. Headache D. Pain at the lumbar injection site

Headache

A nurse is providing care for a client who has a recent diagnosis of giant cell arteritis (GCA). Which aspect of physical assessment should the nurse prioritize? A. Subtle signs of bleeding disorders B. The metatarsal joints and phalangeal joints C. Thoracic pain that is exacerbated by activity D. Headaches and jaw pain

Headaches and jaw pain

A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A. Hearing will not be affected by a decibel level in this range. B. Hearing loss may occur with a decibel level in this range. C. Sounds in this decibel level are not perceived to be harsh to the ear. D. Ear plugs will have no effect on these decibel levels.

Hearing loss may occur with a decibel level in this range.

A client has just been admitted to the postanesthesia care unit following abdominal surgery. As the client begins to awaken, the client is uncharacteristically restless. The nurse checks the skin, and it is cold, moist, and pale. The nurse is concerned the client may be at risk for which condition? A. Hemorrhage and shock B. Aspiration C. Postoperative infection D. Hypertension and dysrhythmias

Hemorrhage and shock

A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? A. Lymphoma B. Leukemia C. Hemophilia D. Hepatic dysfunction

Hepatic dysfunction

The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. A. Hepatitis B. Acute kidney injury C. HIV D. Malignant melanoma E. Cholecystitis

Hepatitis HIV

A client's exposure to which microorganism is most likely to trigger a cellular response? A. Herpes simplex B. Staphylococcus aureus C. Pseudomonas aeruginosa D. Beta-hemolytic Streptococcus

Herpes simplex

The nurse is caring for a postoperative client with a history of congestive heart failure and peptic ulcer disease. The client is highly reluctant to ambulate and will not drink fluids except for hot tea with meals. The client's vital signs are slightly elevated, and the client has a nonproductive cough. The nurse auscultates crackles at the base of the lungs. Which complication should the nurse first suspect? A. Pulmonary embolism B. Hypervolemia C. Hypostatic pulmonary congestion D. Malignant hyperthermia

Hypostatic pulmonary congestion

The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? A. Hypothermia B. Hypovolemic shock C. Neurogenic shock D. Malignant hyperthermia

Hypovolemic shock

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A. Impaired skin integrity B. Hypoxia C. Malignant hyperthermia D. Hypothermia

Hypoxia

A client has presented with signs and symptoms that are consistent with contact dermatitis. Which aspect of care should the nurse prioritize when working with this client? A. Promoting adequate perfusion in affected regions B. Promoting safe use of topical antihistamines C. Identifying the offending agent, if possible D. Teaching the client to safely use an EpiPen

Identifying the offending agent, if possible

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which complication of therapy? A. Immunosuppression B. Agranulocytosis C. Anemia D. Thrombocytopenia

Immunosuppression

A gerontologic nurse is caring for a 78-year-old client who has a diagnosis of pneumonia. Which age-related change increases older adults' susceptibility to respiratory infections? A. Atrophy of the thymus B. Bronchial stenosis C. Impaired ciliary action D. Decreased diaphragmatic muscle tone

Impaired ciliary action

The nurse is admitting an oncology client to the unit prior to surgery. The nurse reads in the electronic health record that the client has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? A. Cognitive deficits B. Impaired wound healing C. Cardiac tamponade D. Tumor lysis syndrome

Impaired wound healing

A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action? A. Housing the resident in a private room B. Implementing a passive ROM program C. Implementing of a plan for fall prevention D. Providing the client with a high-fiber diet

Implementing of a plan for fall prevention

The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? A. Appropriate use of prophylactic antibiotics B. Safe injection of corticosteroids C. Improved skin integrity D. Improved coping with lifestyle modifications

Improved coping with lifestyle modifications

A client is hospitalized because a large abdominal tumor was seen on the computed tomography scan. A biopsy is ordered, and the client wants to know if "this will cause a big scar." Which type of biopsy will this client likely experience? A. Excisional B. Incisional C. Needle D. Fine needle

Incisional

A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? A. Increased eosinophils B. Increased neutrophils C. Increased serum albumin D. Decreased blood glucose

Increased eosinophils

The nurse is performing a preoperative assessment on a client going to surgery. The client reports to the nurse drinking approximately two bottles of wine each day for the last several years. What postoperative difficulties should the nurse anticipate for this client? A. Nonadherence to prescribed treatment after surgery B. Increased risk for postoperative complications C. Alcohol withdrawal syndrome upon administration of general anesthesia D. Increased risk for allergic reactions

Increased risk for postoperative complications

A clinic nurse is caring for a client with suspected gout. While describing the pathophysiology of gout to the client, what should the nurse explain? A. Autoimmune processes in the joints B. Chronic metabolic acidosis C. Increased uric acid levels D. Unstable serum calcium levels

Increased uric acid levels

The nurse on the pediatric unit is caring for a 10-year-old child with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis? A. Hypothermia B. Diarrhea C. Ineffective coping D. Imbalanced nutrition: Less than body requirements

Ineffective coping

A client with a documented history of allergies presents to the clinic. The client reports being frustrated by chronic nasal congestion, anosmia (inability to smell), and inability to concentrate. The nurse should identify which nursing diagnosis? A. Deficient knowledge of self-care practices related to allergies B. Ineffective individual coping with chronicity of condition C. Acute confusion related to cognitive effects of allergic rhinitis D. Disturbed body image related to sequelae of allergic rhinitis

Ineffective individual coping with chronicity of condition

A nurse is planning the care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. Which nursing diagnosis is most likely to apply to this client's care needs? A. Ineffective role performance related to pain B. Risk for impaired skin integrity related to myalgia C. Risk for infection related to tissue alterations D. Unilateral neglect related to neuropathic pain

Ineffective role performance related to pain

The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? A. Rejection of the kidney B. Rejection of the implanted lens C. Infection D. Adrenal storm

Infection

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following? A. Discharge planning B. Informed consent C. Analgesia prescription D. Educational resources

Informed consent

The nurse is caring for a client who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A. Teach the client about the risks of ototoxic medications. B. Instruct the client to protect the ear from water for several weeks. C. Teach the client to remove cerumen safely at least once per week. D. Instruct the client to protect the ear from temperature extremes until healing is complete.

Instruct the client to protect the ear from water for several weeks

A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

Iron

A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed? A. Iron deficiency anemia B. Pernicious anemia C. Sickle cell disease D. Hemolytic anemia

Iron deficiency anemia

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color. D. Limit foods high in fiber due to the risk for diarrhea.

Iron will cause the stools to darken in color

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents. B) Instill normal saline into the eyes of affected residents two to three times daily. C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D) Isolate affected residents from residents who have not developed conjunctivitis.

Isolate affected residents from residents who have not developed conjunctivitis

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints

Joint stiffness lasting longer than 1 hour, especially in the morning

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A. Seat the client in a chair and have them perform deep breathing exercises. B. Ambulate the client as early as possible. C. Limit the client's fluid intake for the first 24 hours' postoperatively. D. Keep the client positioned supine.

Keep the client positioned supine

A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do? A. Wear powdered latex gloves when in public. B. Wash her hands with antibacterial soap every few hours. C. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. D. Keep the hands well moisturized at all times.

Keep the hands well moisturized at all times

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions? A. Keeping the client sterile B. Keeping the client restrained C. Keeping the client warm D. Keeping the client hydrated

Keeping the client warm

The nurse is planning the care of a client who is adapting to the use of a hearing aid for the first time. What is the most significant challenge this client is likely to experience? A. Regulating the tone and volume B. Learning to cope with amplification of background noise C. Constant irritation of the external auditory canal D. Challenges in keeping the hearing aid clean while minimizing exposure to moisture

Learning to cope with amplification of background noise

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? A. Leg exercises increase the client's muscle mass postoperatively. B. Leg exercises improve circulation and prevent venous thrombosis. C. Leg exercises help to prevent pressure sores to the sacrum and heels. D. Leg exercise help increase the client's level of consciousness after surgery.

Leg exercises improve circulation and prevent venous thrombosis

A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care? A. Limit the time that visitors spend at the client's bedside. B. Teach the client to perform all aspects of basic care independently. C. Assign male nurses to the client's care whenever possible. D. Situate the client in a shared room with other clients receiving brachytherapy.

Limit the time that visitors spend at the client's bedside

A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A. Ensuring adequate rest B. Limiting exposure to sunlight C. Limiting intake of alcohol D. Smoking cessation

Limiting intake of alcohol

An adult client is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the client in what manner? A. Dorsal recumbent position B. Trendelenburg position C. Sims position D. Lithotomy position

Lithotomy position

The nurse is caring for a client who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A. Spleen and kidneys B. Kidneys and pancreas C. Pancreas and liver D. Liver and spleen

Liver and spleen

A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread? A. Apoptosis B. Lymphatic circulation C. Invasion D. Angiogenesis

Lymphatic circulation

The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A. Maintain the irrigation fluid at a warm temperature. B. Instill short, sharp bursts of fluid into the ear canal. C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D. Have the client stand during the procedure.

Maintain the irrigation fluid at a warm temperature

An oncology nurse educator is providing health education to a client who has been diagnosed with skin cancer. The client's wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite? A. Malignant cells possess greater mobility than normal body cells. B. Malignant cells contain proteins called tumor-associated antigens. C. Chromosomes contained in cancer cells are more durable and stable than those of normal cells. D. The nuclei of cancer cells are unusually large, but regularly shaped.

Malignant cells contain proteins called tumor-associated antigens

A nurse is creating a teaching plan for a client who has a recent diagnosis of scleroderma. Which topics should the nurse address during health education? Select all that apply. A. Surgical treatment options B. Weight loss C. Management of Raynaud-type symptoms D. Exercise E. Skin care

Management of Raynaud-type symptoms Exercise Skin care

An operating room (OR) nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. Which personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A. Bubble mask B. Mask covering the nose and mouth C. Goggles D. Gloves

Mask covering the nose and mouth

A client with hearing loss is scheduled to undergo aural rehabilitation. When describing this therapy, the nurse would include which information as the primary purpose? A. Increase hearing ability. B. Maximize ability to communicate. C. Facilitate use of a hearing aid. D. Limit extraneous noise.

Maximize ability to communicate

A nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). The nurse should anticipate the administration of which medication? A. Hydromorphone B. Methotrexate C. Allopurinol D. Prednisone

Methotrexate

A client's absolute neutrophil count (ANC) is 440/mm 3but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client? A. Meticulous hand hygiene B. Timely administration of antibiotics C. Provision of a nutrient-dense diet D. Maintaining a sterile care environment

Meticulous hand hygiene

A client received a bee sting on the lip approximately 2 hours ago and has arrived at an urgent/walk-in clinic for treatment because the swelling is now accompanied by nasal congestion. On assessment, the client reports pruritus and a sensation of warmth at the site. Which degree of anaphylaxis is the client experiencing? A. No systemic reaction B. Moderate systemic reaction C. Severe systemic reaction D. Mild systemic reaction

Mild systemic reaction

A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? A. Teach the client to take deep breaths and cough frequently. B. Use antihistamines daily throughout the year. C. Teach the client to seek medical attention at the first sign of an allergic reaction. D. Modify the environment to reduce the severity of allergic symptoms.

Modify the environment to reduce the severity of allergic symptoms

A client with systemic lupus erythematosus (SLE) asks the nurse why the client has to come to the office so often for "check-ups." Which rationale for frequent office visits would be best for the nurse to mention? A. Seeing the client face to face B. Ensuring that the client is taking medications as prescribed C. Monitoring the disease process and how well the prescribed treatment is working D. Drawing blood work every month

Monitoring the disease process and how well the prescribed treatment is working

The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply. A. Monitoring the safe recovery from anesthesia B. Answering family questions about recovery C. Ensuring that informed consent has been signed D. Providing light nourishment E. Assessing the operative site for hemorrhage

Monitoring the safe recovery from anesthesia Answering family questions about recovery Providing light nourishment Assessing the operative site for hemorrhage

A client is learning about a new diagnosis of asthma with the asthma nurse. What medication will best prevent the onset of acute asthma exacerbations? A. Diphenhydramine B. Montelukast C. Albuterol sulfate D. Epinephrine

Montelukast

A nurse is assessing a client with rheumatoid arthritis. The client expresses the intent to pursue complementary and alternative medicine (CAM) therapies. Which fact should underlie the nurse's response to the client? A. New evidence shows CAM to be as effective as medical treatment. B. CAM therapies negate many of the benefits of medications. C. CAM therapies typically do more harm than good. D. Most CAM therapies lack sufficient evidence to support them.

Most CAM therapies lack sufficient evidence to support them

A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A. Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's pain. B. Opioids partially inhibit the client's synthesis of clotting factors. C. Opioids may cause vasodilation and exacerbate bleeding. D. NSAIDs are contraindicated due to the risk for bleeding.

NSAIDs are contraindicated due to the risk for bleeding

A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? A. Pruritis (itching) B. Nausea and vomiting C. Altered glucose metabolism D. Confusion

Nausea and vomiting

The nurse is reviewing the health history of a newly admitted client and reads that the client has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the client's plan of care? A. The nurse should perform the Rinne and Weber tests. B. The nurse should arrange for audiometry testing as soon as possible. C. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D. No specific assessments or interventions are necessary to address exostoses.

No specific assessments or interventions are necessary to address exostoses

A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to which type of immunity? A. Cytokine immunity B. Specific immunity C. Active acquired immunity D. Nonspecific immunity

Nonspecific immunity

A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do? A. Irrigate the catheter with 30 mL normal saline. B. Notify the health care provider and continue to monitor the hourly urine output. C. Decrease the intravenous fluid rate and massage the client's abdomen. D. Have the client sit in high-Fowler position.

Notify the health care provider and continue to monitor the hourly urine output

The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply. A. Notify the surgeon that the client is a cigarette smoker. B. Encourage smoking cessation before surgery. C. Explain the increased risk for venous thromboembolism after surgery. D. Tell the client to stop smoking the day before surgery. E. Provide resources for smoking cessation.

Notify the surgeon that the client is a cigarette smoker Encourage smoking cessation before surgery Explain the increased risk for venous thromboembolism after surgery Provide resources for smoking cessation

When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A. Ensure that the client is well hydrated at all times. B. Encourage self-administration of eye drops. C. Occlude the puncta after applying the medication. D. Position the client supine before administering eye drops.

Occlude the puncta after applying the medication

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? A. Assist the client to the bathroom. B. Offer the client a bedpan or urinal. C. Wait until the client gets to the operating room and is catheterized. D. Have the client go to the bathroom.

Offer the client a bedpan or urinal

The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related? A. Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B. Older adults are less able to increase blood cell production when demand suddenly increases. C. Stem cells in older adults eventually lose their ability to differentiate. D. The ratio of plasma to erythrocytes and lymphocytes increases with age.

Older adults are less able to increase blood cell production when demand suddenly increases

A client has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of which aspects of PMR? Select all that apply. A. PMR has an association with the genetic marker HLA-DR4. B. Immunoglobulin deposits occur in PMR. C. PMR is considered to be a "wear-and-tear" disease. D. Foods high in purines exacerbate the biochemical processes that occur in PMR. E. PMR occurs predominately in Caucasians.

PMR has an association with the genetic marker HLA-DR4 Immunoglobulin deposits occur in PMR PMR occurs predominately in Caucasians

A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? A. Packed red blood cells (PRBCs) B. Vitamin K C. Oral anticoagulants D. Heparin infusion

Packed red blood cells (PRBCs)

The nurse is caring for a client in the postanesthesia care unit after abdominal surgery. The client's blood pressure has increased, and the client is restless. The client's oxygen saturation is 97%. Which factor should the nurse first suspect as the cause for this change in status? A. Hypothermia B. Shock C. Pain D. Hypoxia

Pain

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis? A. Tophi on the pinna and ear lobe B. Dark yellow cerumen in the external auditory canal C. Pain on manipulation of the auricle D. Air bubbles visible in the middle ear

Pain on manipulation of the auricle

The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery? A. Dysrhythmias, blood loss, and hyperthermia B. Electrolyte imbalances and neurologic changes C. A parasympathetic reaction and low blood volumes D. Pain, hypoxia, and bladder distention

Pain, hypoxia, and bladder distention

The nurse is caring for a client who has just been told that the client's stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? A. Palliative B. Reconstructive C. Salvage D. Prophylactic

Palliative

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following? A. Diagnostic B. Laparoscopic C. Curative D. Palliative

Palliative

The nurse is caring for a client who is scheduled to have a needle biopsy of the pleura. The client has had a consultation with the anesthesiologist, and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? A. Transsacral block B. Brachial plexus block C. Pudendal block D. Paravertebral block

Paravertebral block

A client has been brought to the emergency department by the parents after falling through the glass of a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of which type of cell? A. Interferons B. Phagocytic cells C. Helper T cells D. Cytokines

Phagocytic cells

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response? A. Return the client to the previous position and call the health care provider. B. Place saline-soaked sterile dressings on the wound. C. Assess the client's blood pressure and pulse. D. Pull the dehiscence closed using gloved hands.

Place saline-soaked sterile dressings on the wound

A client has sustained a cut to the hand, immediately initiating the process of hemostasis. Following vasoconstriction, which event in the process of hemostasis will take place? A. Fibrin will be activated at the bleeding site. B. Platelets will aggregate at the injury site. C. Thromboplastin will form a clot. D. Prothrombin will be converted to thrombin.

Platelets will aggregate at the injury site

A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? A. Position the client in a prone position to minimize bleeding. B. Establish IV access for the administration of vitamin K. C. Prepare for the administration of factor VIII. D. Administer a normal saline bolus to increase circulatory volume

Prepare for the administration of factor VIII

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room? A. The client should be placed in Trendelenburg position. B. The client must be firmly restrained at all times. C. Pressure points should be assessed and well padded. D. The preoperative shave should be done by the circulating nurse.

Pressure points should be assessed and well padded

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? A. Preventing aspiration of gastric contents B. Preventing the accumulation of abdominal gas postoperatively C. Preventing potential contamination of the peritoneum D. Facilitating better absorption of medications

Preventing potential contamination of the peritoneum

A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for clients with a history of transfusion reactions B. Prevention of viral infections from another person's blood C. Avoidance of complications in clients with alloantibodies D. Prevention of alloimmunization

Prevention of viral infections from another person's blood

A client was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response? A. Effector B. Proliferation C. Response D. Recognition

Proliferation

A client was scratched by an old tool and developed a virulent staphylococcus infection. During the immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage

Proliferation stage

The nurse is describing some of the major characteristics of cancer to a client who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply. A. Rate of growth B. Ability to cause death C. Cell size D. Cell location E. Ability to spread

Rate of growth Ability to cause death Ability to spread

The nurse is preparing to care for a client who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which condition is a component of CREST syndrome? A. Raynaud phenomenon B. Thyroid dysfunction C. Esophageal varices D. Osteopenia

Raynaud phenomenon

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Oral temperature of 99.5°F (37.5°C) C. Red, warm, tender incision D. White blood cell (WBC) count of 8,000/mL

Red, warm, tender incision

A client was diagnosed with cancer several weeks ago and family members describe the client as "utterly distraught." The client has fully withdrawn from social and family contact. What is the nurse's best action? A. Reassure the client and the family that these types of responses to cancer are common. B. Refer the client to the appropriate mental health provider. C. Educate the client about the mental health benefits of exercise. D. Reassure the family that the client is grieving and will eventually come to terms with the diagnosis.

Refer the client to the appropriate mental health provider

After the completion of testing, a 7-year-old client's allergies have been attributed to the family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote which action? A. Removing the cat from the family's home B. Administering over-the-counter antihistamines to the client regularly C. Keeping the cat restricted from the client's bedroom D. Maximizing airflow in the house

Removing the cat from the family's home

A client is scheduled for a splenectomy. During discharge education, which teaching point should the nurse prioritize? A. Adhering to prescribed immunosuppressant therapy B. Reporting any signs or symptoms of infection promptly C. Ensuring adequate folate, iron, and vitamin B 12 intake D. Limiting activity postoperatively to prevent hemorrhage

Reporting any signs or symptoms of infection promptly

A 16-year-old female client has post-chemotherapy alopecia. This prompts the nursing diagnoses of Disturbed Body Image and Situational Low Self-Esteem. Which response by the client would best indicate improved coping related to these diagnoses? A. Requests that her family bring her makeup and a wig B. Begins to discuss the future with her family C. Reports less disruption from pain and discomfort D. Cries openly when discussing her disease

Requests that her family bring her makeup and a wig

A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? A. Take OTC calcium supplements consistently. B. Restrict consumption of foods high in purines. C. Ensure fluid intake of at least 4 L per day. D. Restrict weight-bearing on right foot.

Restrict consumption of foods high in purines

A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin. When assessing the therapeutic response to this medication, which action by the nurse is the most appropriate? A. Assess for signs of myelosuppression. B. Review the client's platelet level. C. Assess the client's capillary refill time. D. Review the client's international normalized ratio (INR).

Review the client's international normalized ratio (INR)

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

Rheumatoid arthritis (RA)

The nurse is developing a plan of care for a client having surgery under general anesthesia. Which nursing diagnos(es) would be appropriate? Select all that apply. A. Risk for compromised human dignity related to general anesthesia B. Risk for impaired nutrition: less than body requirements related to anesthesia C. Risk of latex allergy response related to surgical exposure D. Disturbed body image related to anesthesia E. Anxiety related to surgical concerns

Risk for compromised human dignity related to general anesthesia Risk of latex allergy response related to surgical exposure Anxiety related to surgical concerns

The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? A. Risk for disturbed body image related to skin lesions B. Risk for disuse syndrome related to dermatitis C. Risk for ineffective role performance related to dermatitis D. Risk for self-care deficit related to skin lesions

Risk for disturbed body image related to skin lesions

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? A. Risk for disturbed sensory perception B. Risk for unilateral neglect C. Risk for falls D. Risk for ineffective health maintenance

Risk for falls

The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? A. Risk for infection related to skin sloughing B. Risk for acute pain related to loss of skin integrity C. Risk for impaired skin integrity related to cutaneous lesions D. Risk for impaired gas exchange related to airway obstruction

Risk for impaired gas exchange related to airway obstruction

The nurse on a bone marrow transplant unit is caring for a client with cancer who has just begun hematopoietic stem cell transplantation (HSCT). What is the priority nursing diagnosis for this client? A. Fatigue related to altered metabolic processes B. Altered nutrition: less than body requirements related to anorexia C. Risk for infection related to altered immunologic response D. Body image disturbance related to weight loss and anorexia

Risk for infection related to altered immunologic response

A client with rheumatic disease has developed a gastrointestinal (GI) bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy

Salicylate therapy

A 40-year-old woman was diagnosed with Raynaud phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The client also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem? A. Giant cell arteritis (GCA) B. Fibromyalgia (FM) C. Rheumatoid arthritis (RA) D. Scleroderma

Scleroderma

A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia? A. Venous ulcers and visual disturbances B. Fever and signs of hyperkalemia C. Epistaxis and gastroesophageal reflux D. Shortness of breath and peripheral edema

Shortness of breath and peripheral edema

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A. Slow the infusion rate and monitor the client closely. B. Discontinue the transfusion and begin resuscitation. C. Pause the transfusion and administer a 250 mL bolus of normal saline. D. Discontinue the transfusion and administer a beta-blocker, as prescribed.

Slow the infusion rate and monitor the client closely

The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? A. Sit in a chair for 10 minutes prior to ambulating. B. Drink plenty of fluids to increase circulating blood volume. C. Stand upright for 2 to 3 minutes prior to ambulating. D. Perform range-of-motion exercises for each joint.

Stand upright for 2 to 3 minutes prior to ambulating

The nurse is providing care for a client who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A. Stem cell transplantation B. Serial immunizations C. Immunosuppression D. Genetic engineering

Stem cell transplantation

An operating room nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is which of the following? A. Sterile surfaces or articles may touch other sterile surfaces. B. Sterile supplies can be used on another client if the packages are intact. C. The outer lip of a sterile solution is considered sterile. D. The scrub nurse may pour a sterile solution from a nonsterile bottle.

Sterile surfaces or articles may touch other sterile surfaces

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the client's health care provider. B. Stop the transfusion immediately. C. Remove the client's IV access. D. Assess the client's chest sounds and vital signs.

Stop the transfusion immediately

While a client is receiving intravenous (IV) doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize which action? A. Stopping the administration of the drug immediately B. Notifying the client's health care provider C. Continuing the infusion but decreasing the rate D. Applying a warm compress to the infusion site

Stopping the administration of the drug immediately

A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A. Antihypertensives B. Penicillins C. Sulfa-containing medications D. Aspirin-based drugs E. NSAIDs

Sulfa-containing medications Aspirin-based drugs NSAIDs

The nurse is caring for a client with an advanced stage of breast cancer and the client has recently learned that the cancer has metastasized. The nurse enters the room and finds the client struggling to breathe, and the nurse's rapid assessment reveals that the client's jugular veins are distended. The nurse should suspect the development of what oncologic emergency? A. Increased intracranial pressure B. Superior vena cava syndrome (SVCS) C. Spinal cord compression D. Metastatic tumor of the neck

Superior vena cava syndrome (SVCS)

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present, and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to survive. How should the need for informed consent be addressed? A. A social worker should temporarily sign the informed consent. B. Consent should be obtained from the hospital's ethics committee. C. Surgery should be done without informed consent. D. Surgery should be delayed until the parents arrive.

Surgery should be done without informed consent

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? A. Increased temperature B. Oliguria C. Tachycardia D. Hypotension

Tachycardia

A client has been diagnosed with Stevens-Johnson syndrome. Which factors are common triggers of this condition? Select all that apply. A. Tamoxifen and vemurafenib B. Exposure to cold objects, cold fluids, or cold air C. Allopurinol and nevirapine D. Wearing clothing washed in a detergent E. Radiation in combination with phenytoin

Tamoxifen and vemurafenib Allopurinol and nevirapine Radiation in combination with phenytoin

A client has just been diagnosed with a spondyloarthropathy. Which nursing intervention should the nurse prioritize? A. Referral for assistive devices B. Teaching about symptom management C. Referral to classes to stop smoking D. Setting up an exercise program

Teaching about symptom management

A client is being treated for the effects of a longstanding vitamin B 12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency? A. The client has irregular menstrual periods. B. The client is a vegan. C. The client donated blood 60 days ago. D. The client frequently smokes marijuana.

The client is a vegan

A nurse is planning preoperative teaching for a client with hearing loss due to otosclerosis. The client is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the client's preoperative teaching? A. The procedure is an effective, time-tested treatment for sensory hearing loss. B. The client is likely to experience resolution of conductive hearing loss after the procedure. C. Several months of postprocedure rehabilitation will be needed to maximize benefits. D. The procedure is experimental, but early indications suggest great therapeutic benefits.

The client is likely to experience resolution of conductive hearing loss after the procedure.

The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A. The client may chronically produce excess red blood cells. B. The client may frequently experience a low relative plasma volume. C. The client may have impaired stem cell function. D. The client may previously have undergone bone marrow biopsy.

The client may chronically produce excess red blood cells

The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. Which principle should guide the care of a client receiving this form of anesthesia? A. The client must never be left unattended by the nurse. B. The client should begin a course of antiemetics the day before surgery. C. The client should be informed that the client will remember most of the procedure. D. The client must be able to maintain the client's own airway.

The client must never be left unattended by the nurse

A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this client's health status? A. For some clients, these recurrent infections constitute an age-related physiologic change. B. The client would benefit from a temporary mobility restriction to facilitate healing. C. The client needs to be assessed for nasopharyngeal cancer. D. Blood cultures should be drawn to rule out a systemic infection.

The client needs to be assessed for nasopharyngeal cancer

A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A. The client should not undergo the normal bowel cleansing protocol prior to the procedure. B. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. C. The client should be admitted to the surgical unit on the day before the procedure. D. The client should be given necessary clotting factors before the procedure.

The client should be given necessary clotting factors before the procedure

The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A. The sound is heard better in the ear in which hearing is better. B. The sound is heard equally in both ears. C. The sound is heard better in the ear in which hearing is poorer. D. The sound is heard longer in the ear in which hearing is better.

The sound is heard better in the ear in which hearing is better

In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? A. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediate postoperative period. B. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs

The nurse is providing care for a client who has benefited from a cochlear implant. The nurse should understand that this client's health history likely includes which of the following? Select all that apply. A. The client was diagnosed with sensorineural hearing loss. B. The client's hearing did not improve appreciably with the use of hearing aids. C. The client has deficits in peripheral nervous function. D. The client's hearing deficit is likely accompanied by a cognitive deficit. E. The client is unable to lip-read.

The client was diagnosed with sensorineural hearing loss The client's hearing did not improve appreciably with the use of hearing aids

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? A. The client will be given a low dose of epinephrine before the treatment. B. The client will remain in the clinic to be monitored for 30 minutes following the injection. C. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. D. The allergen will be given by the peripheral intravenous (IV) route.

The client will remain in the clinic to be monitored for 30 minutes following the injection

An advanced practice nurse has performed a Rinne test on a new client. During the test, the client reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A. The client's hearing is likely normal. B. The client is at risk for tinnitus. C. The client likely has otosclerosis. D. The client likely has sensorineural hearing loss.

The client's hearing is likely normal

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? A. Antibodies to donor leukocytes remained in the blood. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. The blood was infused too quickly and overwhelmed the client's circulatory system.

The donor blood was incompatible with that of the client

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment? A. The client will need daily blood testing for the duration of treatment. B. The client must stop all other drugs 72 hours before starting prednisone. C. The drug should be used at the highest dose the client can tolerate. D. The drug should be used for as short a time as possible.

The drug should be used for as short a time as possible

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client? A. The hearing loss will likely resolve with time after the drug is discontinued. B. The client's hearing loss and tinnitus are irreversible at this point. C. The client's tinnitus is likely multifactorial, and not directly related to aspirin use. D. The client's tinnitus will abate as tolerance to aspirin develops.

The hearing loss will likely resolve with time after the drug is discontinued

A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? A. The movement of B cells in and out of lymph nodes B. The interactions that occur between T cells and B cells C. The differentiation between different types of T cells D. The universal role of the complement system

The interactions that occur between T cells and B cells

The nurse is teaching a client to care for a new ocular prosthesis. What should the nurse emphasize during the client's health education? A. The need to limit exposure to bright light B. The need to maintain a low Fowler position when removing the prosthesis C. The need to perform thorough hand hygiene before handling the prosthesis D. The need to apply antiviral ointment to the prosthesis daily

The need to perform thorough hand hygiene before handling the prosthesis

The registered nurse taking shift report learns that an assigned client is blind. How should the nurse best communicate with this client? A. The nurse should provide instructions in simple, clear terms. B. Using a loud voice, the nurse should offer an introduction while in the doorway of the room. C. Lightly touch the client's arm and then say the nurse's name . D. The nurse should state the nurse's name and role immediately after entering the client's room.

The nurse should state the nurse's name and role immediately after entering the client's room

A client is responding to a microbial invasion and the client's differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur? A. The recognition stage B. The effector stage C. The response stage D. The proliferation stage

The response stage

The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action? A. Hypothermia assists in the induction of anesthesia. B. Warming reduces the risk of postoperative infection. C. The risk of bleeding is increased with hypothermia. D. The length of hospital stay is increased with warming.

The risk of bleeding is increased with hypothermia

A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe? A. The tube provides an airway for ventilation. B. The tube protects the client's esophagus from trauma. C. The client may receive an antiemetic through the tube. D. The client's vital signs can be monitored with the tube.

The tube provides an airway for ventilation

A client is postoperative day 6 following tympanoplasty and mastoidectomy. The client has phoned the surgical unit and states experiencing occasional sharp, shooting pains in the affected ear. How should the nurse best interpret this client's report? A. These pains are an expected finding during the first few weeks of recovery. B. The client's report is suggestive of a postoperative infection. C. The client may have experienced a spontaneous rupture of the tympanic membrane. D. The client's surgery may have been unsuccessful.

These pains are an expected finding during the first few weeks of recovery

A nurse is caring for a client who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse explains that the client should self-administer epinephrine at which site? A. Forearm B. Thigh C. Deltoid muscle D. Abdomen

Thigh

A client comes to the ophthalmology clinic for an eye examination. The client tells the nurse that the client often sees floaters in the client's vision. How should the nurse best interpret this subjective assessment finding? A. This is a normal aging process of the eye. B. Glasses will minimize this phenomenon. C. The client may be exhibiting signs of glaucoma. D. This may be a result of weakened ciliary muscles.

This is a normal aging process of the eye

The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority? A. Check the client's oxygen saturation level, and monitor for apnea. B. Tilt the head back and push forward on the angle of the lower jaw. C. Assess the arterial pulses, and place the client in the Trendelenburg position. D. Reintubate the client, and perform a focused assessment.

Tilt the head back and push forward on the angle of the lower jaw

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? A. To prevent chronic obstructive pulmonary disease (COPD) B. To promote optimal lung expansion C. To enhance peripheral circulation D. To prevent pneumothorax

To promote optimal lung expansion

The dressing surrounding a client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A. Describe the appearance of the dressing in the electronic health record. B. Photograph the client's abdomen for later comparison using a smartphone. C. Trace the outline of the drainage on the dressing for future comparison. D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

Trace the outline of the drainage on the dressing for future comparison

A client who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the client's nerve damage. What surgical position places the client at highest risk for nerve damage? A. Trendelenburg B. Prone C. Dorsal recumbent D. Lithotomy

Trendelenburg

The home health nurse is performing a home visit for an oncology client discharged three days ago after completing chemotherapy treatment for non-Hodgkin lymphoma. The nurse's priority assessment should include examination for the signs and symptoms of which complication? A. Tumor lysis syndrome (TLS) B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Disseminated intravascular coagulation (DIC) D. Hypercalcemia

Tumor lysis syndrome (TLS)

A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next? A. Administer a dose of intravenous analgesic. B. Apply a cool cloth to the client's forehead. C. Offer the client a small amount of ice chips. D. Turn the client to one side.

Turn the client to one side

A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV

Type I

The nurse is caring for a client who anticipates pain and anxiety following surgery. Which intervention should the nurse implement in the postoperative period to reduce the client's pain and anxiety? A. Administer NSAIDs for mild-to-moderate pain. B. Encourage the client to increase activity. C. Use guided imagery along with pain medication. D. Teach deep breathing and coughing exercises.

Use guided imagery along with pain medication

A client is admitted to the ED reporting severe abdominal pain and vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled? A. Within 24 hours B. Within the next week C. Without delay D. As soon as all the day's elective surgeries have been completed

Without delay

A nurse is conducting an examination of a client's inner eye. When viewing the retina, which structure(s) would the nurse identify as a retinal landmark? Select all that apply. A. optic disk B. macula C. posterior chamber D. vitreous humor E. ciliary body

optic disk macula

A client is scheduled for audiometry to evaluate hearing. When teaching the client about this test, which characteristic would the nurse include as being evaluated? Select all that apply. A. pitch B. frequency C. intensity D. compliance E. postural control capabilities

pitch frequency intensity