Practice questions!

A. Hematoma

On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest? A. Hematoma B. Hypovolemia C. Infection D. Pulmonary embolus (PE)

D. specific gravity of 1.035

On reading the urinalysis results of a dehydrated pt, the nurse would expect to find A. a pH of 8.4 B. RBCs of 4/hpf C. color: yellow, cloudy D. specific gravity of 1.035

A. obstruction of the urethra

Symptoms of BPH are primarily caused by A. obstruction of the urethra B. untreated chronic prostatitis C. decreased bladder compliance D. excessive secretion of testosterone

C. Manage pain

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is: A. Maintain fluid and electrolyte balance B. Control nausea C. Manage pain D. Prevent urinary tract infection

A. Counsel the woman to consent to HIV screening.

A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? A. Counsel the woman to consent to HIV screening. B. Perform tests for sexually transmitted diseases. C. Discuss her high risk for cervical cancer. D. Refer the client to a family planning clinic.

C. Administer a laxative to the client the evening before the examination.

A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would: A. Instruct the client to maintain a regular diet the day prior to the examination. B. Restrict the client's fluid intake 4 hours prior to the examination. C. Administer a laxative to the client the evening before the examination. D. Inform the client that only 1 x-ray of his abdomen is necessary.

B. Measure the fetal activity

The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to: A. Determine lung maturity B. Measure the fetal activity C. Show the effect of contractions on fetal heart rate D. Measure the wellbeing of the fetus

A. are frequently absent

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydial infection. The nurse understands that Sx of chlamydial infection in women A. are frequently absent B. are similar to those of genital herpes C. include a macular palmar rash in the later stages D. may involve chancres inside the vagina that are not visible

A. Decrease in the level of consciousness

The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention? A. Decrease in the level of consciousness B. Loss of bladder control C. Altered sensation to stimuli D. Emotional lability

D. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol

The nurse is teaching the pt and family that peptic ulcers are A. caused by stressful lifestyle and other acid-producing factors such as H. pylori B. inherited within families and reinforced by bacterial spread of Staph aureus in childhood C. promoted by factors that tend to cause over secretion of acid, such as excess dietary fats, smoking, and H. pylori D. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol

D. Progressive placental insufficiency

The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to: A. Excessive fetal weight B. Low blood sugar levels C. Depletion of subcutaneous fat D. Progressive placental insufficiency

D. adult-onset polycystic kidney disease

The nurse recommends genetic counseling for the children of a pt with A. nephrotic syndrome B. chronic pyelonephritis C. malignant nephrosclerosis D. adult-onset polycystic kidney disease

B. urinate before and after sexual intercourse

The nurse teaches the female pt who has frequent UTIs that she should A. take tub baths with bubble bath B. urinate before and after sexual intercourse C. take prophylactic sulfonamides for the rest of her life D. restrict fluid intake to prevent the need for frequent voiding

A. fluid restriction

The nursing care for a pt with hyponatremia and fluid volume excess includes A. fluid restriction B. Administration of hypotonic IVF C. Administration of a cation-exchange resin D. Placement of an indwelling urinary catheter

D. laparoscopic cholecystectomy is the treatment of choice in most pts who are symptomatic

The nursing management of the pt with cholecystitis associated with cholelithiasis is based on the knowledge that A. shock-wave therapy should be tried initially B. once gallstones are removed, they tend not to recur C. the disorder can be successfully treated with oral bile salts that dissolve gallstones D. laparoscopic cholecystectomy is the treatment of choice in most pts who are symptomatic

A. Position the patient sitting up in bed before you feed her.

The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient? A. Position the patient sitting up in bed before you feed her. B. Check the patient's gag and swallowing reflexes. C. Feed the patient quickly because there are three more waiting. D. Suction the patient's secretions between bites of food.

B. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that A. a lack of clotting factors promotes the collection of blood in the abdominal cavity B. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space C. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel D. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid

A. Tire easily

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will: A. Tire easily B. Grow normally C. Need more calories D. Be more susceptible to viral infections

B. Cerebral hemorrhage.

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy? A. Air embolus. B. Cerebral hemorrhage. C. Expansion of the clot. D. Resolution of the clot.

B. using SCDs

When planning care for a pt at risk for pulmonary embolism, the nurse prioritizes A. maintaining the pt on bed rest B. using SCDs C. encouraging the pt to cough and deep breath D. teaching the pt how to use the IS

C. "Avoid sharing such articles as toothbrushes and razors."

When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction? A. "Put on disposable gloves before bathing." B. "Sterilize all plates and utensils in boiling water." C. "Avoid sharing such articles as toothbrushes and razors." D. "Avoid eating foods from serving dishes shared by other family members."

A. valvular heart disease

When teaching a pt about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of A. valvular heart disease B. pulmonary HTN C. superior vena cava syndrome D. hypertrophy of the RV

A. Assist the patient to reposition every 2 hours. B. Reapply pneumatic compression boots. C. Remind the patient to perform active ROM.

Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. A. Assist the patient to reposition every 2 hours. B. Reapply pneumatic compression boots. C. Remind the patient to perform active ROM. D. Check extremities for redness and edema.

A. use of statins to reduce CVD risk C. use of ACE inhibitors to treat nephropathy E. use of laser photocoagulation to treat retinopathy

Which are appropriate therapies for pts with DM (select all that apply)? A. use of statins to reduce CVD risk B. use of diuretics to treat nephropathy C. use of ACE inhibitors to treat nephropathy D. use of serotonin agonists to decrease appetite E. use of laser photocoagulation to treat retinopathy

C. A blood pressure of 220/120 mmHg.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

D. A 55-year-old African American male.

Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male.

B. Thrombus formation

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A. Angina at rest B. Thrombus formation C. Dizziness D. Falling blood pressure

A. primary cause of death is infection C. disease course in potentially reversible

Which descriptions characterize acute kidney injury (select all that apply) A. primary cause of death is infection B. it almost always affects older people C. disease course in potentially reversible D. most common cause is diabetic nephropathy E. CV disease is most common cause of death

A. older than 65 years D. father diagnosed and treated for early stage prostate cancer

Which factors would place a pt at a higher risk for prostate cancer (select all that apply)? A. older than 65 years B. Asian of Native American C. long-term use of an indwelling catheter D. father diagnosed and treated for early stage prostate cancer E. previous Hx of undescended testicle and testicular cancer

C. Hypertension, oliguria, and fatigue

Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back

A. 45-year-old African-American attorney

Which individual is at the greatest risk for developing hypertension? A. 45-year-old African-American attorney B. 60-year-old Asian-American shop owner C. 40-year-old Caucasian nurse D. 55-year-old Hispanic teacher

A. the best time to take a PRN antacid is 1-3 hrs after meals

Which instructions would the nurse include in a teaching plan for a pt with mild GERD? A. the best time to take a PRN antacid is 1-3 hrs after meals B. a glass of warm milk at bedtime will decrease your discomfort at night C. do not chew gum; the excess saliva will cause you to secrete more acid D. limit your intake of foods high in protein because they take longer to digest

A. administration of antibiotics as ordered

Which is a priority nursing intervention for a pt during the acute phase of rheumatic fever? A. administration of antibiotics as ordered B. management of pain with opioid analgesics C. encouragement of fluid intake for hydration D. performance of frequent active ROM exercises

C. Troponin I

Which of the following blood tests is most indicative of cardiac damage? A. Lactate dehydrogenase B. Complete blood count C. Troponin I D. Creatine kinase

C. Hyperkalemia.

urse Tristan is caring for a male client with acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: A. Hypernatremia. B. Hypokalemia. C. Hyperkalemia. D. Hypercalcemia.

D. Risk for infection

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time? A. Altered tissue perfusion B. Risk for fluid volume deficit C. High risk for hemorrhage D. Risk for infection

B. Explain that this behavior is expected.

A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse? A. Arrange to change client care assignments. B. Explain that this behavior is expected. C. Discuss the appropriate use of "time-out". D. Explain that the child needs extra attention.

B. Pulmonary embolism due to deep vein thrombosis (DVT).

A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms? A. Myocardial infarction due to a history of atherosclerosis. B. Pulmonary embolism due to deep vein thrombosis (DVT). C. Anxiety attacks due to worries about her baby's health. D. Congestive heart failure due to fluid overload.

D. Notify the healthcare provider of the child's status

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first? A. Prepare the child for X-ray of upper airways B. Examine the child's throat C. Collect a sputum specimen D. Notify the healthcare provider of the child's status

A. Expose the cast to air and turn the child frequently.

A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should: A. Expose the cast to air and turn the child frequently. B. Use a heat lamp to reduce the drying time. C. Handle the cast with the abductor bar. D. Turn the child as little as possible.

B. Initiative vs. guilt

A 5-year-old child and has been recently admitted to the hospital. According to Erik Erikson's psychosocial development stages, the child is in which stage? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame and doubt D. Intimacy vs. isolation

B. Nonmobile mass with irregular edges

A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? A. Eversion of the right nipple and mobile mass B. Nonmobile mass with irregular edges C. Mobile mass that is soft and easily delineated D. Nonpalpable right axillary lymph nodes

B. Loss of muscle contraction decreasing venous return.

A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke? A. Elbow contracture secondary to spasticity. B. Loss of muscle contraction decreasing venous return. C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side. D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus.

C. Pneumonia

A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He's being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions? A. Adult respiratory distress syndrome (ARDS) B. Myocardial infarction (MI) C. Pneumonia D. Tuberculosis

C. Schedule for A STAT computer tomography (CT) scan of the head.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.

A. Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.

A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information? A. Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. B. Duchenne's is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease. C. Each child has a 1 in 4 (25%) chance of developing the disorder. D. Sons only have a 1 in 4 (25%) chance of developing the disorder.

C. The tumor extended beyond the kidney but was completely resected.

A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? A. The tumor is less than 3 cm. in size and requires no chemotherapy. B. The tumor did not extend beyond the kidney and was completely resected. C. The tumor extended beyond the kidney but was completely resected. D. The tumor has spread into the abdominal cavity and cannot be resected.

C. Petechiae occur on the soft palate.

A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? A. Scarlet fever is caused by infection with group A Streptococcus bacteria. B. "Strawberry tongue" is a characteristic sign. C. Petechiae occur on the soft palate. D. The pharynx is red and swollen.

B. Chlamydia

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A. Trichomoniasis B. Chlamydia C. Staphylococcus D. Streptococcus

C. Self-blame for the injury to the child

A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent? A. Low self-esteem B. Unemployment C. Self-blame for the injury to the child D. Single status

C. Antecubital space

A common site for the lesions associate with atopic dermatitis is the A. Buttocks B. Temporal area C. Antecubital space D. Plantar surface of the feet

D. The effects of PKU are reversible

A new mother has some questions about phenylketonuria (PKU). Which of the following statements made by a nurse is not correct regarding PKU? A. A Guthrie test can check the necessary lab values B. The urine has a high concentration of phenyl pyruvic acid C. Mental deficits are often present with PKU D. The effects of PKU are reversible

C. renal scan

A diagnostic study that indicates renal blood flow, glomerular filtration, tubular function, and excretion is a(n) A. IVP B. VCUG C. renal scan D. loopogram

D. Glycosylated hemoglobin level.

A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: A. Urine glucose level. B. Fasting blood glucose level. C. Serum fructosamine level. D. Glycosylated hemoglobin level.

A. assess temperature and initiate workup to rule out infection

A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? A. assess temperature and initiate workup to rule out infection B. reassure the pt that this is common after transplantation C. provide warm cover for the pt and give 1 g acetaminophen orally D. notify the nephrologist that the pt has developed Sx of acute rejection

B. Cloudy CSF, elevated protein, and decreased glucose.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose. B. Cloudy CSF, elevated protein, and decreased glucose. C. Clear CSF, elevated protein, and decreased glucose. D. Clear CSF, decreased pressure, and elevated protein.

A. the diet is less restrictive and dialysis can be performed at home

A major advantage of peritoneal dialysis is A. the diet is less restrictive and dialysis can be performed at home B. the dialysate is biocompatible and causes no long-term complications C. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss D. no medications are required because of the enhanced efficacy of the peritoneal membrane in removing toxins

A. applying pyrethrins to the body

A mother and her two children have been diagnoses with pediculosis corporis at a health care center. An appropriate measure in treating this condition is A. applying pyrethrins to the body B. topical application of griseofulvin C. moist compresses applied frequently D. administration od systemic antibiotics

A. Small blue-white spots are visible on the oral mucosa.

A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? A. Small blue-white spots are visible on the oral mucosa. B. The rash begins on the trunk and spreads outward. C. There is low-grade fever. D. The lesions have a "teardrop-on-a-rose-petal" appearance.

B. production of testosterone

A normal male reproductive function that may be altered in a pt who undergoes an orchiectomy (removal of testes) is A. production of GnRH B. production of testosterone C. production of progesterone D. production of seminal fluid

B. Contaminated food

A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? A. Sexual contact with an infected partner B. Contaminated food C. Blood transfusion D. Illegal drug use

B. Impaired tissue integrity r/t decreased blood flow secondary to diabetes and smoking

A nurse is caring for a pt with diabetes who is scheduled for amputation of his necrotic left great toe. The pt's WBC count is 15.0x10^6 /uL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes 2 packs of cigarettes per day. Which priorirt nursing Dx addresses the primary factor affecting the pt's ability to heal? A. Imbalanced nutrition: obesity r/t high-fat foods B. Impaired tissue integrity r/t decreased blood flow secondary to diabetes and smoking C. Ineffective peripheral tissue perfusion r/t narrowed blood vessels secondary to diabetes and smoking D. Ineffective individual coping r/t indifference and denial of the long-term effects of diabetes and smoking

B. Weight gain

A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A. Slow pulse rate B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values

B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg

A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.

D. Cl. difficile

A nurse is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans? A. S. pneumoniae B. H. influenzae C. N. meningitidis D. Cl. difficile

D. Air hunger

A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit? A. Slow, deep respirations B. Stridor C. Bradycardia D. Air hunger

A. Family history of heart disease

A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis? A. Family history of heart disease B. Overweight C. Smoking D. Age

A. Apply pressure to the needle site upon discontinuing hemodialysis.

A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care? A. Apply pressure to the needle site upon discontinuing hemodialysis. B. Keep the head of the bed elevated 45 degrees. C. Place the left arm on an arm board for at least 30 minutes. D. Keep the left arm dry.

C. The NA performs the patient's complete bath and oral care.

A patient with Parkinson's disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene? A. The NA assists the patient to ambulate to the bathroom and back to bed. B. The NA reminds the patient not to look at his feet when he is walking. C. The NA performs the patient's complete bath and oral care. D. The NA sets up the patient's tray and encourages the patient to feed himself.

D. Check blood pressure.

A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? A. Ask the patient to lie down on the exam table. B. Draw blood for chemistry panel and arterial blood gas (ABG). C. Send the patient for a chest x-ray. D. Check blood pressure.

A. Increased appetite

A patient's chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute? A. Increased appetite B. Vomiting C. Fever D. Poor tolerance of light

A. exercise such as walking E. breathing exercises such as pursed-lip breathing that focus on exhalation

A plan of care for the pt with COPD could include (select all that apply) A. exercise such as walking B. high flow rate of O2 administration C. low-dose chronic oral corticosteroid therapy D. use of peak flow meter to monitor the progression of COPD E. breathing exercises such as pursed-lip breathing that focus on exhalation

D. Disseminated intravascular coagulation (DIC)

A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks' gestation. She's at risk for which of the following blood dyscrasias? A. Heparin-associated thrombosis and thrombocytopenia (HATT) B. Idiopathic thrombocytopenic purpura (ITP) C. Thrombocytopenia D. Disseminated intravascular coagulation (DIC)

B. Sx are less severe during recurrent episodes D. lesions from recurrent HSV are more likely to transmit the virus than lesions from primary HSV

A primary HSV infection differs from recurrent HSV episodes in that (select all that apply) A. only primary infections are sexually transmitted B. Sx are less severe during recurrent episodes C. systemic manifestations such as fever and myalgia are more common in primary infection D. lesions from recurrent HSV are more likely to transmit the virus than lesions from primary HSV

D. Explain the pain management plan, including the use of a pain rating scale

A priority nursing intervention to assist a preoperative pt in coping with fear of post-op pain would be to A. Inform the pt that pain meds will be available B. Teach the pt to use guided imagery to help manage pain C. Describe the type of pain expected with the pt's particular surgery D. Explain the pain management plan, including the use of a pain rating scale

B. The pt is having a normal inflammatory response

A pt 1 day post-op after abdominal surgery has incisional pain, 99.5F temp, slight erythema at the incision margins, and 30 ml serosanguineous drainage in the J-P drain. Based on this assessment, what conclusion would the nurse make? A. The abdominal incision shows signs of an infection B. The pt is having a normal inflammatory response C. The abdominal incision shows signs of impending dehiscence D. The pt's physician must be notified about her condition

B. recommending a heart-healthy diet

A pt has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease. The nursing teaching plan should include A. having genetic testing done B. recommending a heart-healthy diet C. the necessity to reduce weight rapidly D. avoiding alcohol until liver enzymes return to normal

D. parasympathetic stimulation

A pt is admitted to the hospital with a Dx of diarrhea with dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to A. sympathetic inhibition B. mixing and propulsion C. sympathetic stimulation D. parasympathetic stimulation

A. progressive irreversible destruction of the kidneys

A pt is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by A. progressive irreversible destruction of the kidneys B. a rapid decrease in UO with an elevated BUN C. an increasing creatinine clearance with a decrease in UO D. prostration, somnolence, and confusion with coma and imminent death

A. administer opioids as prescribed

A pt is admitted to the hospital with severe renal colic. The nurse's first priority in management of the pt is to A. administer opioids as prescribed B. obtain supplies for straining all urine C. encourage fluid intake of 3-4 L/day D. keep the pt NPO in preparation for surgery

A. allergic rhinitis C. Hx of skin allergies D. cough, especially at night E. gastric reflux or heartburn

A pt is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which ones suggest asthma or risk factors for asthma (select all that apply) A. allergic rhinitis B. prolonged inhalation C. Hx of skin allergies D. cough, especially at night E. gastric reflux or heartburn

C. Continue to closely monitor the pt

A pt is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/min. The most appropriate nursing action in this situation is to: A. stop the PCA infusion B. Obtain an oxygen saturation level C. Continue to closely monitor the pt D. Administer naloxone and contact the physician

C. begin an exercise program that aims for at least 5 30min sessions per wk

A pt is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? A. refrain from sexual activity for a minimum of 3 wks B. plan a diet program that aims for a 1-2 lb weight loss per week C. begin an exercise program that aims for at least 5 30min sessions per wk D. consider the use of erectile agents and prophylactic NTG before engaging in sexual activity

A. pruritus is a common problem with jaundice in this phase

A pt with Hepatitis A is in the acute phase. The nurse plans care for the pt based on the knowledge that A. pruritus is a common problem with jaundice in this phase B. the pt is most likely to transmit the disease during this phase C. GI symptoms are not as severe in Hepatitis A as they are in Hepatitis B D. extrahepatic manifestations of glomerulonephritis and polyarthritis are common in this phase

B. use a condom during sexual intercourse

A pt with acute Hepatitis B is being discharged in 2 days. The discharge teaching plan should include instructions to A. avoid alcohol for the 1st 3 wks B. use a condom during sexual intercourse C. have family members get an injection of immunoglobulin D. follow a low-protein, moderate-carb, moderate-fat diet

B. glomerular filtration

A pt with kidney disease has oliguria and a creatinine clearance of 40 mL/min. These findings most directly reflect abnormal function of A. tubular secretion B. glomerular filtration C. capillary permeability D. concentration of filtrate

D. collection and drainage of urine from the kidney

A renal stone in the pelvis of the kidney will alter the function of the kidney by interfering with the A. structural support of the kidney B. regulation of the concentration of kidney C. entry and exit of blood vessels at the kidney D. collection and drainage of urine from the kidney

A. Urine specific gravity of 1.040 B. Urine output of 350 ml in 24 hours C. Brown ("tea-colored") urine

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply. A. Urine specific gravity of 1.040 B. Urine output of 350 ml in 24 hours C. Brown ("tea-colored") urine D. Generalized edema

A. Regular developmental screening is important to avoid secondary developmental delays. B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. D. Parent support groups are helpful for sharing strategies and managing health care issues.

A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply. A. Regular developmental screening is important to avoid secondary developmental delays. B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. C. Developmental milestones may be slightly delayed but usually will require no additional intervention. D. Parent support groups are helpful for sharing strategies and managing health care issues. E. Therapies and surgical interventions can cure cerebral palsy.

C. Autonomy vs. shame and doubt

A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame and doubt D. Intimacy vs. isolation

D. Intimacy vs. isolation

A young adult is 20 years old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation

B. Lack of acquired resistance to the various etiologic organisms.

Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges. B. Lack of acquired resistance to the various etiologic organisms. C. Occlusion or narrowing of the CSF pathway. D. Natural affinity of the CNS to certain pathogens.

A. Left-sided heart failure

After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? A. Left-sided heart failure B. Pulmonic valve malfunction C. Right-sided heart failure D. Tricuspid valve malfunction

D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain.

After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching. B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast. D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain.

A. Abduction

After surgical repair of a hip, which of the following positions is best for the patient's legs and hips? A. Abduction B. Adduction C. Prone D. Subluxated

A. "I would like to add weight lifting to my exercise program"

After teaching about ways to decrease risk factors for CAD, the nurse recognized that additional instruction is needed when the pt says A. "I would like to add weight lifting to my exercise program" B. "I can only keep my blood pressure normal with medication" C. "I can change my diet to decreased my intake of saturated fats" D. "I will change my lifestyle to reduce activities that increase my stress"

C. Recent sore throat

An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? A. Renal calculi B. Renal trauma C. Recent sore throat D. Family history of acute glomerulonephritis

A. successful transplantation usually provides better quality of life than that offered by dialysis

An ESRD pt receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the pt to make a decision about Tx, the nurse informs the pt that A. successful transplantation usually provides better quality of life than that offered by dialysis B. if rejection of the transplanted kidney occurs, no further Tx for the renal failure is available C. hemodialysis replaces the normal functions of the kidneys, and pts do not have to live with the continual fear of rejection D. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of Tx if the kidney fails

C. slight clear urethral discharge

An abnormal finding noted during physical assessment of the male reproductive system is A. descended testes B. symmetric scrotum C. slight clear urethral discharge D. the glans covered with prepuce

D. When in your menstrual Hx did the pain with your period begin?

An appropriate question to ask the pt with painful menstruation to differentiate primary from secondary dysmenorrhea is A. Does your pain become worse with activity or overexertion? B. Have you had recent personal crisis or change in your lifestyle? C. Is your pain relieved by NSAIDS? D. When in your menstrual Hx did the pain with your period begin?

C. Believe what the pt says about the pain

An important nursing responsibility related to pain is to: A. Leave the pt alone to rest B. Help the pt appear to not be in pain C. Believe what the pt says about the pain D. Assume responsibility for eliminating the pt's pain

A. Torticollis, with shortening of the sternocleidomastoid muscle.

An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation? A. Torticollis, with shortening of the sternocleidomastoid muscle. B. Craniosynostosis, with premature closure of the cranial sutures. C. Plagiocephaly, with flattening of one side of the head. D. Hydrocephalus, with increased head size.

A. Weight loss B. Dry oral mucosa E. Decreased central venous pressure

An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (select all that apply): A. Weight loss B. Dry oral mucosa C. Full bounding pulse D. Engorged neck veins E. Decreased central venous pressure

A. Surgery will involve multiple small incisions

An overweight pt (BMI of 28.1) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that A. Surgery will involve multiple small incisions B. This setting is not appropriate for this procedure C. Surgery will involve removing a portion of the liver D. The pt will need special preparation because of obesity

A. Turn him frequently.

Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should: A. Turn him frequently. B. Perform passive range-of-motion (ROM) exercises. C. Reduce the client's fluid intake. D. Encourage the client to use a footboard.

D. It is not "caught" but is a response to a previous B-hemolytic strep infection.

Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent's remark: "We just don't know how he caught the disease!" The nurse's response is based on an understanding that: A. AGN is a streptococcal infection that involves the kidney tubules. B. The disease is easily transmissible in schools and camps. C. The illness is usually associated with chronic respiratory infections. D. It is not "caught" but is a response to a previous B-hemolytic strep infection.

C. Hematuria and proteinuria

Clinical manifestations of acute glomerulonephritis include which of the following? A. Chills and flank pain B. Oliguria and generalized edema C. Hematuria and proteinuria D. Dysuria and hypotension

B. time at which stroke Sx first appeared

For a pt who is suspected of having a stroke, one of the most important pieces of info that the nurse can obtain is A. time of the pt's last meal B. time at which stroke Sx first appeared C. pt's HTN Hx and management D. family Hx of stroke and other CV diseases

A. urine B. vagina C. urethra D. rectum E. endocervix

Cultures used in the Dx of STIs can be obtained from (select all that apply) A. urine B. vagina C. urethra D. rectum E. endocervix

C. decreased function of the loop of Henle and tubules

Diminished ability to concentrate urine, associated with aging of the urinary system, is attributed to A. a decrease in bladder sensory receptors B. a decrease in the number of functioning nephrons C. decreased function of the loop of Henle and tubules D. thickening of the basement membrane of Bowman's capsule

B. A fixed nodular mass with dimpling of the overlying skin

During a breast examination, which finding most strongly suggests that the Luz has breast cancer? A. Slight asymmetry of the breasts B. A fixed nodular mass with dimpling of the overlying skin C. Bloody discharge from the nipple D. Multiple firm, round, freely movable masses that change with the menstrual cycle

A. Osmosis

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is: A. Osmosis B. Diffusion C. Active transport D. Facilitated diffusion

A. cannot palpate the left kidney

During physical assessment of the urinary system, the nurse A. cannot palpate the left kidney B. palpates an empty bladder as a small nodule C. finds a dull percussion sound when 100 ml of urine is present in the bladder D. palpates above the symphysis pubis to determine the level of urine in the bladder

B. Psoriasis

During the assessment of a pt, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the pt's knees and elbows. You recognize this finding as A. Lentigo B. Psoriasis C. Actinic keratosis D. Seborrheic keratosis

C. Blood pressure

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

B. ECG changes D. pulmonary edema

During the oliguric phase of AKI, the nurse monitors the pt for (Select all that apply) A. hypotension B. ECG changes C. hypernatremia D. pulmonary edema E. urine with high specific gravity

D. Small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults

During the post-op care of a 76 yr old pt, the nurse monitors the pt's I&O carefully, knowing that the pt is at risk for fluid and electrolyte imbalanced primarily because: A. Older adults have an impaired thirst mechanism and need reminding to drink fluids B. Water accounts for a greater percentage of body weight in the older adult than in younger adults C. Older adults are more likely thank younger adults to lose ECF during surgical procedures D. Small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults

D. the increasing rates of drug resistance requires the use of at least 2 drugs

Explain to the pt with Gonorrhea that Tx will include both ceftriaxone and azithromycin because A. azithromycin help prevents recurrent infections B. some pts do not respond to oral drugs alone C. coverage with more than one antibiotic will prevent reinfection D. the increasing rates of drug resistance requires the use of at least 2 drugs

A. Altered mental status and dehydration

Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and Dyspnea D. Pleuritic chest pain and cough

C. hypokalemia and hyponatremia

If the pt is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? A. hyperkalemia and hyponatremia B. Hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia

A. syphilis B. gonorrhea C. genital warts D. genital herpes E. chlamydial infection

In assessing pts for STIs, the nurse needs to know that many STIs can be asymptomatic. Which STIs can be asymptomatic (select all that apply)? A. syphilis B. gonorrhea C. genital warts D. genital herpes E. chlamydial infection

C. Bedwetting

In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? A. Polyphagia B. Dehydration C. Bedwetting D. Weight loss

C. often recurs after surgery, whereas UC is curable with a colectomy

In planning care for a pt with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease A. frequently results in toxic megacolon B. causes fewer nutritional deficiencies than UC C. often recurs after surgery, whereas UC is curable with a colectomy D. is manifested by rectal bleeding and anemia more often than is UC

A. teaching the pt to use kegel exercises

In planning nursing interventions to increase bladder control in the pt with urinary incontinence, the nurse includes A. teaching the pt to use kegel exercises B. clamping and releasing a catheter to increase bladder tone C. teaching the pt biofeedback mechanisms to suppress the urge to void D. counseling the pt concerning choice of incontinence containment device

D. "I'll need to have a C-section if I become pregnant and have a baby."

In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says: A. The baby can get the virus from my placenta." B. "I'm planning on starting on birth control pills." C. "Not everyone who has the virus gives birth to a baby who has the virus." D. "I'll need to have a C-section if I become pregnant and have a baby."

A. Acute asthma

Mark, a 7-year-old client, is brought to the emergency department. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions? A. Acute asthma B. Bronchial pneumonia C. Chronic obstructive pulmonary disease (COPD) D. Emphysema

B. abnormal levels of cholesterol, especially low-density lipoproteins C. accumulation of lipid and fibrous tissue within the coronary arteries D. development of angina due to a decreased blood supply to the heart muscle

In teaching a pt about coronary artery disease, the nurse explains that the changes that occur in this disorder include (Select all that apply) A. diffuse involvement of plaque formation in coronary veins B. abnormal levels of cholesterol, especially low-density lipoproteins C. accumulation of lipid and fibrous tissue within the coronary arteries D. development of angina due to a decreased blood supply to the heart muscle E. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

B. short-term use of topical corticosteroids usually does not cause systemic side effects D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis

In teaching a pt who is using topical corticosteroids to treat acute dermatitis, the nurse should tell the pt that (select all that apply) A. the cream form is the most efficient system of delivery B. short-term use of topical corticosteroids usually does not cause systemic side effects C. apply creams and ointments with a glove in small amounts to prevent further infection D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis E. Systemic side effects may be experience from topical corticosteroids if the person in malnourished

D. an ascending infection

In teaching a pt with pyelonephritis about the disorder, the nurse informs the pt that the organisms that cause pyelonephritis most commonly reach the kidneys through A. the bloodstream B. the lymphatic system C. a descending infection D. an ascending infection

B. a hysterosalpingogram is a common diagnostic study

In telling a pt with infertility what she and her partner can expect, the nurse explains that A. ovulatory studies can help determine tube patency B. a hysterosalpingogram is a common diagnostic study C. the cause will remain unexplained for 40% of couples D. if postcoital studies are normal, infection tests will be done

D. sudden onset of severe HA

Information provided by the pt that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes A. sensory disturbance B. a Hx of HTN C. presence of motor weakness D. sudden onset of severe HA

C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.

Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test is consistent with CRF if the result is: A. Increased pH with decreased hydrogen ions. B. Increased serum levels of potassium, magnesium, and calcium. C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl. D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

D. Alteration in the size, shape, and organization of differentiated cells

Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide? A. Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin. B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found. D. Alteration in the size, shape, and organization of differentiated cells.

A. The left kidney usually is slightly higher than the right one.

Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind? A. The left kidney usually is slightly higher than the right one. B. The kidneys are situated just above the adrenal glands. C. The average kidney is approximately 5 cm (2 inches) long and 2 to 3 cm 3/4 inch to 1 1/8 inch) wide. D. The kidneys lie between the 10th and 12th thoracic vertebrae.

A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. D. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.

A. nonpalpable left kidney D. no CVA tenderness elicited by a kidney punch

Normal findings by the nurse on physical assessment of the urinary system include (select all that apply) A. nonpalpable left kidney B. auscultation of renal artery bruit C. CVA tenderness elicited by a kidney punch D. no CVA tenderness elicited by a kidney punch E. palpable bladder to the level of the pubic symphysis

C. The recommended daily allowance of calcium may be found in a wide variety of foods

Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct? A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. B. To avoid fractures, the client should avoid strenuous exercise. C. The recommended daily allowance of calcium may be found in a wide variety of foods D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

C. Changes from previous examinations

Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover: A. Cancerous lumps B. Areas of thickness or fullness C. Changes from previous examinations D. Fibrocystic masses

A. Bone fracture

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager's hump

B. Warm the dialysate solution.

Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first? A. Assess for a bruit and a thrill. B. Warm the dialysate solution. C. Position the client on the left side. D. Insert a Foley catheter

A. older African Americans B. pts more than 60 yrs old D. those with a Hx of HTN E. those with a Hx of DM type 2

Nurses must teach pts at risk for developing chronic kidney disease. Individuals considered to be at risk include (Select all that apply) A. older African Americans B. pts more than 60 yrs old C. those with a Hx of pancreatitis D. those with a Hx of HTN E. those with a Hx of DM type 2

A. checking for signs of hypocalcemia E. monitoring for infection, particularly respiratory tract infection

Nursing management of the pt with acute pancreatitis includes (select all that apply) A. checking for signs of hypocalcemia B. providing a diet low in carbs C. giving insulin based on a sliding scale D. observing stools for signs of steatorrhea E. monitoring for infection, particularly respiratory tract infection

A. fluid is not usually restricted for pts receiving peritoneal dialysis B. Na and K may be restricted in someone with advanced CKD C. decreased fluid intake and a low-potassium diet are hallmarks of the diet for a pt receiving hemodialysis

Nutritional support and management are essential across the entire continuum of CKD. Which statements would be considered true related to nutritional therapy (select all that apply) A. fluid is not usually restricted for pts receiving peritoneal dialysis B. Na and K may be restricted in someone with advanced CKD C. decreased fluid intake and a low-potassium diet are hallmarks of the diet for a pt receiving hemodialysis D. decreased fluid intake and a low-potassium diet are hallmarks of the diet for a pt receiving peritoneal dialysis E. decreased fluid intake and a diet with phosphate-rich foods are hallmarks of a diet for a pt receiving hemodialysis

D. 65 y/o African American man with HTN

Of the following pts, the nurse recognizes that the one with the highest risk for a stroke is a(n) A. obese 45 y/o Native American B. 35 y/o Asian American woman who smokes C. 32 y/o White woman taking oral contraceptives D. 65 y/o African American man with HTN

A. promote early Dx and Tx of sore throats and skin lesions

One of the nurse's most important roles in relation to acute poststreptococcal glomerulonephritis (APSGN) is to A. promote early Dx and Tx of sore throats and skin lesions B. teach pts to obtain antibiotic therapy for upper respiratory tract infections C. teach pts with APSGN that long-term prophylactic antibiotic therapy is necessary to prevent recurrence D. monitor pts for respiratory Sx that indicate the disease is affecting the alveolar basement membrane

B. fluid shifts resulting from the osmotic effect of hyperglycemia

Polydipsia and polyuria related to diabetes mellitus are primarily due to A. the release of ketones from cells during fat metabolism B. fluid shifts resulting from the osmotic effect of hyperglycemia C. damage to the kidneys from exposure to high levels of glucose D. changes in RBCs resulting from attachment of excessive glucose to hemoglobin

C. Recognizing that sensory deficits may be present D. Providing warm blankets to prevent hypothermia

Preoperative considerations for older adults include (select all that apply) A. Using only large-print educational materials B. Speaking louder for patients with hearing aids C. Recognizing that sensory deficits may be present D. Providing warm blankets to prevent hypothermia E. Teaching important information early in the morning

B. the lens becomes inflexible

Presbyopia occurs in older individuals because A. the eyeball elongates B. the lens becomes inflexible C. the corneal curvature becomes irregular D. light rays are focusing in front of the retina

A. HTN B. vascular calcifications D. hyperinsulinemia causing dyslipidemia

Pts with chronic kidney disease experience an increased incidence of CV disease r/t (select all that apply) A. HTN B. vascular calcifications C. a genetic predisposition D. hyperinsulinemia causing dyslipidemia E. increased high-density lipoprotein levels

D. serum creatinine or UO from baseline

RIFLE defines three stages of AKI based on changed in A. BP and urine osmolality B. fractional excretion of urinary sodium C. estimation of GFR with the MDRD equation D. serum creatinine or UO from baseline

C. RH negative, RH positive

Rhogam is most often used to treat____ mothers that have a ____ infant. A. RH positive, RH positive B. RH positive, RH negative C. RH negative, RH positive D. RH negative, RH negative

A. tobacco use C. current pain level E. previous STIs

Significant info about a person's health history related to the reproductive system should include (select all that apply) A. tobacco use B. intellectual status C. current pain level D. previous Hx of shingles E. previous STIs

B. reporting any bile-colored drainage or pus from any incision

Teaching in relation to home management after a laparoscopic cholecystectomy should include A. keeping the bandages on the puncture sites for 48 hrs B. reporting any bile-colored drainage or pus from any incision C. using OTC antiemetics in N/V occur D. emptying and measuring the contents of the bile bag from the T tube every day

D. Scoliosis

The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? A. Spinal flexibility B. Leg length disparity C. Hypostatic blood pressure D. Scoliosis

D. The patient should limit fatty foods.

The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? A. The patient must maintain a low-calorie diet. B. The patient must maintain a high protein/low carbohydrate diet. C. The patient should limit sweets and sugary drinks. D. The patient should limit fatty foods.

D. decreased colloidal osmotic pressure caused by loss of serum albumin

The edema that occurs in nephrotic syndrome is due to A. increased hydrostatic pressure caused by sodium retention B. decreased aldosterone secretion from adrenal insufficiency C. increased fluid retention caused by decreased glomerular filtration D. decreased colloidal osmotic pressure caused by loss of serum albumin

C. degree of collateral circulation

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the A. amount of cardiac output B. O2 content of the blood C. degree of collateral circulation D. level of CO2 in the blood

B. deposition of immune complexes and complement along the GBM

The immunologic mechanisms involved in acute poststreptococcal glomerulonephritis (APSGN) include A. tubular blocking by precipitates of bacteria and antibody reactions B. deposition of immune complexes and complement along the GBM C. thickening of the GBM from autoimmune microangiopathic changes D. destruction of glomeruli by proteolytic enzymes contained in the GBM

B. barrier methods of contraception

The individual with the lowest risk for sexually transmitted pelvic inflammatory disease is a woman who uses A. oral contraceptives B. barrier methods of contraception C. in IUD for contraception D. Norplant implant or injectable Depo-Provera for contraception

A. Digoxin

The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which medication? A. Digoxin B. Epinephrine C. Aminophylline D. Atropine

C. left ventricular dysfunction

The most common common finding in individuals at risk for sudden cardiac death is A. aortic valve disease B. mitral valve disease C. left ventricular dysfunction D. atherosclerotic heart disease

B. Elevated BUN level

The most common early sign of kidney disease is: A. Sodium retention B. Elevated BUN level C. Development of metabolic acidosis D. Inability to dilute or concentrate urine

D. Normally, the testes descend by one year of age.

The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate? A. Normally, the testes are descended by birth. B. The infant will likely require surgical intervention. C. The infant probably has only one testis. D. Normally, the testes descend by one year of age.

B. Impetigo of the face

The nurse determines that a pt with a diagnosis of which disorder is most at risk for spreading the disease? A. Tinea pedis B. Impetigo of the face C. Candidiasis of the nails D. Psoriasis on the palms and soles

B. Calcium supplements

The nurse expects long-term treatment of a pt with hyperphosphatemia secondary to renal failure will include A. Fluid restriction B. Calcium supplements C. Magnesium supplements D. Increased intake of dairy products

B. tobacco use

The nurse identifies a risk factor for kidney and bladder cancer in a pt who relates a history of A. aspirin use B. tobacco use C. chronic alcohol use D. use of artificial sweeteners

hyperparathyroidism

The nurse identifies a risk for urinary calculi in a pt who relates a past health Hx that includes A. hyperaldosteronism B. serotonin deficiency C. adrenal insufficiency D. hyperparathyroidism

A. Unequal leg length

The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A. Unequal leg length B. Limited adduction C. Diminished femoral pulses D. Symmetrical gluteal folds

D. common changes in endometrial cells in relation to progesterone levels will be assessed

The nurse is caring for a pt schedule for an endometrial biopsy who is having difficulty becoming pregnant. The nurse explains to the woman that A. the outpatient procedure is usually done preovulation B. bleeding and discharge is common 2-4 days after the procedure C. a small sample of tissue is obtained to Dx and treat cervical dysplasia D. common changes in endometrial cells in relation to progesterone levels will be assessed

B. History of cerebral hemorrhage

Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency department following the onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? A. Worsening chest pain that began earlier in the evening B. History of cerebral hemorrhage C. History of prior myocardial infarction D. Hypertension

C. palpate the area of the graft to feel a normal thrill D. listen with a stethoscope over the graft to detect a bruit E. frequently monitor the pulses and neurovascular status distal to the graft

To assess the patency of a newly placed AV graft for dialysis, the nurse should (select all that apply) A. monitor the BP in the affected arm B. irrigate the graft daily with low-dose heparin C. palpate the area of the graft to feel a normal thrill D. listen with a stethoscope over the graft to detect a bruit E. frequently monitor the pulses and neurovascular status distal to the graft

C. performing regular aerobic, weight-bearing exercise

To prevent or decrease age-related changes that occur after menopause in a pt who chooses not to take hormone therapy, the most important self-care measure to teach is A. maintaining usual sexual activity B. increasing the intake of dairy products C. performing regular aerobic, weight-bearing exercise D. taking vitamin E and B complex supplements

A. Prostate-specific antigen, which is used to screen for prostate cancer.

Vic asks the nurse what PSA is. The nurse should reply that it stands for: A. Prostate-specific antigen, which is used to screen for prostate cancer. B. Protein serum antigen, which is used to determine protein levels. C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia. D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

A. Disappearance of protein from the urine.

What change indicates recovery in a patient with nephritic syndrome? A. Disappearance of protein from the urine. B. Decrease in blood pressure to normal. C. Increase in serum lipid levels. D. Gain in body weight.

B. Pupil size and pupillary response

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

A. 15 minutes

What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure? A. 15 minutes B. 30 minutes C. 1 hour D. 2 to 3 hours

C. Arrhythmias

What is the most common complication of a myocardial infarction? A. Cardiogenic shock B. Heart failure C. Arrhythmias D. Pericarditis

D. To decrease oxygen demand on the client's heart

What is the primary reason for administering morphine to a client with myocardial infarction? A. To sedate the client B. To decrease the client's pain C. To decrease the client's anxiety D. To decrease oxygen demand on the client's heart

B. Fluid volume excess

What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? A. Activity intolerance B. Fluid volume excess C. Knowledge deficit D. Pain

D. Yearly weight gain of about 5.5 pounds per year

What would the nurse expect to see while assessing the growth of children during their school-age years? A. Decreasing amounts of body fat and muscle mass B. Little change in body appearance from year to year C. Progressive height increase of 4 inches each year D. Yearly weight gain of about 5.5 pounds per year

A. auscultating lung sounds

When caring for a pt with acute bronchitis, the nurse will prioritize A. auscultating lung sounds B. encouraging fluid restriction C. administering antibiotic therapy D. teaching the pt to avoid cough suppressants

A. being a women over age 60

When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is A. being a women over age 60 B. experiencing menstruation for 30 years or more C. using hormone therapy for 5 years for menopausal symptoms D. having a paternal grandmother with postmenopausal breast cancer

B. Middle ear infection

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A. Bladder infection B. Middle ear infection C. Fractured clavicle D. Septic arthritis

D. Right-sided heart failure

Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? A. Angina pectoris B. Cardiomyopathy C. Left-sided heart failure D. Right-sided heart failure

C. Coronary artery thrombosis

Which of the following conditions is most commonly responsible for myocardial infarction? A. Aneurysm B. Heart failure C. Coronary artery thrombosis D. Renal failure

B. Prior infection with group A Streptococcus within the past 10-14 days.

Which of the following conditions most commonly causes acute glomerulonephritis? A. A congenital condition leading to renal dysfunction. B. Prior infection with group A Streptococcus within the past 10-14 days. C. Viral infection of the glomeruli. D. Nephrotic syndrome.

B. Fluid and electrolyte balance

Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management B. Fluid and electrolyte balance C. Management of hypoglycemia D. Pain control

D. No special orders are necessary for this examination

Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test? A. Client must be NPO before the examination B. Enema to be administered prior to the examination C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination D. No special orders are necessary for this examination

B. Costovertebral angle tenderness and chills

Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? A. Jaundice and flank pain B. Costovertebral angle tenderness and chills C. Burning sensation on urination D. Polyuria and nocturia

C. A 50 y.o. postmenopausal woman

Which patient is at greatest risk for developing a urinary tract infection (UTI)? A. A 35 y.o. woman with a fractured wrist B. A 20 y.o. woman with asthma C. A 50 y.o. postmenopausal woman D. A 28 y.o. with angina

C. 42 yr old woman with SLE and renal failure

Which pt is at greatest risk for developing hypermagnesemia? A. 83 yr old man with lung cancer and HTN B. 65 yr old woman with HTN taking beta-adrenergic blockers C. 42 yr old woman with SLE and renal failure D. 50 yr old man with BPH and a UTI

D. the pt may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome

Which statement would be correct for a pt with DM type 2 who was admitted to the hospital with pneumonia? A. the pt must receive insulin therapy to prevent ketoacidosis B. the pt has islet cell antibodies that have destroyed the pancreas's ability to produce insulin C. the pt has minimal or absent endogenous insulin secretion and requires daily insulin injections D. the pt may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome

B. speak normally and slowly E. write out names or difficult words

Which strategies would best assist the nurse in communicating with a pt who has a hearing loss (select all that apply)? A. overenunciated speech B. speak normally and slowly C. exaggerate facial expressions D. raise voice to a higher pitch E. write out names or difficult words

C. Inspiratory grunt E. Nasal flaring F. Cyanosis G. Asymmetric chest movement

While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? (Select all that apply) A. Abdominal respirations B. Irregular breathing rate C. Inspiratory grunt D. Increased heart rate with crying E. Nasal flaring F. Cyanosis G. Asymmetric chest movement

B. Massage the fundus.

While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? A. Check vital signs. B. Massage the fundus. C. Offer a bedpan. D. Check for perineal lacerations.

B. They are able to think logically in organizing facts.

While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age? A. They are able to make simple associations of ideas. B. They are able to think logically in organizing facts. C. Interpretation of events originates from their own perspective. D. Conclusions are based on previous experiences.

B. Separation from parents.

While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? A. Strange bed and surroundings. B. Separation from parents. C. Presence of other toddlers. D. Unfamiliar toys and games.

C. "I understand the need to use those new skills."

While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A. "I want to protect my child from any falls." B. "I will set limits on exploring the house." C. "I understand the need to use those new skills." D. "I intend to keep control over our child."

C. Turn the patient to the side and protect the airway.

While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. B. Administer lorazepam (Ativan) 1 mg IV. C. Turn the patient to the side and protect the airway. D. Assess level of consciousness during and immediately after the seizure.

A. insulin administration D. use of a portable blood glucose monitor E. hypoglycemia prevention, Sx, and Tx

You are caring for a pt with newly diagnosed DM type 1. What information is essential to include in your pt teaching before discharge from the hospital (select all that apply)? A. insulin administration B. elimination of sugar from the diet C. need to reduce physical activity D. use of a portable blood glucose monitor E. hypoglycemia prevention, Sx, and Tx

D. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relive some discomfort

You are caring for a young woman who has painful fibrocystic breast changes. Management of this pt would include A. scheduling a biopsy to rule out malignant changes B. teaching that Sx will probably subside if she stops using oral contraceptives C. preparing her for surgical removal of the lumps, since they will become larger and more painful D. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relive some discomfort

B. Set up oxygen and suction equipment

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment B. Set up oxygen and suction equipment C. Place a padded tongue blade at the bedside D. Pad the side rails before the patient arrives

C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain."

You are providing care for a patient with an acute hemorrhage stroke. The patient's husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response? A. "Your wife was not admitted within the time frame that alteplase is usually given." B. "This drug is used primarily for patients who experience an acute heart attack." C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." D. "Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase."

A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression.

You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene? A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression. B. The student moves the patient's tray to the right side of her over-bed tray. C. The student assists the patient with passive range-of-motion (ROM) exercises. D. The student combs the left side of the patient's hair when the patient combs only the right side.

A. Check for kinks in the outflow tubing.

You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing. B. Raise the drainage bag above the level of the abdomen. C. Place the patient in a reverse Trendelenburg position. D. Ask the patient to cough.

B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.

You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? A. Administer codeine 15 mg orally for the patient's headache. B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.