Trans M4

14. 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."

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

16. 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."

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

18. 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."

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

14. 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."

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

18. 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.

A. Administer an antiemetic.

32. 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.

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

30. A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. Which factors contribute to this phenomenon? Select all that apply. A. Decreased kidney mass B. Increased conservation of sodium C. Increased total body water D. Decreased renal blood flow E. Decreased excretion of potassium

A. Decreased kidney mass D. Decreased renal blood flow E. Decreased excretion of potassium

20. The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration, the nurse explains to a newly licensed nurse how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing which process? A. Diffusion B. Osmosis C. Active transport D. Filtration

A. Diffusion

2. The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Tachycardia C. Cool, clammy skin D. Acute flank pain

A. Diminished deep tendon reflexes

23. 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

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

24. The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern with this infiltration? A. Extravasation of the medication B. Discomfort to the client C. Blanching at the site D. Hypersensitivity reaction to the medication

A. Extravasation of the medication

6. 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

A. Impaired nutritional status

19. The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A. Increased serum sodium B. Decreased serum potassium C. Decreased hemoglobin D. Increased platelets

A. Increased serum sodium

12. 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.

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.

33. 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.

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

2. 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

A. Liver function tests (LFTs)

34. The nurse is providing discharge education to a client who had hypophosphatemia while in the hospital. The client has a diet prescribed that is high in phosphate. Which foods should the nurse teach this client to include in the diet? Select all that apply. A. Milk B. Beef C. Potatoes D. Green vegetables E. Liver

A. Milk B. Beef E. Liver

24. 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

A. Monitoring the client's physiologic status

25. 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

A. Monitoring the safe recovery from anesthesia B. Answering family questions about recovery D. Providing light nourishment E. Assessing the operative site for hemorrhage

29. A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't sterile water be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? A. Never, because it rapidly enters red blood cells, causing them to rupture. B. When the client is severely dehydrated, resulting in neurologic signs and symptoms C. When the client is in excess of calcium and/or magnesium ions D. When a client's fluid volume deficit is due to acute or chronic kidney disease

A. Never, because it rapidly enters red blood cells, causing them to rupture.

27. 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

A. Palliative

22. 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

A. Rate of growth B. Ability to cause death E. Ability to spread

23. The nurse is caring for a client who has been involved in a motor vehicle accident. The client's labs indicate a minimally elevated serum creatinine level. The nurse should further assess which body system for signs of injury? A. Renal B. Cardiac C. Pulmonary D. Nervous

A. Renal

17. 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

A. Requests that her family bring her makeup and a wig

14. A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

A. Respiratory acidosis

7. 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

A. Stopping the administration of the drug immediately

30. 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

A. Tumor lysis syndrome (TLS)

22. 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

A. Verifies completion of preoperative diagnostic testing

16. The community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? A. "I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup." B. "Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids." C. "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D. "Confusion and bladder issues are a normal consequence of aging, so I am not too concerned."

B. "Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids."

8. A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply. A. Administer potassium by IV push. B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. C. Monitor complete blood count during potassium infusion. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

9. 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.

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

23. 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

B. Different proteins in the cell membrane

10. The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia

B. Hypocalcemia

31. 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

B. Impaired wound healing

34. 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

B. Incisional

2. 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

B. Increased risk for postoperative complications

7. 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.

B. Leg exercises improve circulation and prevent venous thrombosis.

21. 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

B. Lymphatic circulation

20. 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.

B. Malignant cells contain proteins called tumor-associated antigens.

33. The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly? A. Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. D. Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate.

B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.

8. 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

B. Nausea and vomiting

8. 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.

B. Offer the client a bedpan or urinal.

9. A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which of the following terms? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport

B. Osmosis and osmolality

25. The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low? A. Diarrhea B. Paresthesias C. Increased muscle tone D. Joint pain

B. Paresthesias

21. 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 the client will be asleep before it is time to leave for surgery. D. Take the client's vital signs every 15 minutes.

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

35. 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.

B. Refer the client to the appropriate mental health provider.

4. A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. Metabolic acidosis

B. Respiratory alkalosis

1. 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

B. Smoking cessation

28. 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

B. Superior vena cava syndrome (SVCS)

27. A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C. The kidneys react rapidly to compensate for imbalances in the body. D. The kidneys regulate the bicarbonate level in the intracellular fluid.

B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

17. 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

B. To promote optimal lung expansion

26. 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

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

4. 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."

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

19. 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."

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

3. 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

C. Baked apricot chicken and steamed broccoli

24. 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

C. Breast cancer D. Esophageal cancer E. Liver cancer

29. 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.

C. Consume 2 to 4 L of fluid daily.

15. One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will help to achieve what goal? A. Distinguish hyponatremia from hypernatremia. B. Evaluate pituitary gland function. C. Distinguish reduced renal blood flow from decreased renal function. D. Provide an effective treatment for hypertension-induced oliguria.

C. Distinguish reduced renal blood flow from decreased renal function.

18. A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake.

C. Ensure the client has sufficient potassium intake.

9. 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

C. Epistaxis

10. 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.

C. Facilitate a detailed analysis of the client's electrolyte levels.

28. The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation? A. Endocarditis B. Multiple myeloma C. Guillain-Barré syndrome D. Overdose of amphetamines

C. Guillain-Barré syndrome

31. The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? A. Hypocalcemia B. Hyponatremia C. Hyperchloremia D. Hypophosphatemia

C. Hyperchloremia

37. The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance would a positive Chvostek sign indicate? A. Hypermagnesemia B. Hyponatremia C. Hypocalcemia D. Hyperkalemia

C. Hypocalcemia

7. The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor? A. Overhydration is common among healthy older adults. B. Dehydration causes the skin to appear spongy. C. Inelastic skin turgor is a normal part of aging. D. Skin turgor cannot be assessed in clients over the age of 70.

C. Inelastic skin turgor is a normal part of aging.

6. While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation? A. Air embolism B. Phlebitis C. Infiltration D. Fluid overload

C. Infiltration

12. 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

C. Lung

12. The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? A. Hypercalcemia B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis

19. 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

C. Preventing potential contamination of the peritoneum

4. 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

C. Promoting and providing vaccines

5. 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

C. Prophylactic surgery

13. 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

C. Risk for infection related to altered immunologic response

25. 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

C. Secondary prevention

16. 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

C. The client

3. 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.

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.

11. A nurse, who is orienting a newly licensed nurse, is planning care for a nephrology client. The nurse states, "A client with kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability? A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B. The kidneys buffer acids through electrolyte changes. C. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH. D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

C. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH.

20. 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.

C. Use guided imagery along with pain medication.

27. 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

C. When assisting with the resuscitation

1. 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

C. Without delay

13. The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: A. ensure that anticoagulants are placed on hold for the duration of IV therapy. B. replace the IV dressing with a new, clean dressing if it is soiled. C. ensure that the tubing is firmly anchored to the client's skin. D. periodically remove hair from 2 cm around the IV site.

C. ensure that the tubing is firmly anchored to the client's skin.

11. 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."

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

5. 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

D. As soon as possible, and before the surgical procedure

36. A client's most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? A. Apples B. Fish C. Rice D. Bananas

D. Bananas

22. Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A. Decrease in the release of aldosterone B. Increase of filtration in the Loop of Henle C. Decrease in the reabsorption of sodium D. Decrease in glomerular filtration

D. Decrease in glomerular filtration

15. 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.

D. Discuss a referral for hospice care.

10. 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.

D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.

32. Diagnostic testing has been prescribed to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill client. What health problem often precedes normal anion gap acidosis? A. Metastases B. Excessive potassium intake C. Water intoxication D. Excessive administration of chloride

D. Excessive administration of chloride

1. The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The plan of care includes assessment of specific gravity every four hours. The results of this test will allow the nurse to assess which aspect of the client's health? A. Nutritional status B. Potassium balance C. Calcium balance D. Fluid volume status

D. Fluid volume status

21. When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart

D. Hydrostatic pressure resulting from the pumping action of the heart

26. The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? A. Hypernatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalcemia

D. Hypercalcemia

3. The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

D. Hypovolemia

13. 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

D. Infection

5. The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis with no compensation B. Metabolic alkalosis with compensatory alkalosis C. Metabolic acidosis with no compensation D. Metabolic acidosis with compensatory respiratory alkalosis

D. Metabolic acidosis with compensatory respiratory alkalosis

6. 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

D. Palliative

38. The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 20 mEq/L. The nurse should recognize the likelihood of which acid-base disorder(s)? A. Respiratory acidosis only B. Respiratory acidosis and metabolic alkalosis C. Respiratory alkalosis and metabolic acidosis D. Respiratory acidosis and metabolic acidosis

D. Respiratory acidosis and metabolic acidosis

26. 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

D. Sentinel node biopsy

35. The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations

D. Shallow respirations

11. 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.

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

17. A client comes into the emergency department (ED) by ambulance with a hip fracture after slipping and falling while at home. The client is alert and oriented but anxious and reports thirst. The client's pupils are equal and reactive to light and accommodation, and the heart rate is elevated. An indwelling urinary catheter is inserted, and 40 mL of urine is present. What is the nurse's most likely explanation for the client's urinary output? A. The client urinated prior to arrival to the ED and will probably not need to have the urinary catheter kept in place. B. The client likely has a traumatic brain injury, lacks antidiuretic hormone, and needs vasopressin. C. The client is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output. D. The client is having a sympathetic reaction, which has stimulated the renin- angiotensin-aldosterone system, whic

D. The client is having a sympathetic reaction, which has stimulated the renin- angiotensin-aldosterone system, which results in diminished urine output.

15. 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.

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