Unit 4

A benign breast condition that includes dilation and inflammation of the collecting ducts is called a. Ductal ectasia b. Intraductal papilloma c. Chronic cystic disease d. Fibroadenoma

A

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best? a. Breathing so quickly can be dehydrating. b. Everyone with pneumonia is dehydrated. c. This is really just to administer your antibiotics. d. Why do you think you are so dehydrated?

A

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

A

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

A

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. d. Its going to be really hard but I will stop smoking.

A

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

A

A patient has a serum cholesterol level of 270 mg/dL. The patient asks the nurse what this level means. Which response by the nurse is correct? a. You have a high risk for coronary artery disease. b. You have a moderate risk for coronary artery disease. c. You have a low risk for coronary artery disease. d. You have no risk for coronary artery disease.

A

A patient will begin taking rosuvastatin calcium (Crestor) to treat hyperlipidemia. The patient asks the nurse how to take the medication for best effect. Which statement by the nurse is correct? a. Increase your fluid intake while taking this medication. b. Stop taking the medication if you develop muscle aches. c. Take the medication with food to improve absorption. d. You may increase dietary fat while taking this medication.

A

A patient will begin using an albuterol metered-dose inhaler to treat asthma symptoms. The patient asks the nurse about the difference between using an oral form of albuterol and the inhaled form. The nurse will explain that the inhaled form of albuterol a. has a more immediate onset than the oral form. b. may cause more side effects than the oral preparation. c. requires an increased dose in order to have therapeutic effects. d. will not lead to tolerance with increased doses.

A

A patient will begin using ipratropium bromide (Atrovent), albuterol (Proventil), and an inhaled glucocorticoid medication (steroid) to treat chronic bronchitis. When teaching this patient about disease and medication management, the nurse will instruct the patient to administer these medications in which order? a. Albuterol, ipratropium bromide, steroid b. Albuterol, steroid, ipratropium bromide c. Ipratropium bromide, albuterol, steroid d. Steroid, ipratropium bromide, albuterol

A

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

A

The nurse is caring for a patient recently diagnosed with mild emphysema and provides teaching about the disease and medications for treatment. Which statement by the patient indicates understanding of the medication regimen? a. I should use albuterol when my symptoms worsen. b. I will need to take oral prednisone on a daily basis. c. My provider will prescribe prophylactic antibiotics. d. My symptoms are reversible with proper medications.

A

When discussing estrogen replacement therapy (ERT) with a perimenopausal woman, the nurse should include the risks of a. Breast cancer b. Vaginal and urinary tract atrophy c. Osteoporosis d. Arteriosclerosis

A

While interviewing a 48-year-old patient during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this patient to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include (select all that apply) a. Reluctance to hear bad news b. Fear of x-ray exposure c. Belief that lack of family history makes this test unnecessary d. Expense of the procedure e. Having heard that the test is painful

A, B, D, E

The exact cause of breast cancer remains undetermined. Researchers have found that there are a number of common risk factors that increase a womans chance of developing a malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? Select all that apply. a. Family history b. Late menarche c. Early menopause d. Race e. Nulliparity or first pregnancy after age 30

A, D, E

Which woman is most likely to have osteoporosis? a. A 50-year-old woman receiving estrogen therapy b. A 60-year-old woman who takes supplemental calcium c. A 55-year-old woman with a sedentary lifestyle d. A 65-year-old woman who walks 2 miles each day

C

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

B

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

B

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the clients pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

B

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.

B

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

B

A patient has been taking atorvastatin (Lipitor) for several months to treat hyperlipidemia. The patient reports muscle weakness and tenderness. The nurse will counsel the patient to a. ask the provider about switching to simvastatin. b. contact the provider to report these symptoms. c. start taking ibuprofen to combat these effects. d. stop taking the medication immediately.

B

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

B

Acid-base balance occurs when the pH level of the blood is between: a. 7.3 and 7.5 b. 7.35 and 7.45 c. 7.4 and 7.5 d. 7.25 and 7.35

B

During her annual gynecologic checkup, a 17-year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse should document this complaint as a. Amenorrhea b. Dysmenorrhea c. Dyspareunia d. PMS

B

The nurse is discussing smoking cessation with a nurse colleague who smokes. Which statement indicates a readiness to quit smoking? a. I dont smoke around my children or inside the house. b. I want to stop smoking, but I will need help to do it. c. I will quit so my co-workers will stop harassing me about it. d. If I cut down gradually, I should be able to quit.

B

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

B

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by nurse is best? a. Take the clients vital signs and record them in the chart. b. Notify the surgeon about the aspirin ingestion by the client. c. Warn the client that health insurance may not pay for the procedure. d. Teach the client about avoiding twisting above the waist after the operation.

B

A 36-year-old woman has been diagnosed as having uterine fibroids. When planning care for this patient, the nurse should know that a. Fibroids are malignant tumors of the uterus that require radiation or chemotherapy. b. Fibroids will increase in size during the perimenopausal period. c. Abnormal uterine bleeding is a common finding. d. Hysterectomy should be performed.

C

A patient will begin taking simvastatin (Zocor) to decrease serum cholesterol. When teaching the patient about this medication, the nurse will counsel the patient to take which action? a. Return to the clinic annually for laboratory testing. b. Take care when rising from a sitting to standing position. c. Take the medication in the evening for best effect. d. Use ibuprofen as needed for muscle aches and pain.

C

A provider has prescribed ipratropium bromide/albuterol sulfate (Combivent) for a patient who has chronic obstructive pulmonary disease (COPD). The nurse explains that this combination product is prescribed primarily for which reason? a. To be more convenient for patients who require both medications b. To improve compliance in patients who may forget to take both drugs c. To increase forced expiratory volume, an indicator of symptom improvement d. To minimize the side effects that would occur if the drugs are given separately

C

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

C

The nurse is examining a womans breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask? a. When was your last mammogram at the clinic? b. How many cans of caffeinated soda do you drink in a day? c. Do the small lumps seem to change with your menstrual period? d. Do you have a first-degree relative who has breast cancer?

C

The nurse is performing a medication history on a patient who reports long-term use of montelukast (Singulair) and an albuterol metered-dose inhaler (Proventil). The nurse will contact the provider to discuss an order for which laboratory tests? a. Cardiac enzymes and serum calcium b. Electrolytes and a complete blood count c. Liver function tests and serum glucose d. Urinalysis and serum magnesium

C

The nurse provides teaching to a patient who will begin taking simvastatin (Zocor) to treat hyperlipidemia. Which statement by the patient indicates understanding of the teaching? a. I may have diarrhea as a result of taking this medication. b. I may stop taking this medication when my lipid levels are normal. c. I will need an annual eye examination while taking this medication. d. I will increase my intake of vitamins A, D, and E while taking this medication.

C

With regard to endometriosis, nurses should be aware that a. It is characterized by the presence and growth of endometrial tissue inside the uterus. b. It affects 25% of all women. c. It may worsen with repeated cycles or remain asymptomatic and disappear after menopause. d. It is unlikely to affect sexual intercourse or fertility.

C

patient with high cholesterol is ordered to take atorvastatin (Lipitor). What information will be included in the patient teaching? (Select all that apply.) a. Dietary management is not a priority with this medication. b. The medication should be taken on an empty stomach. c. The medicine should be taken with a full glass of water. d. The patient should watch for body aches or gastrointestinal upset as side effects. e. The patient should have renal function tests frequently. f. The patient should have liver function tests frequently.

C, D, F

A female patient has serum lipid levels performed, which reveal a total cholesterol of 285 mg/dL, triglycerides of 188 mg/dL, a low-density lipoprotein (LDL) of 175 mg/dL, and a high-density lipoprotein (HDL) of 40 mg/dL. The patients blood pressure is 138/72 mm Hg. The nurse may expect the provider to order which medication for this patient? a. Amlodipine and atorvastatin (Caduet) b. Colestipol HCl (Colestid) c. Fenofibrate (TriCor) d. Niacin and lovastatin (Advicor)

D

A patient who uses an inhaled glucocorticoid medication reports having a sore tongue. The nurse notes white spots on the patients tongue and oral mucous membranes. After notifying the provider, the nurse will remind the patient to perform which action? a. Avoid using a spacer with the inhaled glucocorticoid medication. b. Clean the inhaler with hot, soapy water after each use. c. Consume yogurt daily while using this medication. d. Rinse the mouth thoroughly with water after each use.

D

A patient will be discharged home with albuterol (Proventil) to use for asthma symptoms. What information will the nurse include when teaching this patient about this medication? a. Failure to respond to the medication indicates a need for a higher dose. b. Monitor for hypoglycemia symptoms when using this medication. c. Palpitations are common with this drug even at normal, therapeutic doses. d. Overuse of this medication can result in airway narrowing and bronchospasm.

D

The nurse is counseling a patient who wants to stop smoking. Which statement by the nurse is correct? a. Bupropion (Zyban) is effective and does not have serious adverse effects. b. Nicotine replacement therapies are effective and eliminate the need for behavioral therapy. c. Varenicline (Chantix) may be used short-term for 1 to 2 months. d. You may experience headaches and increased appetite for several months after stopping smoking.

D

The nurse provides teaching for patient who will begin taking montelukast sodium (Singulair). The patient reports sensitivity to aspirin. Which statement by the patient indicates a need for further teaching? a. I will need to have periodic laboratory tests while taking this medication. b. I will not take ibuprofen for pain or fever while taking this drug. c. I will take one tablet daily at bedtime. d. I will use this as needed for acute symptoms.

D

While evaluating a patient for osteoporosis, the nurse should be aware of what risk factor? a. African-American race b. Low protein intake c. Obesity d. Cigarette smoking

D

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

A

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

A

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best? a. Ensure the client gets 15 minutes of sun exposure daily. b. Give the client daily vitamin D injections. c. Hide vitamin D supplements in favorite foods. d. Plan to serve foods naturally high in vitamin D.

A

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.

A

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? a. I am glad that these tubes will fall out at home when I finally shower. b. I should measure the drainage each day to make sure it is less than an ounce. c. I should be careful how I lie in bed so that I will not kink the tubing. d. If there is a foul odor from the drainage, I should contact my doctor.

A

Which patient is most at risk for fibroadenoma of the breast? a. A 38-year-old woman b. A 50-year-old woman c. A 16-year-old woman d. A 27-year-old woman

C

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

A, D

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

A, D, E

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A, D, E

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination

A, D, E

A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Reduce the pain by low-level heat. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Suggest resources such as the Endometriosis Association.

A, C, E

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

A

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

A

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar

A

A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding? a. Client who has had two saturated perineal pads in the last 2 hours b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg c. Client who has pain of 4 on a scale of 0 to 10 d. Client with a urinary catheter output of 150 mL in the last 3 hours

A

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics

A

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. No, women should only have one beer a day as a general rule. b. No, you should not drink any alcohol with hypertension. c. Yes, since you are larger, you can have more alcohol. d. Yes, two beers per day is an acceptable amount of alcohol.

A

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

A

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

A

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

A

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding? a. This condition will become malignant over time. b. I should refrain from using hormone replacement therapy. c. One cup of coffee in the morning should be enough for me. d. This condition makes it more difficult to examine my breasts.

A

The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Hydrogen ions. b. Bicarbonate. c. Oxygen. d. Phosphate.

A

The process to control cellular growth, replication, and differentiation to maintain homeostasis is called: a. cellular regulation. b. cellular impairment. c. cellular reproduction. d. cellular tumor.

A

What information does the nurse teach a womens group about osteoporosis? a. For 5 years after menopause you lose 2% of bone mass yearly. b. Men actually have higher rates of the disease but are underdiagnosed. c. There is no way to prevent or slow osteoporosis after menopause. d. Women and men have an equal chance of getting osteoporosis.

A

The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.) a. I should not have any problems driving to see my mother, who lives 3 hours away. b. Now that I have time off from work, I can return to my exercise routine next week. c. My granddaughter weighs 23 pounds, so I need to refrain from picking her up. d. I will have to limit the times that I climb our stairs at home to morning and night. e. For 1 month, I will need to refrain from sexual intercourse.

A, B

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.) a. Avoid drinking fluids just before and during meals. b. Rest before meals if you have dyspnea. c. Have about six small meals a day. d. Eat high-fiber foods to promote gastric emptying. e. Increase carbohydrate intake for energy.

A, B, C

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

A, B, C, E

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

A, B, D

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

A, B, D, E

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

A, B, D, E

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors

A, B, E

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.) a. Peau dorange b. Dense breast tissue c. Nipple retraction d. Mobile mass at two oclock e. Nontender axillary nodes

A, C, D

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A, C, D, E

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.) a. What color is your sputum? b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? d. Do you walk upstairs every day? e. Have you lost any weight lately?

B, C, E

A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate? a. You are too old to receive an HPV vaccine. b. Either Gardasil or Cervarix can provide protection. c. You will need to have three injections over a span of 1 year. d. The most common side effect of the vaccine is itching at the injection site.

B

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is the most appropriate? a. Breast cancer in men is quite rare. b. It is good that you came to be carefully evaluated. c. Gynecomastia usually comes from overeating. d. When you get older, the male breast always enlarges.

B

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

B

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

B

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky; most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

B

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the clients support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the clients obligations.

B

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the clients chart. d. Notify the surgeon immediately.

B

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

B

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

B

The nurse is doing preoperative teaching for a client who is scheduled for removal of cervical polyps in the office. Which statement by the client indicates a correct understanding of the procedure? a. I hope that I do not have cancer of the cervix. b. There should be little or no discomfort during the procedure. c. There may be a lot of bleeding after the polyp is removed. d. This may prevent me from having any more children.

B

Which statement by the patient indicates that she understands breast self-examination? a. I will examine both breasts in two different positions. b. I will perform breast self-examination 1 week after my menstrual period starts. c. I will examine the outer upper area of the breast only. d. I will use the palm of the hand to perform the examination.

B

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

B, C, D

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.

C

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. Checking the amount of urine in the urine catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

C

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

C

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. Do you have a strong support system? b. What do you understand about your disease? c. Do you experience shortness of breath with basic activities? d. What medications are you prescribed to take each day?

C

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. There are a variety of support groups for people who have COPD. b. I will ask your provider to prescribe you with an antianxiety agent. c. Share any thoughts and feelings that cause you to limit social activities. d. Friends can be a good support system for clients with chronic disorders.

C

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

C

A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It means it is caused by another disease. b. It means it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension.

C

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all times in case I need it. b. I will take this medication when I start to experience an asthma attack. c. I will take this medication every morning to help prevent an acute attack. d. I will be weaned off this medication when I no longer need it.

C

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it. b. It may take a while before I notice a change in my asthma. c. I will use the drug when I have an asthma attack. d. I will be careful not to let the drug escape out of my nose and mouth.

C

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. Press down firmly on the canister to release one dose of medication. 2. Breathe in slowly and deeply. 3. Shake the whole unit vigorously three or four times. 4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 5. Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece. 6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds. a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

C

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. I plan to wear my oxygen when I exercise and feel short of breath. b. I will use my portable oxygen when grilling burgers in the backyard. c. I plan to use cotton balls to cushion the oxygen tubing on my ears. d. I will only smoke while I am wearing my oxygen via nasal cannula.

C

What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago? a. Placing the head of bed at 30 degrees b. Elevating the left arm on a pillow c. Administering morphine for pain at a 4 on a 0-to-10 scale d. Supporting the left arm while initially ambulating the client

C

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

C

Which statement is true about primary dysmenorrhea? a. It occurs in young multiparous women. b. It is experienced by all women. c. It may be due to excessive endometrial prostaglandin. d. It is unaffected by oral contraceptives.

C

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each of my three children for 12 months. b. It looks as though I need to start working out at the gym more often. c. I am glad that we can still have wine with every evening meal. d. When I have menopausal symptoms, I must avoid hormone replacement therapy.

C

A nurse is providing education to a community womens group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

C, D, E

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. A good abrasive pumice stone will keep my feet soft. b. Ill always wear shoes if I can buy cheap flip-flops. c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

C, D, E

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

C, E

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Include support people, such as the male partner, in the decision making.

D

A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess heart, lung, and bowel sounds. b. Check the hemoglobin and hematocrit levels. c. Evaluate the dressing for drainage. d. Empty the urine from the urinary catheter bag

D

A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

D

A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)? a. Aid in the draining of the cysts by needle aspiration. b. Teach the client to wear a supportive bra to bed. c. Administer diuretics to decrease breast swelling. d. Obtain a cold pack to temporarily relieve the pain.

D

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

D

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

D

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

D

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

D

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes. b. Im glad I get energy assistance so my house isnt so cold. c. My daughter makes sure I have plenty of lotion for my feet. d. My hands shake when I try to do things requiring coordination.

D

During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99 F (37.2 C) d. Dusky color of the flap

D

The best way for an individual to maintain acid-base balance is to a. avoid or quit smoking. b. exercise regularly. c. eat healthy and well-balanced meals. d. All of the above.

D

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond? a. You are using the inhaler incorrectly. This medication should be taken daily. b. If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks. c. Tell me more about your fears related to feelings of breathlessness. d. It is important to use this type of inhaler every day. Lets identify potential community services to help you.

D

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

D

When a nurse is counseling a woman for primary dysmenorrhea, which non-pharmacologic intervention might be recommended? a. Increasing the intake of red meat and simple carbohydrates b. Reducing the intake of diuretic foods, such as peaches and asparagus c. Temporarily substituting physical activity for a sedentary lifestyle d. Using a heating pad on the abdomen to relieve cramping

D