EAQ Med Surg HESI

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? 1 Encouraging expression of concerns 2 Administering antibiotics as prescribed 3 Teaching the importance of getting rest 4 Explaining that everything will be all right

1 Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? 1 Highly contagious 2 Caused by a fungus 3 Chronic with exacerbations 4 Associated with other allergies

1 Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.

Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1 Apples 2 Chocolate 3 Rye bread 4 Cheddar cheese

1 Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus.

Which predisposing condition may be present in a client with pitting edema? 1 Shock 2 Kidney disease 3 Hypothyroidism 4 Severe dehydration

2 Kidney disease may be a predisposing condition associated with pitting edema. Shock may be associated with a decreased temperature. Hypothyroidism may be a predisposing condition of non-pitting edema, which occurs due to an endocrine imbalance. Severe dehydration may be associated with decreased elasticity of the dermis.

Which drug treats hay fever by preventing leukotriene synthesis? 1 Zileuton 2 Cromolyn sodium 3 Chlorpheniramine 4 Diphenhydramine

3 Zileuton [1] [2] is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E.. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.

A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease? 1 Albumin 2 Creatinine 3 Blood urea nitrogen (BUN) 4 Prostate-specific antigen (PSA)

4 The PSA is an indication of cancer of the prostate; the higher the level, the greater the tumor burden. Albumin is a protein that is an indicator of nutritional and fluid status. Increased creatinine or BUN levels may be caused by impaired renal function as a result of blockage by an enlarged prostate but do not indicate that metastasis has occurred.

A client suspected to have hyperpituitarism is sent by the primary healthcare provider to undergo a suppression test. Which laboratory value would indicate a positive result? 1 3 ng/mL 2 4 ng/mL 3 5 ng/mL 4 6 ng/mL

4 When the growth hormone level in a suppression test is above 5 ng/mL, this indicates a positive result, which means the client is suffering from hyperpituitarism. Therefore, 6 ng/mL indicates a positive suppression test. When growth hormone level falls below 5 ng/mL, this indicates a negative result, which means the client is not suffering with hyperpituitarism. Therefore, 3 ng/mL, 4 ng/mL, and 5 ng/mL indicate negative results, and the client does not have hyperpituitarism.

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? 1 It indicates dilute urine. 2 It indicates blood in the urine. 3 It indicates concentrated urine. 4 It indicates the presence of myoglobin.

1 Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobin.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? 1 Low fat 2 Low carbohydrate 3 Soft-textured and bland 4 High protein and kilocalories

1 The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.

A client who had an above-the-knee amputation (AKA) has a pressure dressing on the end of the residual limb. The client asks, "Why do I have to have this tight dressing on my leg?" Which answer by the nurse is correct? 1 "It decreases the swelling of the area." 2 "It decreases the formation of scar tissue." 3 "It prevents the formation of blood clots." 4 "It reduces phantom limb pain."

1 The pressure dressing prevents fluid from shifting into the interstitial compartment; this promotes shrinkage of the residual limb to facilitate use of a prosthesis. Bandaging will not affect the formation of a scar, prevent blood clots, or reduce phantom limb pain.

When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do? 1 Hyperextend the client's neck 2 Move obstacles away from the client 3 Restrain the client's body movements 4 Attempt to place an airway in the client's mouth

2 Moving obstacles away from the client helps the client avoid hitting objects and thus prevents trauma during the tonic-clonic phase of the seizure [1] [2]. Hyperextending the neck is contraindicated; it may injure the client. Restraining the client's body movements is contraindicated; it may injure the client. Attempting to place an airway in the client's mouth during the tonic-clonic phase of the seizure can cause injury.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? 1 Hypervigilance 2 Constricted pupils 3 Increased heart rate 4 Widening pulse pressure

4 Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

Which intervention is most likely to decrease mortality in the septic client? 1 Oxygen 2 Antibiotics 3 Vasopressors 4 Intravenous fluids

2 Of the interventions listed, administering antibiotics is the only intervention that fights the source of the problem. Intravenous fluids, oxygen, and vasopressors are necessary, but are designed to sustain the body until the antibiotic can kill the pathogen.

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable? 1 Blue 2 Gray 3 Brick red 4 Dark purple

3 A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

Which medications are useful to treat psoriasis? Select all that apply. 1 Psoralen 2 Anthralin 3 Isotretinoin 4 Clindamycin 5 Calcipotriene

1,2,5 Psoriasis is a chronic autoimmune dermatitis treated with a systemic photosensitizer such as psoralen and topical agents such as calcipotriene and anthralin. Isotretinoin and clindamycin are used to treat acne vulgaris.

Which type of cast will the nurse be caring for in a child with a fractured femur? 1 Cylinder 2 Hip spica 3 Prefabricated knee 4 Robert Jones

2 A hip spica cast is now mainly used for femur fractures in children. A cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle. A prefabricated knee splint is a commonly used cast for lower extremity injuries. A Robert Jones dressing is composed of bulky padding materials, splints, and elastic wrap or stockinette used for lower extremity injuries.

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash

2 A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout.

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? 1 Monitor vital signs. 2 Maintain an open airway. 3 Maintain fluid and electrolytes. 4 Monitor pupil response and equality.

2 A patent airway is the priority because the airway may become occluded by the tongue in an unconscious client. Monitoring vital signs is not the priority, although it is an important nursing function. Monitoring pupil response and equality and maintaining fluid and electrolytes are not the priority, although they are important nursing functions.

Which may cause a foreign body sensation in the eye? 1 Herniated orbital fat 2 Superficial corneal erosion 3 Inflammation of anterior uveal tract 4 Infection of sebaceous gland of eyelid

2 A superficial corneal erosion may cause a foreign body sensation in the eye. Herniated orbital fat may result in ectropion, which is characterized by an outward turning of the lower lid margin. Inflammation of the anterior uveal tract may result in photophobia. An eyelid sebaceous gland infection may cause a hordeolum, which manifests as a small, superficial white nodule along the lid margin.

Four clients with tuberculosis are prescribed medications. Which client is at risk for optic neuritis? 1 Client A (Isoniazid) 2 Client B (Rifampin) 3 Client C (Pyrazinamide) 4 Client D (Euthambutol)

4 Ethambutol is an antitubercular medication that causes optic neuritis. Therefore client D is at risk for optic neuritis. Client A is at risk for vitamin B deficiency. Client B is at risk for liver toxicity. Client C is at risk for sunburn.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? 1 Offer soft-textured foods to reduce the digestive burden 2 Offer low-cholesterol foods to avoid further formation of gallstones 3 Increase protein intake to promote tissue healing and improve energy reserves 4 Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

4 Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

How would the nurse describe the exudate characteristic of a serosanguineous wound? 1 Greenish-blue pus 2 Creamy yellow pus 3 Blood-tinged amber fluid 4 Beige pus with a fishy odor

3 Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow pus, and beige pus with a fishy odor are characteristics of purulent wound exudate.

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? 1 High caloric intake, liberal potassium intake, and 3 g protein/kg/day 2 High caloric intake, restricted potassium intake, and 1 g protein/kg/day 3 Moderate caloric intake, liberal potassium intake, and 3 g protein/kg/day 4 Moderate caloric intake, restricted potassium intake, and 1 g protein/kg/day

1 A high-calorie diet is needed for the increased metabolic rate associated with burns; the administration of potassium prevents hypokalemia, which can occur after the first 48 to 72 hours when potassium moves from the extracellular compartment into the intracellular compartment; protein promotes tissue repair. High caloric intake, restricted potassium intake, and 1 g protein/kg/day do not meet the body's needs for tissue repair; the protein and potassium are too limited. Moderate caloric intake, liberal potassium intake, and 3 g protein/kg/day do not meet the body's needs for tissue repair; the calories are too limited. Moderate caloric intake, restricted potassium intake, and 1 g protein/kg/day do not meet the body's needs for tissue repair; the calories, potassium, and protein are too limited.

While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion is observed in the client? 1 Papule 2 Vesicle 3 Pustule 4 Macule

1 A papule is an elevated, solid skin lesion of less than 0.5 to 1 cm in diameter. A macule is a circumscribed, flat area with a change in skin color. The vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan? 1 "Wash used dishes in hot, soapy water." 2 "Let dishes soak in hot water for 24 hours before washing." 3 "You should boil the client's dishes for 30 minutes after use." 4 "Have the client eat from paper plates so they can be discarded."

1 A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client's dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.

A home care nurse is visiting a client who had a below-the-knee amputation. Which client statement indicates to the nurse that further teaching is needed? 1 "At night, I sleep with a pillow under my knees." 2 "When I sit in a chair, I put my legs out straight on an ottoman." 3 "I apply a firm, even bandage around the end of my affected leg every day." 4 "I press the end of my affected leg against a soft surface several times during the day."

1 A pillow may promote a flexion contracture of the hip and knee and may interfere with use of a prosthesis and ambulation. The response "When I sit in a chair, I put my legs out straight on an ottoman" expresses an action that prevents pooling of blood and edema in the extremities. The response "I apply a firm, even bandage around the end of my affected leg every day" explains an activity that prevents edema and promotes residual limb shrinkage. Pressing the end of the affected leg against a soft surface several times during the day prepares the residual limb for weight-bearing and for use of a prosthesis.

Which malnutrition condition may predispose a client to secondary immunodeficiency? 1 Cachexia 2 Cirrhosis 3 Diabetes mellitus 4 Hodgkin's lymphoma

1 Cachexia is a nutrition disorder that may occur due to wasting of muscle mass and weight, resulting in secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin's lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders.

The nurse is providing instructions to a client on how to reduce the dietary intake of sodium. Which information should the nurse include in the instructions? 1 Avoid carbonated beverages 2 Use steak sauce for flavoring foods 3 Increase the intake of dairy products 4 Restrict the use of artificial sweeteners

1 Carbonated beverages generally are high in sodium and should be avoided. Steak sauce is high in sodium and should be avoided. Many dairy products contain sodium and should be avoided. Artificial sweeteners do not contain sodium and do not have to be restricted.

Which electrolyte deficiency triggers the secretion of renin? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

1 Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? 1 Drug eruption 2 Atopic dermatitis 3 Contact dermatitis 4 Nonspecific eczematous dermatitis

1 Drug eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? 1 Pulse 50 bpm and BP 140/60 mm Hg 2 Pulse 56 bpm and BP 130/110 mm Hg 3 Pulse 60 bpm and BP 126/96 mm Hg 4 Pulse 120 bpm and BP 80/60 mm Hg

1 Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate. Pulse 56 bpm and BP 130/110 mm Hg, pulse 60 bpm and BP 126/96 mm Hg, and pulse 120 bpm and BP 80/60 mm Hg do not meet these criteria.

What is the function of limbic system? 1 Influence emotional behavior 2 Regulate autonomic functions 3 Facilitate automatic movements 4 Relay sensory and motor inputs for cerebrum

1 Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells? 1 Nevi 2 Psoriasis 3 Acne vulgaris 4 Plantar warts

1 Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells. Psoriasis is an autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells. Acne vulgaris is an inflammatory disorder of sebaceous glands. Plantar warts are formed due to a viral infection. Plantar warts appear on the bottom surface of the feet and grow inward because of pressure.

Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia

1 Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is the more common in a client infected with AIDs. It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.

A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? 1 Continue to monitor the client. 2 Notify the primary healthcare provider. 3 Ensure that a defibrillator is close by. 4 Administer lidocaine intravenously as per protocol.

1 Premature atrial contractions usually are benign if they occur at a rate of fewer than 10 per minute. Their presence indicates atrial irritability, and the client should be monitored closely. Notifying the primary healthcare provider is premature; more data are needed. Defibrillation is used for ventricular, not atrial, fibrillation. Lidocaine is specific for ventricular, not atrial, irritability.

Which estrogen antagonist is specifically used to prevent and treat osteoporosis in postmenopausal women? 1 Raloxifene 2 Denosumab 3 Alendronate 4 Zoledronic acid

1 Raloxifene is used to prevent and treat osteoporosis in postmenopausal women by increasing bone mineral density, reducing bone desorption, and reducing incidences of osteoporotic vertebral fractures. Denosumab is a monoclonal antibody used to treat osteoporosis when other drugs are not effective. Alendronate and zoledronic acid are commonly used for the prevention and treatment of osteoporosis.

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter

1 Sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention? 1 Space activities throughout the day. 2 Restrict activities and encourage bed rest. 3 Teach the client about limitations imposed by the disorder. 4 Have a family member stay at the bedside to give the client support.

1 Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychologic adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not address the concerns voiced by the client.

Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. 1 Slowed movement 2 Cartilage degeneration 3 Increased bone density 4 Increased range of motion 5 Increased bone prominence

1,2,5 The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? 1 Azotemia 2 Hypokalemia 3 Metabolic alkalosis 4 Respiratory alkalosis

1 The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

What is the cup-like structure that collects a client's urine and is located at the end of each papilla? 1 Calyx 2 Capsule 3 Renal cortex 4 Renal columns

1 The calyx is a cup-like structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.

What is the causative organism for syphilis? 1 Treponema pallidum 2 Campylobacter jejuni 3 Trichomonas vaginalis 4 Chlamydia trachomatis

1 The causative organism for syphilis is Treponema pallidum. Campylobacter jejuni is the causative organism for proctitis. Trichomonas vaginalis is the causative organism for vulvovaginitis. Chlamydia trachomatis is the causative organism for salpingitis.

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1 Interrupt the therapy. 2 Encourage deep breathing. 3 Place the client in the low-Fowler position. 4 Have the client complete the therapy before resting.

1 The client's response indicates lack of physiologic tolerance to the procedure, and it must be interrupted. Encouraging deep breathing may be encouraged, but it is not the first intervention. Deep breathing must be done cautiously because it may precipitate respiratory alkalosis. The high-Fowler or orthopneic position is more appropriate for clients who are experiencing cardiopulmonary difficulties. Having the client complete the therapy before resting is contraindicated because the client is not tolerating the procedure. The therapy is intended to clear the respiratory passages of sputum and increase oxygenation. The heart rate should remain the same or decrease, not increase.

While assessing an older client's eyes in a darkened examination room, the nurse notices that the client has a bilateral reduction in pupil diameter. Which ocular muscular atrophy is responsible for this condition? 1 Radial dilator muscle 2 Iris sphincter muscle 3 Medial rectus muscle 4 Lateral rectus muscle

1 The iris radial dilator muscle dilates the pupils; therefore, atrophy of this muscle can cause a bilateral reduction in pupil diameter due to age-related eye changes. This condition is called senile miosis. The iris sphincter muscle constricts the pupils; therefore, atrophy of this muscle may cause pupil constriction sluggishness or absence when a light is shone on it. The medial and lateral rectus muscles are extraocular muscles that facilitate eye movement through the cardinal fields of gaze and are not associated with pupil dilation or constriction.

What are the functions of a client's subcutaneous layer of skin? Select all that apply. 1 It provides insulation. 2 It acts as an energy reservoir. 3 It prevents systemic dehydration. 4 It provides cells for wound healing. 5 It acts as a mechanical shock absorber.

1,2,5 The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? 1 Place the head and neck in alignment. 2 Administer 1 gram mannitol intravenously (IV) as prescribed. 3 Increase the ventilator's respiratory rate to 20 breaths/minute. 4 Administer 100 mg of pentobarbital IV as prescribed.

1 The nurse should first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the healthcare provider, who may prescribe mannitol. The nurse would notify the healthcare provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves? 1 Removing the dilated superficial veins 2 Bypassing the varicosities with artificial veins 3 Stripping the cholesterol deposits from the veins 4 Creating fistulas between superficial and deep veins

1 The saphenous vein is ligated at its juncture with the femoral vein; injection sclerotherapy is used as the method of choice, but in chronic venous insufficiency and recurrent thrombophlebitis, surgery may be necessary. A bypass is unnecessary; the deep veins compensate for the removed saphenous vein. Cholesterol plaques are characteristic of atherosclerosis, an arterial, not venous, disease. Communicating veins normally exist between the superficial and deep veins; they are ligated to prevent further engorgement and varicosities.

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client? 1 Urgency or frequency of urination 2 An increase of ketones in the urine 3 The inability to maintain an erection 4 Pain radiating to the external genitalia

1 Urgency or frequency of urination occur with a urinary tract infection [1] [2] because of bladder irritability; burning on urination and fever are additional signs of a UTI. Increase of ketones is associated with diabetes mellitus, starvation, or dehydration. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus, not infection.

A client visited the nurse with a complaint of chalk white patches on the skin. What could be the condition of the client? 1 Vitiligo 2 Jaundice 3 Cyanosis 4 Erythema

1 Vitiligo is the abnormal condition in which chalky white patches appear on the skin. This is due to a complete absence of melanin. Jaundice is an abnormal condition in which the skin appears yellow or yellow-brownish in color due to increased bilirubin in the blood. Cyanosis is the condition in which the skin is slightly bluish or purple in color due to excessive or reduced hemoglobin in capillaries. Erythema is the condition in which red-colored patches appear on the skin in variable sizes and shapes.

Which structures are included in the external genitalia in males? Select all that apply. 1 Penis 2 Testes 3 Scrotum 4 Urethra 5 Seminal vesicles

1,3 The male reproductive system is divided into primary reproductive organs and secondary reproductive organs. Secondary reproductive organs include ducts, sex glands, and external genitalia. The external genitalia consists of the penis and the scrotum. Testes are the primary reproductive organs. The urethra is the duct, and the seminal vesicles are sex glands.

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult? 1 Withdrawing the leg 2 Making no movement 3 Plantar flexing the left foot 4 Flexing the upper extremities

1 Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

Which is a leukotriene modifier used to manage and prevent allergic rhinitis? 1 Zileuton 2 Ephedrine 3 Scopolamine 4 Cromolyn sodium

1 Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing drug used to prevent mast cell membranes from opening when an allergen binds to IgE.

Which cytokine is used to treat multiple sclerosis? 1 β-Interferon 2 Interleukin-2 3 Erythropoietin 4 Colony-stimulating factor

1 β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia.

A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply. 1 Obesity 2 Hypertension 3 Diabetes insipidus 4 Asian-American ancestry 5 Increased high-density lipoprotein (HDL)

1,2 Obesity increases cardiac workload associated with vascular changes that lead to ischemia, which causes an MI. Hypertension damages blood vessels and increases peripheral resistance and cardiac workload, which may lead to an MI. Diabetes mellitus, not insipidus, is a risk factor for an MI. The risk is higher for African-Americans, not Asian-Americans. Increased levels of low-density lipoprotein (LDL), not HDL, increase the risk for heart disease.

Which are examples of a type IV hypersensitivity reaction? Select all that apply. 1 Poison ivy allergic reaction 2 Sarcoidosis 3 Myasthenia gravis 4 Rheumatoid arthritis 5 Systemic lupus erythematosus

1,2 Sarcoidosis and poison ivy reactions are examples of type IV hypersensitivity reactions. In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized T cells with the antigen and the resultant activation of macrophages due to lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic hypersensitivity reaction. Rheumatoid arthritis and systemic lupus erythematosus are examples of type III immune complex-mediated reactions.

What are the roles of an unlicensed assistive personnel in skin care? Select all that apply. 1 To assist the client in bathing 2 To apply wet dressings to the skin 3 To report changes in the skin appearance 4 To reinforce teaching as done by the registered nurse 5 To determine whether the client is taking a drug that increases photosensitivity

1,2,3 The unlicensed assistive personnel may be responsible for assisting the client in bathing, applying wet dressings to the skin, and reporting changes in the skin appearance. Teaching done by the registered nurse can be reinforced by a licensed practical nurse or a vocational nurse. The registered nurse would be responsible for determining whether the client is taking a drug that increases photosensitivity.

A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. 1 Fever 2 Oliguria 3 Jaundice 4 Polydipsia 5 Weight gain

1,2,5 Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further. Jaundice is unrelated to rejection. Polydipsia is associated with diabetes mellitus; it is not a clinical manifestation of rejection.

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. 1 Burns 2 Skin cancer 3 Osteomyelitis 4 Diabetic ulcers 5 Myocardial infarction

1,3,4 Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue's oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy. Skin cancer and myocardial infarctions are not treated using hyperbaric oxygen therapy.

A couple approaches the primary healthcare provider to seek guidance on permanent contraception. Which surgeries are suggested to the couple? Select all that apply. 1 Vasectomy 2 Cryosurgery 3 Mastectomy 4 Varicocelectomy 5 Tubal ligation

1,5 Vasectomy is the surgical removal of a portion of the vas deference, which is considered to be a form of male permanent contraception or sterilization. In tubal sterilization, the fallopian tubes are ligated. Therefore tubal sterilization is a form of permanent contraception. Cryosurgery is used to treat and kill abnormal cells with the aid of subfreezing temperature. The surgical removal of either one or both the breasts is called mastectomy and is included in the treatment of breast cancer. The surgery performed to repair the varicose veins of the scrotum is called varicocelectomy.

A client's laboratory report reveals a CD4+ T-cell count of 520 cells/mm3. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

2 According to the CDC, HIV disease is divided into four stages. A client with a CD4+ T-cell count of greater than 500 cells/mm3 is in the first stage of HIV disease. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 is in the second stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 is in the third stage of HIV disease. The fourth stage of HIV disease indicates a confirmed HIV infection with no information regarding the CD4+ T-cell counts.

An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? 1 "The prevalence of hypertension is about equal for women of all races." 2 "The higher-risk population is composed of African-American men and women." 3 "The highest-risk population consists of older Caucasian-American men and women." 4 "The prevalence of hypertension is greater for African-American men than for African-American women."

2 African-Americans represent a higher-risk population than Caucasian-Americans for hypertension; the reason is unknown. African-American women are more frequently affected by hypertension than are Caucasian women. African-Americans of both sexes have a higher prevalence than Caucasian-Americans of both sexes. African-American women have a higher risk than African-American men.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1 "I am unable to run a mile (1.6 kilometers) now." 2 "I wake up at night short of breath." 3 "My wife says I snore very loudly." 4 "My shoes seem larger lately."

2 Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

A 90-year-old resident of a nursing home falls and fractures the proximal end of the right femur. The surgeon plans to reduce the fracture with an internal fixation device. What general fact about the older adult should the nurse consider when caring for this client? 1 Aging causes a lower pain threshold. 2 Physiologic coping defenses are reduced. 3 Most confused states result from dementia. 4 Older adults psychologically tolerate changes well.

2 Aging causes a lowering of the physiologic coping reserve of various systems of the body. The pain threshold increases with aging. There are many etiologies for confusion (e.g., drug intolerance, altered metabolic state, unfamiliar surroundings). As individuals age they become more entrenched in ideas, environment, and objects that are familiar, and thus do not tolerate change well.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? 1 Asking the client's parent 2 Using Wong's "Pain Faces" 3 Observing the client's body language 4 Explaining the use of a 0 to 10 pain scale

2 An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

What is the most essential nursing care for a client who just had a cardiac catheterization? 1 Maintain the semi-Fowler position. 2 Monitor the apical pulse and blood pressure. 3 Take the temperature hourly until it stabilizes. 4 Encourage frequent coughing and deep breathing.

2 An apical pulse is taken to detect dysrhythmias related to cardiac irritability; blood pressure is monitored to detect hypotension, which may indicate bleeding or shock. Maintaining the semi-Fowler position is contraindicated; flexion of the groin may compromise the clot at the femoral insertion site. A fever may indicate a bacterial invasion, but this will not be evident during the first few hours after catheterization. Encouraging frequent coughing and deep breathing is not necessary; the client did not have general anesthesia and will soon be ambulatory.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness? 1 Hepatitis A 2 Rheumatic fever 3 Spinal meningitis 4 Rheumatoid arthritis

2 Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus (HAV), not by bacteria. The most common causes of meningitis, an infection of the membranes surrounding the brain and spinal cord, include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Rheumatoid arthritis is believed to be an autoimmune disorder; it is not caused by microorganisms.

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? 1 "This test will detect your heart sounds." 2 "This test will reflect any heart damage." 3 "This procedure helps us change your heart's rhythm." 4 "The ECG will tell us how much stress your heart can tolerate."

2 Changes in an ECG will reflect the area of the heart that is damaged because of hypoxia. A stethoscope is used to detect heart sounds. Medical interventions, such as cardioversion or cardiac medications, not an ECG, can alter heart rhythm. An ECG will reflect heart rhythm, not change it. Identifying how much stress a heart can tolerate is accomplished through a stress test; this uses an ECG in conjunction with physical exercise.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing? 1 White blood cells migrate into the wound 2 Epithelial cells grow over the granulation tissue bed 3 Scar tissue gradually becomes thinner and pale in color 4 Vasodilation occurs with increased capillary permeability

2 During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

Which disease is caused by Escherichia coli? 1 Tetanus 2 Peritonitis 3 Diphtheria 4 Food poisoning

2 Escherichia coli causes peritonitis. Clostridium tetani causes tetanus. Corynebacterium diphtheria causes diphtheria. Clostridium botulinum causes food poisoning.

An older client who was found unconscious at home was admitted to the hospital with a fractured hip, renal failure, and dehydration. In the 24 hours since admission, the client has received 3 L of intravenous fluid. The client has also developed hyponatremia. Which element would the nurse conclude is the most likely to have contributed to the client developing hyponatremia? 1 Reduced dietary salt intake 2 Intravenous fluid infusion 3 Potassium reabsorption rate 4 Increased glomerular filtration

2 Hemodilution has most likely occurred because 3 L of intravenous fluid will lower the serum sodium level by increasing intravenous fluid and reducing the serum concentration of sodium. A reduced dietary salt intake is not the most likely cause of hyponatremia developing during the first 24 hours of this hospitalization. Changes to the serum potassium reabsorption rate are not likely to have caused hyponatremia in the last 24 hours. A decreased, not increased, glomerular filtration rate occurs with renal failure.

Which hypersensitivity reaction may occur in a newborn with hemolytic disease? 1 Type I 2 Type II 3 Type III 4 Type IV

2 Hemolytic disease in a pregnant woman may result in erythroblastosis fetalis, a type II hypersensitivity reaction. Type I reactions involve immunoglobulin E (IgE)-mediated reactions such as anaphylaxis and wheal-and-flare reactions. Type III reactions are immune complex reactions such as rheumatoid arthritis or systemic lupus erythematosus. Type IV reactions are delayed hypersensitivity reactions such as contact dermatitis.

Which organism causes malaria? 1 Vibrio 2 Sporozoa 3 Ringworm 4 Spirochetes

2 Sporozoa such as Plasmodium malariae cause malaria. Vibrio are curved-rod-shaped bacteria; these microorganisms causes cholera. Ringworm such as tinea corporis may cause mycotic infections. Spirochetes are spiral-shaped bacteria; these microorganisms may cause leprosy and syphilis.

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? 1 Fluid volume 2 Skin integrity 3 Physical mobility 4 Urinary elimination

2 Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.

The nurse uses which principles of body mechanics when caring for immobilized clients? 1 Bending at the waist to provide the power for lifting 2 Placing the feet apart to increase the stability of the body 3 Keeping the body straight when lifting to reduce pressure on the abdomen 4 Relaxing the abdominal muscles while using the extremities to prevent strain

2 Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. Bending at the waist should be avoided because it strains the lower back muscles; the power of lifting should be supplied by the muscles of the thighs and buttocks. Pressure on the abdomen is prevented by tightening the abdominal and gluteal muscles to form an internal girdle; keeping the body straight does not reduce strain on the abdominal musculature. Relaxing the abdominal muscles with physical activity increases back strain.

Which factor may cause a client neck pain? 1 Headache 2 Poor posture 3 Low body weight 4 Sedentary lifestyle

2 Poor posture may affect the nerves innervating the neck, thereby causing pain in the neck. Headache may be associated with neck pain, but it cannot precipitate neck pain. Low body weight and sedentary lifestyle may cause osteoporosis. 91%of students nationwide answered this question correctly.

A client returns from surgery after a right below-the-knee amputation with the residual limb elevated on a pillow to prevent edema. In which position should the nurse place the client after the first postoperative day? 1 With the residual limb immobilized 2 Turn client to prone position at least three times a day 3 For short periods in the right side-lying position 4 With the residual limb elevated for a total of three days

2 Positioning the client in the prone position for short periods helps prevent hip flexion contractures. The client's residual limb should not be immobilized. Exercises to prevent contractures are begun as soon as possible. Positioning the client in the right side-lying position can cause trauma to the incision site and should be avoided. The client's residual limb should not be elevated for more than 48 hours because hip flexion contractures can result.

A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? 1 "I must touch the shunt several times a day to feel for the bruit." 2 "I have to take his blood pressure every day in the arm with the fistula." 3 "He will have to be very careful at night not to lie on the arm with the fistula." 4 "We really should check the fistula every day for signs of redness and swelling."

2 Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. Redness and swelling are signs of infection, which is a complication of cannulization.

Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. What is the nurse's priority action? 1 Obtain a prescription for an antibiotic. 2 Report the client's concern to the primary healthcare provider. 3 Administer the prescribed medication for pain. 4 Explain that this is typical after a cast is applied.

2 The client's concern indicates tissue hypoxia or breakdown and should be reported to the primary healthcare provider. Other data, such as elevated temperature or increased white blood cells, are not present to support the presence of an infection. Although administering the prescribed medication for pain will be done to provide relief of pain, the priority is to notify the primary healthcare provider. This is not a typical response to a cast and may indicate a complication.

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR? 1 Cataract 2 Glaucoma 3 Corneal abrasions 4 Keratoconjunctivitis sicca

2 The common causes for glaucoma are associated conditions such as diabetes mellitus, hypertension, and severe myopia. Therefore a client with these diseases is at higher risk for glaucoma. Cataracts may be caused by diabetes mellitus but not hypertension. Corneal abrasions and keratoconjunctivitis sicca are not associated with disease conditions such as diabetes mellitus and hypertension.

A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she tells the nurse that she does not feel well. The nurse reviews the medical record and notices WBCs 2200/mm3 (2.2 x 109/L), RBCs 4.0 million/mm3 (4.7 x 1012/L), hemoglobin 12.0 g/dL (120 mmol/L), hematocrit 38%, platelets 170,000/mm3 (170 x 109/L). Vital signs are heart rate 97 beats/minute, respiration rate 25 breaths/minute, oral temperature 99.1 ºF (37.3 ºC), blood pressure 110/72. Based on this information, what does the nurse conclude is the client's priority need? 1 Promoting rest 2 Preventing infection 3 Avoiding bodily harm 4 Maintaining fluid balance

2 The prevention of infection is the priority because an infection can be life threatening for a client who is immunocompromised. Chemotherapeutic medications depress the bone marrow, causing leukopenia. This client's white blood cell count is below the expected range of 4500 to 11,000/mm3 (4.5 to 11 x 109/L) for an older female adult. Although the elevation in the client's temperature, pulse, and respirations may be related to the direct effects of the chemotherapeutic agents, they also may reflect that the client is resisting a microbiologic stress. Although a balance between rest and activity is important, it is not the priority. Although chemotherapeutic medications depress the bone marrow and cause anemia, this client's red blood cell count is within the expected range of 4.0 to 5.0 million/mm3 (4.7 to 6.1 x 1012/L) for an older female adult. The client's hemoglobin level is within the expected range of 11.5 to 16.0 g/dL (115 to 160 mmol/L). Even though preventing injury is important, it is not the priority. Although chemotherapeutic medications depress the bone marrow, causing thrombocytopenia, this client's platelet count is within the expected range of 150,000 to 400,000/mm3 (150 × 109 /L to 400 × 109 /L) for an adult. Although maintaining fluid balance is important, it is not the priority. The client's hematocrit is within the expected range of 38% to 41% for an older female adult, indicating that the client is not dehydrated. The client's blood pressure is not decreased, which occurs with dehydration. Although chemotherapeutic medications may cause nausea, vomiting, and diarrhea, the client did not indicate that these occurred.`

Which part of the nephron secretes creatinine required for elimination? 1 Glomerulus 2 Loop of Henle 3 Collecting duct 4 Proximal tubule

2 The proximal tubule of the nephron secretes creatinine and hydrogen ions. It also reabsorbs water and electrolytes. The glomerulus filters the blood selectively. The ascending loop of Henle reabsorbs sodium and chloride, whereas the descending loop of Henle concentrates the filtrate. The collecting duct reabsorbs water.

One week after an above-the-knee amputation, a client refuses to go to physical therapy and tells the nurse, "I'll never be a whole person again!" What is the nurse's best response? 1 "You're still the same person you've always been. Just relax." 2 "You've lost a part of yourself. That must be very difficult for you." 3 "You may feel that way, but I'm sure your family considers you a whole person." 4 "You must go to physical therapy every day or you will develop muscle contractures."

2 The response "You've lost a part of yourself. That must be very difficult for you" acknowledges and reflects the client's feelings and encourages further communication. The response "You're still the same person you've always been. Just relax" negates the client's feelings. The nurse does not know how the client's family members feel; the response "You may feel that way, but I'm sure your family considers you a whole person" takes the focus off the client. The response "You must go to physical therapy every day or you will develop muscle contractures" is true, but telling the client this serves no therapeutic purpose at this time.

Which client eye movement does the superior oblique muscle control? 1 Pulls the eye upward 2 Pulls the eye downward 3 Turns the eye towards the nose 4 Turns the eye towards the side of the head

2 The superior oblique muscle contracts alone and pulls the eye downward. The inferior oblique muscle helps in pulling the eye upwards. The medial rectus muscle contracts alone and turns the eye towards the nose. The lateral rectus muscle turns the eye towards the side of the head.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record? 1 "Has intact plantar reflexes" 2 "Exhibits a positive Babinski sign" 3 "Demonstrates normal sensory function" 4 "Able to perform active range of motion"

2 This is a positive Babinski sign [1] [2] [3]; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings? 1 Put the stockings on at the first sign of discomfort. 2 Don the stockings before getting out of bed in the morning. 3 Ensure that the cuff of the stockings reaches the middle of the knees. 4 Substitute elastic bandages for compression stockings if they are more comfortable.

2 To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs. Knee-high stockings should end 2 inches (5.1 cm) below the knee to avoid popliteal pressure, which limits venous return. Stockings apply uniform pressure. Elastic bandages may slip or develop wrinkles, creating uneven pressure and constriction; edema may result.

What determines if a client will develop AIDS from an HIV infection? 1 Level of IgM in the blood 2 The number of CD4+ T-cells available 3 Presence of antigen-antibody complexes 4 Speed with which the virus invades the RNA

2 Whether HIV becomes AIDS depends upon the number of CD4+ T-cells. IgM and the presence of antigen-antibody complexes have no effect on HIV. The speed with which HIV invades the RNA has no impact on the future development of AIDS.

What are the functions of antidiuretic hormone (ADH)? Select all that apply. 1 Controlling calcium balance 2 Increasing arteriole constriction 3 Increasing tubular permeability to water 4 Stimulating the bone marrow to make red blood cells 5 Promoting the reabsorption of sodium in the distal convoluted tubule (DCT)

2,3 Antidiuretic hormone (ADH), also known as vasopressin, is a hormone released from the posterior pituitary gland. ADH increases arteriole constriction and tubular permeability to water. Calcium balance is controlled by blood levels of calcitonin and the parathyroid hormone (PTH). Erythropoietin stimulates the bone marrow to make red blood cells. Aldosterone promotes the reabsorption of sodium in the distal convoluted tubule (DCT).

A nurse is teaching a client about human immunodeficiency virus (HIV). What are the various ways HIV is transmitted? Select all that apply. 1 Mosquito bites 2 Sharing syringe needles 3 Breastfeeding a newborn 4 Dry kissing the infected partner 5 Anal intercourse

2,3,5 Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites or dry kissing.

What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply. 1 Cytokines 2 Mast cells 3 Histamines 4 Neutrophils 5 Leukotrienes

2,3,5 Mast cells, histamines, and leukotrienes are the mediators of injury in IgE-mediated hypersensitivity reactions. Cytokines are the mediators of injury in the delayed type of hypersensitivity reaction. Neutrophils are the mediators of injury in the immune-complex type of hypersensitivity reaction.

Which medications are administered to inhibit purine synthesis and suppress cell-mediated and humoral immune responses? Select all that apply. 1 Sirolimus 2 Azathioprine 3 Cyclophosphamide 4 Methylprednisolone 5 Mycophenolate mofetil

2,5 Azathioprine and mycophenolate mofetil are administered to inhibit purine synthesis and suppress cell-mediated and humoral immunity. Sirolimus binds to a mammalian target of rapamycin (mTOR), which suppresses T-cell activation and proliferation. Cyclophosphamide is administered to treat cancers, autoimmune disorders, and amyloidosis. Methylprednisolone is a corticosteroid that inhibits cytokine production.

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? 1 Stimulate continuous formation of urine. 2 Facilitate the measurement of urinary output. 3 Prevent the development of clots in the bladder. 4 Provide continuous pressure on the prostatic fossa.

3 A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.

The nurse finds that a client has reduced urinary output. Which condition would the nurse document in the client's medical record? 1 Anuria 2 Dysuria 3 Oliguria 4 Nocturia

3 A reduced urinary output of less than 400 mL in a 24-hour interval is called oliguria. Anuria is the absence of urination. Painful or difficult urination is called dysuria. Frequent urination at night is called nocturia.

A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should place the client's affected extremity in which position? 1 External rotation 2 Slight hip flexion 3 Moderate abduction 4 Anatomic body alignment

3 Abduction reduces stress on anatomic structures and maintains the head of the femur in the acetabulum. External rotation places stress on the acetabulum and the head of the femur. Hip flexion may dislodge the head of the femur from the acetabulum. Functional alignment places stress on the bone, soft tissue, and nail plate; it can cause damage and dislocation of the head of the femur.

Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)? 1 It is most common in women. 2 It is manifested by intense bilateral pain. 3 It is caused by an overactive hypothalamus. 4 It is associated with headaches of long duration.

3 According to neuroimaging studies, the etiology of cluster headaches is related to an overactive and enlarged hypothalamus. Cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours.

A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest? 1 Ice cream 2 Cheese sticks 3 Fresh orange wedges 4 Peanut butter cookies

3 An orange contains only trace amounts of sodium. Dairy products such as ice cream and cheese are high in sodium and should be avoided. Peanut butter cookies are high sodium.

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client? 1 Severe radiating abdominal pain 2 Pattern of visible peristaltic waves 3 Visible pulsating abdominal mass 4 Cyanosis with other symptoms of shock

3 As the heart contracts, an expanding midline mass may be visible to the left of the umbilicus. Severe radiating abdominal pain is not definitive for abdominal aortic aneurysm. There is no problem or pathology in the intestinal tract; patterning of visible peristaltic waves is associated with intestinal obstruction. Cyanosis with other symptoms of shock is not definitive for abdominal aortic aneurysm; pallor occurs with shock.

A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101° F (38.3° C). The nurse notifies the primary healthcare provider. Aspirin 650 mg every 4 hours as needed for temperature equal to or greater than 101° F (38.3° C) is prescribed. What should the nurse do regarding this prescription? 1 Express concern about the dosage prescribed. 2 Request a prescription for an antacid. 3 Express concern about the type of antipyretic prescribed. 4 Ask if the frequency should be every 6 hours instead.

3 Aspirin is contraindicated in the presence of bleeding tendencies, which often occur with acute lymphocytic leukemia because of its inhibitory effect on platelet aggregation. Although expressing a concern about the dosage is within acceptable limits, this analgesic is contraindicated. Although an antacid will reduce the gastric irritation common with aspirin, this analgesic is contraindicated. Although the frequency is within acceptable limits, this analgesic is contraindicated.

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan? 1 "Rinse the mouth three times a day with lemon juice and water." 2 "Brush the teeth once daily and use dental floss after each meal." 3 "Clean the mouth with a soft toothbrush or a gentle spray." 4 "Gently clean the mouth with commercial mouthwash."

3 Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? 1 Loss of skin integrity caused by the burns 2 Potential infection as a result of the burn injury 3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns

3 Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.

The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition? 1 Allergy 2 Insect bite 3 Fungal infection 4 Bacterial infection

3 Exposure to the pathological fungal varieties may cause infections to the nails along with hair and skin. Dermatological problems associated with allergies and hypersensitivity reactions may include only skin and may not include nails and hair. Insect bites may cause life-threatening allergic reactions due to the venom of the insect. Bacteria may cause scalp infections to hair and skin but do not usually cause nail infections.

Which description is associated with fissures? 1 Deep erosions that extend beneath the epidermis 2 Thinning of the skin surface with a loss of skin markings 3 Linear cracks in the epidermis that extend into the dermis 4 Thickened areas of epidermis with accentuated skin markings

3 Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.

Which hormone is released in response to low serum levels of calcium? 1 Renin 2 Erythropoietin 3 Parathyroid hormone 4 Atrial natriuretic peptide

3 If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis. Renin is a hormone released in response to decreased renal perfusion; this hormone is responsible for regulating blood pressure. Erythropoietin is released by the kidneys in response to poor blood flow to the kidneys; it stimulates the production of red blood cells. Atrial natriuretic peptide is produced by the right atrium of the heart in response to increased blood volume. This hormone then acts on the kidneys to promote sodium excretion, which decreases the blood volume.

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? 1 Drug eruption 2 Atopic dermatitis 3 Contact dermatitis 4 Nonspecific eczematous dermatitis

3 In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? 1 Polyuria 2 Tachypnea 3 Increased restlessness 4 Intermittent tachycardia

3 Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

A client develops a nonhealing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. Which would be the best response by the nurse? 1 "Muscle weakness occurs in the legs because of a lack of exercise." 2 "Edema and cyanosis occur in the legs because they are dependent." 3 "Pain occurs in the legs while walking because there is a lack of oxygen to the muscles." 4 "Pressure occurs in the legs because of vasodilation and pooling of blood in the extremities."

3 Intermittent claudication is the pain that occurs during exercise because of a lack of oxygen to muscles in the involved extremities. It is exercise, not the lack of exercise, that precipitates muscle weakness. Edema and cyanosis in the legs and pressure in the legs are related to venous problems, not an arterial problem.

Which test is used to specifically detect intracranial aneurysms in clients? 1 Diffusion imaging 2 Magnetic resonance imaging 3 Magnetic resonance angiography 4 Magnetic resonance spectroscopy

3 Magnetic resonance angiography is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations. Magnetic resonance spectroscopy is indicated in epilepsy, Alzheimer disease, and stroke to assess abnormalities in the brain's biochemical processes. Diffusion imaging is indicated for evaluation of ischemia in the brain to determine the location and severity of a stroke. Magnetic resonance imaging is taking multiple sets of images to determine normal and abnormal anatomy.

Metoprolol is prescribed for a client. Which condition in the client's electronic medical record will cause the nurse to question the prescription? 1 Hypertension 2 Angina pectoris 3 Sinus bradycardia 4 Myocardial infarction

3 Metoprolol is a beta blocker; it decreases the heart rate and thus is contraindicated with bradycardia. Metoprolol is an antihypertensive agent and is given for hypertension. By reducing cardiac output, metoprolol reduces myocardial oxygen consumption, which helps prevent ischemia from anginal pain and myocardial infarction.

A client with a distal femoral fracture has a long leg cast applied. Which important element of a discharge program should the nurse focus on when teaching crutch-walking? 1 Establishing a schedule for pain medication 2 Maintaining a fixed schedule of daily activities 3 Modifying the home environment to prevent accidents 4 Understanding that a more sedentary lifestyle is necessary

3 Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.

Which refractive error condition is due to a decrease in elasticity of the client's lens? 1 Myopia 2 Hyperopia 3 Presbyopia 4 Astigmatism

3 Presbyopia is an age-related problem in which the lens loses its elasticity and is less able to change its shape to focus the eye for close work. As a result, images fall behind the retina. Myopia, or nearsightedness, is a condition in which the eye over-refracts the light and the bent images fall in front of, not on, the retina. Hyperopia, also called hypermetropia, or farsightedness, is a condition in which refraction is too weak, causing images to be focused behind the retina. Astigmatism occurs when the curve of the cornea is uneven. Because light rays are not refracted equally in all directions, the image does not focus on the retina.

Which hormone is crucial in maintaining the implanted egg at its site? 1 Inhibin 2 Estrogen 3 Progesterone 4 Testosterone

3 Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

Which synovial joint movement is involved in turning the client's palm downward? 1 Eversion 2 Inversion 3 Pronation 4 Supination

3 Pronation is the movement involved in turning the palm inward. Eversion involves turning the sole outward away from the midline of the body. Inversion involves turning the sole inward towards the midline of the body. Supination involves turning the palm upward.

A client who is receiving radiation therapy for bone cancer lives alone and works full time. What should the nurse encourage this client to do? 1 Perform regularly scheduled aerobic activity daily. 2 Take a leave of absence from work when receiving therapy. 3 Include rest periods during the day while receiving radiation. 4 Continue the activities usually performed before becoming ill.

3 Radiation is fatiguing; therefore, rest periods will combat fatigue. Rest ultimately will promote performance of activities of daily living and independence. Increasing activity at this time is not advised because fatigue is a side effect of radiation. Maintaining independence is important, and a leave of absence may not be emotionally or financially feasible. Although normalizing activities is desirable, this may be unrealistic when the side effects of radiation therapy are considered.

The nurse is providing discharge teaching to a 30-year-old client who was hospitalized for exacerbation of rheumatoid arthritis. Which statement by the client indicates correct understanding of the treatment plan? 1 "I will plan to rest in bed for the next 2 weeks." 2 "I will only take my medications when I am having joint pain." 3 "When I exercise, I will reduce the number of repetitions when I have pain." 4 "When I get out of bed, I will push off with my fingers rather than the palms of my hands."

3 The amount of exercise and number of repetitions should be reduced to prevent further joint damage if the client is experiencing increased pain. Activity should be balanced with rest. Medications should not be discontinued without consulting the primary healthcare provider. Pushing off with fingers may cause further damage to the phalangeal joints.

A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response? 1 "Well, yes, that will certainly lower the amount of your blood fats." 2 "That's good, but be sure to compensate by adding more carbohydrates." 3 "You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume." 4 "You need some cholesterol in your diet because your body cannot manufacture it, so just avoid excessive amounts."

3 The essential fatty acids, linoleic acid and linolenic acid, are necessary for muscle tissue integrity, especially of the myocardium. All fats cannot and should not be eliminated from the diet. Carbohydrates do not contain the essential fatty acids, linoleic acid and linolenic acid. The body does manufacture cholesterol.

A nurse is providing client teaching to a woman who has recurrent urinary tract infections. Which information should the nurse include concerning the reason why women are more susceptible to urinary tract infections than men? 1 Inadequate fluid intake 2 Poor hygienic practices 3 The length of the urethra 4 The continuity of mucous membranes

3 The length of the urethra is shorter in women than in men; therefore, microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in women also increases the incidence of urinary tract infections. Fluid intake may or may not be adequate in both men and women and does not account for the difference. Hygienic practices can be inadequate in men or women. Mucous membranes are continuous in both men and women.

A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L (20 mmol/L). Which client should the nurse consider is most likely to exhibit these results? 1 A 54-year-old with vomiting 2 A 17-year-old with panic attacks 3 A 24-year-old with diabetic ketoacidosis 4 A 65-year-old with advanced emphysema

3 The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic attacks most likely will experience respiratory alkalosis from hyperventilation. A 65-year-old with advanced emphysema most likely will experience respiratory acidosis.

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? 1 Calices 2 Glomerulus 3 Macula densa 4 Juxtaglomerular cells

3 The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase? 1 "The client will adhere to the teaching plan." 2 "The client will achieve psychologic adjustment." 3 "The client will maintain present muscle strength." 4 "The client will prepare for a possible myasthenic crisis."

3 Until the diagnosis has been confirmed, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis has not yet been established. The response "achieve psychologic adjustment" is too early; the client cannot adjust if a diagnosis has not yet been confirmed. The response "prepare for a possible myasthenic crisis" is an intervention, not an objective.

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage? 1 Decreases phantom limb sensations 2 Encourages a normal walking pattern 3 Reduces the incidence of wound infection 4 Allows for fitting of the prosthesis before discharge

3 Without a prosthesis, a walker or crutches are necessary, and these require readjustment of weight bearing on one leg. Early use of a prosthesis does not affect the incidence of phantom limb pain, which occurs in about 10% of clients with amputations. Early use of a prosthesis has no effect on wound infection. Although true, fitting of the prosthesis before discharge is not the major purpose; a prosthesis can be fitted easily after discharge when the residual limb has healed completely and is no longer edematous.

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply. 1 Furuncle 2 Cellulitis 3 Impetigo 4 Folliculitis 5 Erysipelas 00:00:03 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

3,5 Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.

A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client makes which comment? 1 "X-rays will be taken to identify where I may have lost calcium from my bones." 2 "Portions of my bone marrow will be removed and examined for cell composition." 3 "A radioactive chemical will be injected into my vein that will destroy cancer cells present in my bones." 4 "A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."

4 A bone scan maps the uptake of a bone-seeking radioactive isotope; an increased uptake is seen in metastatic bone disease, osteosarcoma, osteomyelitis, and certain fractures. A bone scan measures the uptake of radioactive material, not the absence of calcium, which is seen in an x-ray examination of bone. The response "Portions of my bone marrow will be removed and examined for cell composition" refers to a bone marrow aspiration, when a small amount of marrow is examined to determine the presence of abnormal cells in diseases such as leukemia. A bone scan involves a small diagnostic dosage of a radioactive substance; it is not therapeutic.

Which structure connects the client's tibia to the femur at the knee joint? 1 Fascia 2 Bursae 3 Tendons 4 Ligaments

4 A ligament is a dense, fibrous connective tissue that connects bone to bone, such as the tibia to the femur at the knee joint. Ligaments provide stability while permitting controlled movement at the joint. Fascia is a connective tissue that can withstand limited stretching; it provides strength to muscle tissues. Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that are located at bony prominences and joints to relieve pressure. A tendon is a dense, fibrous connective tissue that attaches muscle to bone.

A nurse is counseling a woman who has had recurrent urinary tract infections. Which factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection? 1 Altered urinary pH 2 Hormonal secretions 3 Juxtaposition of the bladder 4 Proximity of the urethra to the anus

4 Because a woman's urethra is closer to the anus than a man's, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in men and women.

Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue? 1 Continuous wet gauze 2 Moisture-retentive dressing 3 Topical enzyme preparations 4 Wet-to-dry damp saline moistened gauze

4 A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.

What is the color of a client's wound caused by skin tears? 1 Red 2 Gray 3 Black 4 Yellow

4 A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.

Which skin color in a client indicates an increased urochrome level? 1 Red 2 Blue 3 Reddish blue 4 Yellow-orange

4 A yellow-orange skin color indicates an increased urochrome level. A red-colored face, cheeks, nose, and upper chest indicate increased blood flow to the skin. A bluish color of the nail beds indicates an increase in deoxygenated blood in the body. A reddish-blue color of the distal extremities indicates decreased peripheral circulation.

According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance? 1 1 2 2 3 3 4 4

4 According to the common scale for grading muscle strength, a client who can complete range of motion with some resistance is given the rating 4. Rating 1 is given to a client with no joint motion and slight evidence of muscle contractility. Rating 2 is given to a client who can complete range of motion with gravity eliminated. Rating 3 is given to a client who can complete range of motion against gravity.

The nurse is educating a couple concerning the process of fertilization. The nurse explains to the couple that which component stimulates the release of estrogen and progesterone after fertilization? 1 Inhibin 2 Testosterone 3 Follicle-stimulating hormone (FSH) 4 Human chorionic gonadotropin (hCG)

4 After fertilization, human chorionic gonadotropin (hCG) stimulates the corpus luteum to produce estrogen and progesterone. Inhibin is a hormone produced by the ovarian follicles; it inhibits the secretion of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Testosterone does not affect the release of estrogen and progesterone. Follicle-stimulating hormone (FSH) stimulates the growth and maturity of the ovarian follicle necessary for ovulation.

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? 1 Thready, weak pulse 2 Narrowing pulse pressure 3 Regular, shallow breathing 4 Lowered level of consciousness

4 Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin? 1 Punch biopsy 2 Shave biopsy 3 Incisional biopsy 4 Excisional biopsy

4 An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction? 1 P wave 2 T wave 3 PR interval 4 QRS interval

4 Atrial and ventricular depolarization and repolarization are represented on the electrocardiogram (ECG) as a series of waves: the P wave followed by the QRS complex and the T wave. The first deflection is the P wave associated with right and left atrial depolarization followed by the QRS complex that reflects ventricular depolarization.

Which joint permits movement in any direction? 1 Pivot joint 2 Hinge joint 3 Biaxial joint 4 Ball-and-socket joint

4 Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.

A nurse is counseling a woman who had recurrent urinary tract infections. Which factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection? 1 Altered urinary pH 2 Hormonal secretions 3 Juxtaposition of the bladder 4 Proximity of the urethra to the anus

4 Because a woman's urethra is closer to the anus than a man's, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in men and women.

A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms? 1 Cetirizine 2 Fexofenadine 3 Desloratadine 4 Chlorpheniramine

4 Chlorpheniramine [1] [2] is an antihistamine that helps to manage allergic symptoms by preventing vasodilation and decreasing allergic symptoms. Sedation is a side effect of chlorpheniramine; therefore this drug is prescribed to clients experiencing sleep issues due to allergic symptoms. Cetirizine effectively blocks histamine from binding to receptors and has less sedating potential. Fexofenadine and desloratadine are also less sedating antihistamine drugs.

A client is admitted to the hospital for surgical replacement of the mitral valve with a mechanical valve. Which risk factor would be the primary reason that the nurse must frequently check pulses in the client's legs after surgery? 1 Atrial fibrillation 2 Postsurgical bleeding 3 Arteriovenous shunting 4 Peripheral thromboembolism

4 Depending on the type of replacement mitral valve used during surgery, thrombus formation on the valve surface with subsequent emboli has the highest risk of occurring with mechanical valves, which require long-term anticoagulation therapy. Atrial fibrillation is assessed by cardiac monitoring and comparing peripheral and apical pulses for deficit. Bleeding is detected by checking the wound dressing and observing for signs of shock (e.g., lowered blood pressure, tachycardia, restlessness). Arteriovenous shunting is not a danger after mitral valve replacement.

Which virus is responsible for causing infectious mononucleosis in clients? 1 Parvovirus 2 Coronavirus 3 Rotavirus 4 Epstein-Barr virus

4 Epstein-Barr virus is responsible for mononucleosis and possibly Burkitt's lymphoma. Parvovirus and rotavirus cause gastroenteritis. Corona virus causes upper respiratory tract infections

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse? 1 "I don't know. I will ask the health care provider for a prescription." 2 "Antibiotics are used to treat viruses and you have a bacterial infection." 3 "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." 4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."

4 Generally, upper respiratory infections are viral; therefore antibiotics should not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? 1 Recognize that depression often occurs after surgery 2 Ask the primary healthcare provider to arrange for a psychologic consultation 3 Reassure the client that things will feel better after the discharge date has been set 4 Talk with the client about the prognosis and emphasize activities the client is still able to perform

4 Honest discussion with emphasis on functional and psychologic abilities helps promote adjustment. Postoperative depression is not a characteristic feature of thymectomy. Asking the client's practitioner to arrange for a psychologic consultation is too soon; it may eventually be necessary if the client has difficulty adjusting to the chronicity of this condition. Reassuring the client that things will feel better when the discharge date is set provides false reassurance; there is no guarantee the client will feel better on discharge.

Which is the first antibody formed after exposure to an antigen? 1 IgA 2 IgE 3 IgG 4 IgM

4 IgM (immunoglobulin M) is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience the most pain and limited movement of the joints? 1 After assistive exercise 2 When the room is cool 3 During the evening hours 4 In the morning on awakening

4 Inactivity over an extended time increases stiffness and pain in joints. The client typically has morning stiffness, or gel phenomenon. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The pain is not as severe in the evening as in the morning.

A nurse is developing a health teaching plan for clients with pacemakers. Which activity should the nurse teach these clients to avoid? 1 Having a computed tomography (CT) scan 2 Standing near a microwave 3 Swimming in saltwater 4 Touring a power plant

4 Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.

Which urinalysis finding indicates a urinary tract infection? 1 Presence of crystals 2 Presence of bilirubin 3 Presence of ketones 4 Presence of leukoesterase

4 Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.

Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? 1 Electrical stimulation 2 Topical growth factors 3 Hyperbaric oxygen therapy 4 Negative pressure wound therapy

4 Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.

The nurse notices sudden bursts of fast rhythm that end abruptly. The heart rate is 220 beats per minute during these bursts, but the P waves are very difficult to see. The QRS interval is normal. The nurse notifies the primary healthcare provider. Which rhythm did the nurse share with the primary healthcare provider? 1 Sinus tachycardia 2 Atrial tachycardia 3 Ventricular tachycardia (VT) 4 Paroxysmal supraventricular tachycardia (PSVT)

4 PSVT occurs above the ventricles, and it has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because the P wave arises outside the sinus node, the shape is different from the sinus P wave. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The client may or may not have a pulse.

A client signs a legal consent for hip replacement surgery. Shortly before surgery, the client states, "I decided not to go through with the surgery." Which is the best initial response by the nurse? 1 "Then you shouldn't have signed the consent." 2 "I can understand why you changed your mind." 3 "Tell me why you decided to refuse the operation." 4 "Let's talk about your concerns regarding the procedure."

4 The response "Let's talk about your concerns regarding the procedure" attempts to explore why the client is refusing the procedure and promotes communication. The response "Then you shouldn't have signed the consent" is accusatory; the client has the right to withdraw consent at any time. The response "I can understand why you changed your mind" draws a conclusion without adequate data; also, it may increase the client's anxiety level. The response "Tell me why you decided to refuse the operation" may be too direct and authoritative; also it may put the client on the defensive.

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? 1 "You may be able to lessen your feelings of guilt by seeking counseling." 2 "It would be helpful if you become involved in volunteer work at this time." 3 "I recognize it's hard to deal with this, but try to remember that this too shall pass." 4 "Joining a support group of people who are coping with this problem may be helpful."

4 Talking with others in similar circumstances provides support and allows for sharing of experiences. The response "You may be able to lessen your feelings of guilt by seeking counseling" is inappropriate because the feeling of guilt was not expressed directly and is too early for this intervention. The response "It would be helpful if you become involved in volunteer work at this time" avoids the partner's concerns and makes a recommendation for which the partner may not have the energy. Also, it cuts off communication. Although the response "I recognize it's hard to deal with this, but try to remember that this too shall pass" identifies feelings, it offers false reassurance.

The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next? 1 Call the primary healthcare provider to obtain a prescription for an antihistamine. 2 Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3 Slow down the rate of the infusion. 4 Stop the transfusion immediately.

4 The client is experiencing an allergic reaction to the transfusion. The nurse should stop the transfusion immediately. The health care provider then should be notified. Flushing red blood cells with dextrose and normal saline will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate will make the situation worse.

A client expresses concern that because of supply and demand there is no vaccine available for the annual flu vaccine. What is the nurse's best reply? 1 "It's unfortunate, but there was such a limited supply available." 2 "There are many others who also were unable to get a flu vaccine." 3 "It doesn't matter because the vaccine is for just one particular strain." 4 "There are other things you can do to prevent the flu, such as hand washing."

4 The statement "There are other things you can do to prevent the flu, such as hand washing" is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response "It's unfortunate, but there was such a limited supply available" is empathic, but it does not address the client's concern of vulnerability. The response "There are many others who also were unable to get a flu vaccine" belittles the client for being concerned. The response "It doesn't matter because the vaccine is for just one particular strain" may be true, but it belittles the client's concern.

A client with arthritis reports receiving several dietary suggestions over the years. Which recommendation for a daily diet should the nurse reinforce? 1 Wheat germ and yeast 2 Yogurt and blackstrap molasses 3 Multiple vitamin supplements in large doses 4 Adequate foods in a variety of different food groups

4 There is no special diet for arthritis. A balanced diet, consisting of foods from all groups of the MyPlate dietary guidelines, is essential in maintaining nutrition. Limiting the diet to particular foods does not provide all the essential nutrients. If nutritional intake is adequate, large doses of multivitamins are unnecessary and are dangerous.

A client with an indwelling catheter is prescribed a urinalysis test. Arrange the steps involved in the collection of the urine sample in correct order. 1. Aspirate the urine 2. Remove the clamp 3. Attach a sterile syringe 4. Clamp drainage tubing

4,3,1,2 In a client with an indwelling catheter, urine sample is collected by first applying a clamp, distal to the injection port, on to the drainage tubing. Then the injection port cap of the catheter drainage tubing is cleaned with alcohol. The next step is to attach a 5-mL sterile syringe into the port and aspirate the urine sample required. Finally the clamp is removed so that the drainage is resumed.

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? 1 "You seem concerned about your diagnosis." 2 "You are feeling guilty about your smoking." 3 "There have been advances in lung cancer therapy." 4 "Trust your healthcare provider, who is very competent in treating cancer."

1 The correct response acknowledges the client's concerns and allows them to set the framework for discussion and express self-identified feelings. The client's statement is not specific enough to come to the conclusion that the client feels guilty; this is an assumption by the nurse. Talking about advances in lung cancer therapy or trust for the healthcare provider avoids the client's concerns and cuts off communication.

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? 1 Wheezing 2 Rhonchi 3 Pleural friction rub 4 Low-pitched crackles

1 Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is an adventitious breath sound that may indicate bronchospasm. Rhonchi are associated with obstruction by a foreign body. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.

A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? 1 Assess the person's breathing. 2 Offer the person sips of water. 3 Cover the person with a warm blanket. 4 Calculate the extent of the person's burns.

1 A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be initiated. The person should be kept nothing by mouth because extensive burns decrease intestinal peristalsis, and the person may vomit and aspirate. Covering the person with a warm blanket is not done until the assessment for breathing is completed. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all options but one deal with signs and symptoms, you would be correct in choosing the treatment-specific option.

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis? 1 Spiral (helical) computed tomographic angiography (CTA) 2 D-dimer and arterial blood gas (ABG) laboratory tests 3 Ventilation-perfusion (V/Q) scan 4 Pulmonary angiography

1 A spiral (helical) computed tomographic angiography (CTA) is considered the gold standard for a pulmonary embolism (PE) medical diagnosis. The spiral CTA also has the added advantage of diagnosing other pulmonary abnormalities. A pulmonary angiography is still used as a PE diagnostic test, usually if the client also has coronary disease and invasive treatment (i.e., angioplasty) may become necessary; however, it is no longer the gold standard because it is expensive and invasive, and the spiral CTA has excellent accuracy and better accessibility. Ventilation/perfusion (V/Q) scans are currently used only in certain circumstances such as when the client has contrast dye allergy. D-dimer and arterial blood gas (ABG) laboratory tests are typically prescribed for a client with a possible PE; however, these tests are not specific or sensitive enough to be used alone to make the PE diagnosis. An ABG is used to evaluate the client's oxygenation status during medical diagnosis and treatment to determine if additional emergency treatment is needed, such as intubation and mechanical ventilation. A D-dimer simply reveals the presence or absence of fibrin split products which occur when a blood clot degrades or breaks down; however, about half of clients with a PE still test negative (a normal result) and several other conditions can produce a positive D-dimer result.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings 4 Adequate nutritional intake and spending extensive time in a wheelchair

1 Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention? 1 Nasogastric tube for decompression 2 Antiemetic for nausea/vomiting 3 Intravenous (IV) lactated Ringer for fluid replacement 4 Stat electrolytes to assess for probable electrolyte imbalance

1 Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. Vomiting will subside as the bowel is decompressed. Although IV lactated Ringer for fluid replacement is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? 1 Peripherally inserted central catheter (PICC) line 2 #20 angiocatheter in either antecubital area 3 Large-gauge butterfly needle in hand 4 Femoral line

1 Dopamine hydrochloride is a vesicant, and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly needle are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. When teaching when to call the primary healthcare provider, what statement made by the client shows that teaching was effective? 1 "I should call the primary healthcare provider for dry hair and an intolerance to cold." 2 "I should call the primary healthcare provider for muscle cramping and sluggishness." 3 "I should call the primary healthcare provider for fatigue and an increased pulse rate." 4 "I should call the primary healthcare provider for tachycardia and an increase in weight."

1 Dry, sparse hair and cold intolerance are characteristic responses to low serum thyroxine. Muscle cramping is associated with hypocalcemia. Low thyroxine levels reduce the metabolic rate, resulting in fatigue, but do not increase the pulse rate. Low thyroxine levels reduce the metabolic rate, resulting in weight gain and bradycardia, not tachycardia.

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypomagnesemia

1 Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1 Increases the cardiac workload 2 Interferes with usual respirations 3 Produces an elevation in temperature 4 Decreases the amount of oxygen used

1 Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure. Anxiety does not directly interfere with respirations; an increase in cardiac workload will increase respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen used and leads to an increased respiratory rate.

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? 1 Ketoacidosis 2 Somogyi phenomenon 3 Hypoglycemic reaction 4 Hyperosmolar nonketotic coma

1 Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? 1 68 mg/dL (3.8 mmol/L) 2 78 mg/dL (4.3 mmol/L) 3 88 mg/dL (4.9 mmol/L) 4 98 mg/dL (5.4 mmol/L)

1 Normal blood glucose level for an adult is 72-108 mg/dL (4-6 mmol/L). Clients who have blood glucose levels below 72 mg/dL (4 mmol/L) may experience hypoglycemia; 78 mg/dL (4.3 mmol/L), 88 mg/dL (4.9 mmol/L), and 98 mg/dL (5.4 mmol/L) are normal blood glucose levels.

Which hormone regulates blood levels of calcium? 1 Parathormone 2 Luteinizing hormone 3 Thyroid stimulating hormone 4 Adrenocorticotropic hormone

1 Parathyroid hormone (PTH), or parathormone, regulates the blood levels of calcium and phosphorus. Luteinizing hormone (LH) stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. Thyroid stimulating hormone (TSH) stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. Adrenocorticotropic hormone (ACTH) promotes the growth of the adrenal cortex and stimulates the release of corticosteroids.

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1 Initiate oxygen via a nasal cannula 2 Administer the prescribed morphine 3 Prepare the client for endotracheal intubation 4 Place a nitroglycerin tablet under the client's tongue

1 Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. Endotracheal intubation is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is not the priority intervention and requires a prescription.

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion

1 The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? 1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities

1 The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion

1 The low pH and elevated Pco2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1 "When was your last drink of vodka?" 2 "What prompts your drinking episodes?" 3 "Do you also eat when you drink?" 4 "Why do you mix the vodka with orange juice?"

1 The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

Which gland secretes melatonin? 1 Pineal gland 2 Thyroid gland 3 Adrenal gland 4 Parathyroid gland

1 The pineal gland secretes the hormone melatonin, which regulates the circadian rhythm and reproductive system at the onset of puberty. The thyroid gland secretes thyroid hormones. The adrenal gland secretes androgens, corticosteroids, and catecholamines. The parathyroid gland secretes the hormone calcitonin.

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do? 1 Keep a record of the day's activities. 2 Avoid going through laser-activated doors. 3 Record the pulse and blood pressure every 4 hours. 4 Delay taking prescribed medications until the monitor is removed

1 The purpose of monitoring is to correlate dysrhythmias with the client's reported activity. Laser-activated doors have no effect on a Holter monitor and will not affect the readings. Recording the pulse and blood pressure every 4 hours is not required for interpretation of the test. The client should take medication as prescribed and note it in the activities diary.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? 1 Support systems that can assist the client at home 2 Potential nursing homes in which the client can recuperate 3 Agencies that can help the client regain activities of daily living 4 Ways that the client can develop relationships with neighbors

1 The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? 1 Remain with the client to assess responses. 2 Allow family members to participate in the process. 3 Permit the client more extended times alone for independence. 4 Observe monitoring devices at the control panel of the ventilator.

1 This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress (e.g., shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, and tachypnea). Allowing family members to participate in the process delegates professional responsibility inappropriately. Permitting the client more extended times alone for independence will not ensure the client's safety. Observing monitoring devices at the control panel of the ventilator will not provide the client with support and professional assistance.

The nurse is caring for the client posttranssphenoidal hypophysectomy. When assessing the client, the nurse observes clear drainage from the nares. What could be the cause of this drainage? 1 A cerebral spinal fluid leak from an opening to the brain. 2 A normal occurrence for this client's procedure. 3 The client is developing an infection. 4 The client may have had a cold preoperatively, and the nurse will continue to monitor.

1 Transsphenoidal hypophysectomy is removal of the pituitary gland. This procedure is close to the brain. Clear drainage from the nares could indicate a cerebral spinal fluid (CSF) leak. The nurse should contact the primary healthcare provider and send the drainage to the laboratory for glucose evaluation. If the glucose level is greater than 30 mg/dL, this would indicate a CSF leak. This is not a normal occurrence postoperatively for this procedure. Clear drainage would not indicate an infection.

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg

1 When the sound disappears at 72 mm Hg, it is known as phase five of Korotkoff sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely. 90 mm Hg is recorded as the diastolic pressure in adolescents and adults. The muffled sound heard at 90 mm Hg is phase four of Korotkoff sounds; the muffled sound represents the point at which the cuff pressure falls below the pressure within the arterial wall. This number is recorded as the diastolic pressure in infants and children. The tapping sound heard at 100 mm Hg is known as phase three of Korotkoff sounds; this reflects blood flow through an increasingly open artery as constriction of the cuff decreases. The swishing sound heard at 130 mm Hg is phase two of Korotkoff sounds; this is caused by blood turbulence.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? 1 There is less chance of aspiration. 2 This procedure does not require a pump. 3 Self-administration of the feeding is possible. 4 More tube feeding mixture can be given each time.

1 When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1 Pink 2 Clear 3 Green 4 Yellow

1 With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? 1 Fluid retention 2 Urinary retention 3 Renal insufficiency 4 Abdominal distention

1 With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. 1 Rye 2 Oats 3 Rice 4 Corn 5 Wheat

1, 2, 5 Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. 1 Polyps 2 Gag reflex 3 Shotty nodes 4 Poor dentition 5 Gum retraction

1, 4, 5 The nurse should place a tongue blade along the side of the client's pharynx behind the tonsil and stimulate the gag reflex. Using a good light source, the nurse should inspect the interior of the mouth for poor dentition and gum retraction. These findings may indicate the presence of a respiratory disorder. Polyps may result from a long-term infection of the oral mucosa. The nurse should observe for the presence of polyps during an inspection of the nose. The presence of small, mobile nontender or shotty nodes is not a sign of the pathologic condition.

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. What is the nurse's priority action immediately postoperative? 1 Check the neck dressing and behind neck for excessive bleeding. 2 Monitor the trachea for deviation to the right or left. 3 Assess the client's level of discomfort and medicate as prescribed. 4 Encourage coughing and deep breathing to prevent atelectasis.

2 A deviated trachea is an imminent sign of airway compromise which requires immediate intervention. The client is at high risk for bleeding within the first 24 hours postoperative. Bleeding can accumulate at the incision site as well as in the neck causing tracheal compression with swelling that may compromise the client's ability to breath. Checking for bleeding may alert the nurse of an increasing risk of airway compromise. Pain management and breathing exercises are standard postoperative interventions.

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first? 1 Feel for a pulse 2 Begin chest compressions 3 Leave to call for assistance 4 Perform the abdominal thrust maneuver

2 According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, the nurse has established that the client has no pulse when cardiopulmonary arrest was determined. Therefore, chest compressions should be initiated immediately. Never leave the client to call for assistance; either call the emergency medical services (EMS) by dialing 911 in the US or 112 in Canada on a cellular phone (and leave the phone on so that EMS can find you) or shout out to others in the area for assistance in seeking EMS. The longer the client goes without circulation, the higher the risk of death, so initiating chest compressions has highest priority when cardiopulmonary arrest has been established. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? 1 Ginger ale 2 Apple juice 3 Orange juice 4 Cola beverages

2 Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? 1 Reaction formation; this is related to the client's recent altered body image 2 Denial; the client is having difficulty accepting reality 3 Impotency resulting from the surgery; sexual counseling may be indicated 4 Suicidal thoughts; consultation with a psychiatrist should be prescribed

2 As long as no one else confirms the presence of the stoma and the client does not adhere to a prescribed regimen, the client's denial is supported. There is no evidence to document that reaction formation is being used. There are no data to support the conclusion that the client has an inability to function sexually. There is no evidence that suicidal thoughts are present or will be acted upon.

A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? 1 Level of pain 2 Quality and depth of respirations 3 Amount of serosanguineous drainage 4

2 Blood pressure and pupillary response The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is applicable in all clinical emergencies for immediate assessment and treatment. The approach likely improves outcomes by helping healthcare providers focus on the most life-threatening clinical problems. The rate and characteristics of respirations, in addition to the presence or absence of breath sounds, oxygen saturation, and unilateral chest movements, should be assessed so that the client's respiratory status can be determined. The concern is to identify a pneumothorax caused by the injury, which can be life threatening. Although important, pain is not a life-threatening symptom. Bleeding may accumulate in the pleural space, but it is inaccessible to direct observation. Excessive blood loss will cause a decreased blood pressure, but bleeding is indicated first by respiratory changes because the blood will accumulate in the pleural space; pupillary response is unaffected.

Which statement regarding calcitonin is correct? 1 It is secreted by follicular cells. 2 Its actions are opposite to that of parathyroid hormone. 3 It decreases phosphorous levels by increasing bone resorption. 4 It works along with thyroid hormone to maintain normal calcium levels in blood.

2 Calcitonin reduces serum calcium levels, whereas parathyroid hormone increases serum calcium levels. Therefore, the actions of calcitonin are opposite to that of parathyroid hormone. Calcitonin is secreted by parafollicular cells of the thyroid gland. Calcitonin decreases calcium and phosphorus levels by decreasing bone resorption. Calcitonin works along with parathyroid hormone to maintain calcium levels in blood.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? 1 Checking for the last bowel movement 2 Checking for residual stomach contents 3 Checking to determine time of last medication for nausea 4 Checking to make sure the head of bed is elevated at least 15 degrees

2 Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

Which hormone secretion does the nurse state is an example of a positive feedback mechanism? 1 Insulin 2 Estradiol 3 Parathormone 4 Catecholamines

2 Estradiol secretion pattern is an example of a positive feedback mechanism. Insulin secretion pattern is an example of a negative feedback mechanism. The relationship between calcium and parathormone is also an example of a negative feedback mechanism. Catecholamines secretion is controlled by the nervous system. It is secreted by the sympathetic nervous system.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? 1 Irritability, polydipsia, and polyuria 2 Polyuria, polydipsia, and polyphagia 3 Nocturia, weight loss, and polydipsia 4 Polyphagia, polyuria, and diaphoresis

2 Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based

2 In addition to dilation of bronchi, treatment is aimed at expectoration of mucus. Mucus interferes with gas exchange in the lungs. Curing the condition permanently is an unrealistic goal; asthma is a chronic illness. Increased fluid intake helps liquefy secretions. Asthma has a psychogenic factor, but this is not the only cause; it may occur as an allergic response to an antigen, such as dust.Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1 Tell the client to drink more fluids. 2 Instruct the client to remain in bed. 3 Gently rub the client's legs for circulation. 4 Tell the client about the dangers of prolonged bed rest.

2 Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Bed rest is indicated to prevent the possibility of further damage. Symptoms indicate a possible problem with thrombus formation. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present.

A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. Which conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse? 1 Appropriate, because such clients usually experience painful swallowing for several days 2 Appropriate, because early eating or drinking after such a procedure may cause aspiration 3 Inappropriate, because the client is likely to be anxious, and it is easier to remove the water pitcher 4 Inappropriate, because the client is conscious and may be thirsty after not being allowed to drink fluids

2 Oral intake should not be attempted until return of the gag reflex because the client could aspirate. Although some slight irritation may occur following this test, there are usually no painful sequelae; oral intake would not be withheld because of painful swallowing, although the consistency of food may be changed. The statements that the performance of the graduate nurse is inappropriate because the client may be anxious or thirsty are not correct; additional factors must be considered.

A client is diagnosed with a peptic ulcer. What should the nurse expect when assessing the client's pain? 1 Intensifies after vomiting stomach contents 2 Occurs in one to two hours after having a meal 3 Increases when an excess of fatty foods are ingested 4 Begins in the epigastrium and radiates to the abdomen

2 Pain occurs after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain. Vomiting temporarily alleviates pain because acid secretions are removed. There is no intolerance of fats and eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated.

What must the nurse do to determine a client's pulse pressure? 1 Multiply the heart rate by the stroke volume. 2 Subtract the diastolic from the systolic reading. 3 Determine the mean blood pressure by averaging the two. 4 Calculate the difference between the apical and radial rate.

2 Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? 1 "My blood type is A positive." 2 "I smoke one pack of cigarettes a day." 3 "I have been overweight most of my life." 4 "My blood pressure has been high lately."

2 Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? 1 The stockings should reach the middle of the knee. 2 The stockings should be applied before getting out of bed. 3 The stockings should be applied at the first sign of discomfort. 4 The stockings may be substituted with loose elastic bandages.

2 To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; loose elastic bandages may slip, creating uneven, ineffective pressure. Edema also may result.

Which clinical manifestation occurs in a client with vasopressin deficiency? 1 Impotence 2 Hypotension 3 Amenorrhea 4 Decreased libido

2 Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.

After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client? 1 Edema at extremities 2 Uneven patches of pigment loss 3 Reddish-purple stretch marks on the abdomen 4 "Buffalo hump" between shoulders on the back

2 Vitiligo [1] [2] is manifested by the presence of large patchy areas of pigment loss. This is mainly caused by primary hypofunction of the adrenal gland. Presence of edema at extremities indicates fluid and electrolyte imbalances mainly observed in a client with thyroid problems. Presence of reddish-purple stretch marks on the abdomen and "buffalo hump" between shoulders on the back of the neck often indicates excessive adrenocortical secretions.

How does the nurse arrange the events that take place during the promotion of glucose transportation into the cells through cell membranes? 1. Attachment of insulin to receptors 2. Secretion of proinsulin by beta cells 3. Storage of proinsulin in the pancreas 4. Transformation of proinsulin into active insulin

2, 3, 4, 1 Proinsulin is a prohormone that is secreted by beta cells and is stored in the beta cells of islets of Langerhans of the pancreas. Active insulin is a protein made up of 51 amino acids; it is produced when C-peptide is removed from the proinsulin. Insulin attaches to receptors present on the target tissues, such as adipose tissue or muscle, where the promotion of glucose transport into the cells through cell membranes occurs.

Arrange the series of reactions that occurs when plasma volume and osmolarity are disturbed. 1. Increased blood volume 2. Change in posture 3. Increased reabsorption of water and sodium 4. Formation of active form of angiotensin 5. Conversion of angiotensinogen to angiotensin I

2, 5, 4, 3, 1 Extracellular fluid volume decreases during conditions such as posture changes and blood loss. This results in release of rennin enzyme, which converts angiotensinogen to angiotensin I. In the presence of angiotensin-converting enzyme, angiotensin I is converted to angiotensin II, which is an active form of angiotensin. Angiotensin II stimulates the adrenal secretion of aldosterone, which increases the reabsorption of water and sodium. This results in increased blood volume.

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? 1 "You must be quite frightened about having high blood pressure." 2 "I'm glad to hear you have felt well enough to stop the medication." 3 "It is important to take your medications daily to achieve optimal results." 4 "You will need to document daily whether you took your medication or not."

3 "It is important to take your medications daily to achieve optimal results" is a nonjudgmental response that does not pressure the client but does indicate clearly that treatment is necessary. The response "I'm glad to hear you felt well enough to stop the medication" is not supported by the client's statement. The response "You must be quite frightened about having high blood pressure" does not address the correlation between blood pressure medication and controlling hypertension. Although it is important to document medication taking, the initial response should address the importance of medication to control the client's hypertension.

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? 1 Offering psychological support 2 Monitoring the client's fluid balance 3 Keeping the client's respiratory passages patent 4 Providing a pad and pencil for writing messages

3 A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. 3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3 A peak flow meter measures the peak expiratory flow rate, the maximum flow of air that can be forcefully exhaled in one second; this monitors the pulmonary status of a client with asthma. The peak flow measurement should be done daily in the morning before the administration of medication or when experiencing dyspnea. The client should be standing. Placing the mouthpiece between the lips and in front of the teeth before starting the procedure will interfere with an accurate test; the mouthpiece should be in the mouth between the teeth with the lips creating a seal around the mouthpiece.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? 1 Hematocrit 46% 2 Hemoglobin 14.1 g/dL (141 mmol/L) 3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm3 (9.2 × 109/L)

3 A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).

A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. On what fact should the nurse base her response? 1 Hypothyroidism is a gradual slowing of the body's function. 2 There will be a decrease in pituitary thyroid-stimulating hormone (TSH). 3 There may not be enough thyroid tissue to supply adequate thyroid hormone. 4 Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

3 After a subtotal thyroidectomy the thyroxine output may be inadequate to maintain an appropriate metabolic rate. Hypothyroidism is a decrease in thyroid functioning, not a slowing of the entire body's functions. In hypothyroidism the level of TSH from the pituitary usually is increased. Atrophy of the remaining thyroid tissue does not occur.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? 1 Increased blood urea nitrogen (BUN) and hypotension 2 Hyperkalemia and poor skin turgor 3 Hyponatremia and decreased urine output 4 Polyuria and increased specific gravity of urine

3 Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

What other name can the nurse use for vasopressin? 1 Growth hormone 2 Luteinizing hormone 3 Antidiuretic hormone 4 Thyroid-stimulating hormone

3 Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

3 Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABC's: Airway, Breathing, Circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after airway, breathing, and circulation needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? 1 Crackling 2 Wheezing 3 Decreased sounds 4 Adventitious sounds

3 Because the affected lung will not expand, aeration of the lung is not complete, and breath sounds are diminished. Crackling sounds occur with pulmonary edema, not with a pneumothorax; with a pneumothorax there is no air in the alveoli to produce crackles. Wheezing sounds occur with asthma, not with a pneumothorax. "Adventitious sounds" is a broad term that includes all abnormal breath sounds; it is not specific to pneumothorax.

A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent? 1 Orthostatic hypotension 2 Headache with disorientation 3 Bleeding at the arterial puncture site 4 Infiltration of radiopaque dye into tissue

3 Bed rest with immobilization of the leg promotes coagulation and healing at the puncture site of the femoral artery. In the absence of bleeding and the presence of adequate fluid replacement, a cardiac catheterization does not cause orthostatic hypotension. Headache with disorientation is not expected after a cardiac catheterization. A small amount of radiopaque dye is injected (via the catheter) directly into the heart, where the blood dilutes it; it does not create a problem at the puncture site.

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client? 1 "Have your dinner completed by 6:00 PM tonight and then no food or fluids after that." 2 "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." 3 "Consume a light evening meal tonight and then no food or fluids after midnight." 4 "Eat lunch today and then do not drink or eat anything until after your surgery."

3 By eating a light meal and eliminating food and fluids after midnight, complications are limited during and after surgery; these include aspiration, nausea, dehydration, and possible ileus. A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. Clear liquids in the morning can cause nausea, vomiting, and aspiration. Fluids should not be withheld for more than eight hours to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 50 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? 1 Hypocapnia 2 Hyperkalemia 3 Metabolic alkalosis 4 Respiratory acidosis

3 Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? 1 Advancing the tube to the original insertion depth if the tube becomes dislodged. 2 Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. 3 Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. 4 Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period.

3 Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.

After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? 1 Postural drainage 2 Pursed-lip breathing 3 Incentive spirometry 4 Sustained exhalation

3 Incentive spirometry expands collapsed alveoli and enhances surfactant activity, thereby preventing atelectasis. Postural drainage helps clear accumulated secretions from the pulmonary tree; it does not directly promote alveolar expansion. Pursed-lip breathing promotes sustained exhalation, not inhalation. Sustained exhalation promotes the collapse, not expansion, of alveoli.

Which clinical manifestation is found in a client with a deficiency of adrenocorticotropic hormone? 1 Anovulation 2 Dehydration 3 Malaise and lethargy 4 Menstrual abnormalities

3 Malaise is a general feeling of discomfort or illness and lethargy is a lack of energy. A client with deficiency of adrenocorticotropic hormone may experience malaise and lethargy. Adrenocorticotropic hormone deficiency is not associated with anovulation, dehydration, and menstrual abnormalities. Anovulation (ovaries do not release an oocyte during the menstrual cycle) occurs due to deficiency of gonadotropins. Dehydration is a result of deficiency of antidiuretic hormone. The deficiency of thyroid-stimulating hormone may result in menstrual abnormalities.

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood

3 Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? 1 Fear of dying 2 Skipped heartbeats 3 Pain at the insertion site 4 Anxiety in response to intensive monitoring

3 Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.

Which disorder would the nurse state is related to the tonsils? 1 Rhinitis 2 Sinusitis 3 Pharyngitis 4 Pneumonia

3 Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions

3 Reassurance decreases anxiety and slows respirations; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to an acid-base balance. Administering oxygen is not necessary because there is no evidence of hypoxia. Using an incentive spirometer is used to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1 Urinary retention 2 Gastric hyperacidity 3 Rebound tenderness 4 Increased lower bowel motility

3 Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? 1 "I'm sure you will be able to do it." 2 "Maybe a family member can do it for you." 3 "You seem to be nervous about going home." 4 "Perhaps you can stay in the hospital another day."

3 Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help to reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.

The treatment regimen for a female diagnosed with Hodgkin disease, stage III, will start with nodal irradiation. Because the client and her husband have been trying to conceive a child, the client becomes visibly anxious when she learns that the radiation therapy includes the pelvic nodal area. The nurse refers the client to the primary healthcare provider when the client starts to question the treatment. What is the rationale for the nurse's actions? 1 Radiation used is not radical enough to destroy ovarian function. 2 Intermittent radiation to the area does not cause permanent sterilization. 3 Reproductive ability may be preserved through a variety of interventions. 4 Ovarian function will be destroyed temporarily but will return in about six months.

3 Reproductive ability may be preserved through shielding the ovaries or harvesting ova. Radiation can influence or destroy ovarian functioning. Sterilization can occur. Women in the childbearing years should be informed of all options available to preserve ovarian function. Once ova are destroyed, they cannot regenerate.

Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate 3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli

3 The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.

Which term should the nurse use in a report to describe the absence of menstrual periods in a 35-year-old non-pregnant client? 1 Rhinorrhea 2 Menopause 3 Amenorrhea 4 Dyspareunia

3 The absence of menstrual periods in a non-pregnant client less than 55 years old is called amenorrhea. Rhinorrhea is an allergic state that is manifested by a runny nose. Menopause is cessation of menstruation after 55 years of age. Dyspareunia is pain during sexual intercourse.

A client has a pulse deficit. Which documentation by the nurse supports this finding? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2 Capillary refill greater than 3 seconds indicating pulse deficit. 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

3 The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

Four hours after surgery, the blood glucose level of a client who has type 1 diabetes is elevated. What intervention should the nurse implement? 1 Administer an oral hypoglycemic 2 Institute urine glucose monitoring 3 Give supplemental doses of regular insulin 4 Decrease the rate of the intravenous infusion

3 The blood glucose level needs to be reduced; regular insulin begins to act in 30 to 60 minutes. The client has type 1, not type 2, diabetes, and an oral hypoglycemic will not be effective. Blood glucose levels are far more accurate than urine glucose levels. The rate may be increased because polyuria often accompanies hyperglycemia.

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted? 1 Supine 2 Mid-Fowler 3 High-Fowler 4 Trendelenburg

3 The high-Fowler position promotes optimal entry into the esophagus aided by gravity. Supine position does not take full advantage of the effect of gravity. Mid-Fowler and Trendelenburg positions will contribute to aspiration. The head of the bed should be raised, not lowered.

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? 1 Hypernatremia 2 Hyperchloremia 3 Metabolic alkalosis 4 Respiratory acidosis

3 The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client? 1 Intravascular to interstitial as a result of glycosuria 2 Extracellular to interstitial as a result of hypoproteinemia 3 Intracellular to intravascular as a result of hyperosmolarity 4 Intercellular to intravascular as a result of increased hydrostatic pressure

3 The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.

Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? 1 PaO2-72, SpO2- 96 2 PaO2-60, SpO2- 90 3 PaO2-55, SpO2- 88 4 PaO2-40, SpO2- 75

3 The primary healthcare provider uses the criteria of PaO2-55, SpO2- 88 for the prescription of long-term continuous oxygen therapy. The values PaO2-72, SpO2-96 are adequate unless the client is hemodynamically unstable. The values PaO2-60, SpO2-90 are adequate for almost all clients. The value PaO2-40, SpO2-75 is inadequate but may be acceptable on a short-term basis if the client also has carbon dioxide retention.

The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? 1 Antibiotic 2 Antihistamine 3 Bronchodilator 4 Expectorant

3 Theophylline is a bronchodilator. It relaxes the smooth muscles in the bronchial airway and relieves bronchospasms. This in turn improves air exchange. An antibiotic is used to treat a bacterial infection. An antihistamine blocks the action of histamine. An expectorant is used to loosen mucus in the lungs. An antibiotic, an antihistamine, or an expectorant will not relax the smooth muscles in the bronchial airway for clients experiencing an acute episode.STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive? 1 Tachycardia 2 Extended Korotkoff sound 3 Sustained systolic pressure ranging from 110 to 120 mm Hg 4 Diastolic blood pressure that remains higher than 90 mm Hg

4 A sustained diastolic pressure that exceeds 90 mm Hg reflects pathology and indicates hypertension. Tachycardia reflects the heart rate, not the pressures within the arteries. Extended Korotkoff sound is heard when measuring blood pressure by auscultation; it is unrelated to hypertension. Sustained systolic pressure ranging from 110 to 120 mm Hg is an expected systolic blood pressure.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1 Slow, deep respirations 2 Normal oral temperature 3 Dry, unproductive cough 4 Diminished breath sounds

4 Because atelectasis [1] [2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.

The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? 1 Cystitis 2 Thin and dry skin 3 Decreased bone density 4 Frequent yeast infections

4 Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do? 1 Shave the client's abdomen. 2 Medicate the client for pain. 3 Encourage the client to drink fluids. 4 Instruct the client to empty the bladder.

4 Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. Shaving the client's abdomen and medicating the client for pain are not necessary. Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? 1 Presence of distention 2 Extent of weight gained 3 Amount of high-fiber food consumed 4 Length of time this problem has existed

4 First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? 1 Sickle cell anemia is a random condition with no known cause. 2 If one parent is a carrier and one is negative for the gene, the child will get the disease. 3 If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. 4 If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.

4 If both parents are carriers, the odds are one in four an offspring will get the disease, two in four will be carriers, and one in four will be disease free. It is an autosomal recessive inherited condition. Sickle cell anemia is not random; the gene must come from both parents. One parent being a carrier and the other not having the gene would not cause the disease. If both parents are carriers there is the possibility of 25% with each pregnancy that the child may inherit the disease, and 50% of being a carrier.

A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage? 1 Dry mouth 2 Rigidity of neck muscles 3 Fall in blood pressure upon standing 4 A yellow edge around nasal discharge

4 Nasal hypophysectomy is a surgical procedure performed to treat hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up, the appearance of light-yellow at the edge of otherwise clear nasal discharge in the dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign" and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal because the client breathes through the mouth due to the nasal packing. Neck rigidity could be an indication of infection, such as meningitis following the surgery. A fall in blood pressure upon standing is called orthostatic hypotension and is a side effect of bromocriptine.

A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic? 1 40 to 60 mg/dL (2.2 to 3.3 mmol/L) 2 80 to 99 mg/dL (4.5 to 5.5 mmol/L) 3 100 to 125 mg/dL (5.6 to 6.9 mmol/L) 4 126 to 140 mg/dL (7.0 to 7.8 mmol/L)

4 Results in the range 126 to 140 mg/dL (7.0 to 7.8 mmol/L) indicate diabetes. Results in the range 40 to 60 mg/dL (2.2 to 3.3 mmol/L) indicate hypoglycemia. Results in the range 80 to 99 mg/dL (4.5 to 5.5 mmol/L) are considered expected (normal). Results in the range 100 to 125 mg/dL (5.6 to 6.9 mmol/L) indicate prediabetes according to the American Diabetes Association. (Results in the range of 6.1 to 6.9 mmol/L indicate prediabetes according to the Canadian Diabetes Association Guidelines.)

A nurse is assessing the needs of a client who just learned that a tumor is malignant and has metastasized to several organs and that the illness is terminal. What behavior does the nurse expect the client to exhibit during the initial stage of grieving? 1 Crying uncontrollably 2 Criticizing medical care 3 Refusing to receive visitors 4 Asking for a second opinion

4 Seeking other opinions to disprove the inevitable is a form of denial employed by individuals who have illnesses with a poor prognosis. If the client is crying, the client is aware of the magnitude of the situation and is past the stage of denial. Criticism that is unjust often is characteristic of the stage of anger. Refusing to receive visitors is most common during the depression experienced as one moves toward acceptance or during the acceptance stage.

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse? 1 "Intermittent claudication will be reduced." 2 "Your breathing will become regular and shallow." 3 "Perspiration will be less when you run, and you'll use less energy." 4 "You will be able to run progressively longer distances before tiring."

4 The ability to endure progressive activity indicates that collateral circulation has improved cardiopulmonary functioning. Intermittent claudication is related to peripheral arterial occlusive disease, not cardiopulmonary function. Breathing when jogging should be regular and deep to meet the oxygen demands of the body. Perspiration is an expected and desired adaptation to promote heat loss through evaporation.

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Poor gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea

4 The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.

4 The drainage system is kept below the chest to allow gravity to drain the pleural space. The chest tube should not be stripped because this action can cause negative pressure and damage lung tissue. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. The closed system is not entered for emptying; when full, the entire device is replaced.

A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? 1 The alveoli need oxygen to live. 2 The alveoli have no direct effect on oxygenation. 3 Collapsed alveoli increase oxygen demand. 4 Oxygen is exchanged for carbon dioxide in the alveolar membrane.

4 The exchange of oxygen and carbon dioxide occurs in the alveolar membrane. Therefore, if the alveoli collapse, this exchange cannot occur because pulmonary ventilation is reduced. Explaining this process in simple terms to a client may increase compliance with recommended breathing exercises aimed at improving oxygenation. Alveoli do have a direct effect on oxygenation. The statements that alveoli need oxygen to live and that collapsed alveoli increase oxygen demand are nonspecific regarding the pathophysiology of the alveolar membrane.STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? 1 Increased fiber intake 2 Bacterial contamination 3 Inappropriate positioning 4 High osmolarity of the feedings

4 The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? 1 Long-term use of an irritant-type laxative 2 Emotional response resulting in physical symptoms 3 Inadequate dietary practices resulting in altered bowel function 4 Systemic responses of the body to a localized inflammatory process

4 With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).