Final

A client who has a heart murmur due to vegetative growth on the leaflets of the heart valves asks the nurse what caused this condition. The best reply is:

"A residual virus following a bout of childhood chickenpox." "Alcohol and nicotine abuse use over many years." *"Strep throat or respiratory infection, resulting in rheumatic fever."* "Uncontrolled triglycerides and cholesterol."

The nurse tells the patient that his HDL cholesterol is elevated. Which statement made by the patient would indicate the need for further patient teaching?

"HDL has a protective function." "HDL clears cholesterol from the body." "It is good that my HDL is elevated." *"I have an increased risk for heart disease."*

The nurse determines that the client with venous stasis ulcers understood dietary teaching when the client says:

"I have decreased my fat intake." "I have reduced my sugar intake." "I have increased my carbohydrate intake." *"I have increased my protein intake."*

The nurse is preparing a client for a lumbar puncture. Which statement made by the client indicates the need for further instruction?

"I will need to curl my knees and head into my chest." *"I will be put to sleep for this procedure."* "I will need to drink a lot of fluids after the procedure." "I will need to lie flat for 6 hours after the procedure."

While working in a pediatric clinic, the nurse cares for a client with a diagnosis of impetigo. The nurse teaches the client how to care for himself, and determines further teaching is needed when the client states:

"I will wash the sore with mild soap to remove crusts." "I will apply bacitracin to the wound and cover it with a bandage." "I will call the doctor if the wound does not improve, or gets bigger." *"I will watch the wound carefully and call the doctor if it feels hot."*

The nurse has just finished explaining the necessity of coughing and deep breathing following surgery to a preoperative client. Which of the following responses by the client would indicate his understanding and acceptance of what he has been taught?

"It really hurts too much to do that. Deep breathing and coughing are impossible." "I thought that spirometry thing was supposed to do the job." *"When I do the coughing and deep breathing, I reduce my chances of getting pneumonia."* "I guess I'll try to remember to take a couple of deep breaths once and a while.

Which statement by a nursing student reflects an understanding of Alzheimer's disease?

"Most clients with Alzheimer's disease die shortly after diagnosis." "All elderly people have some symptoms of Alzheimer's disease, especially after age 85." "A simple blood test confirms the diagnosis of Alzheimer's disease." *"The symptoms of Alzheimer's disease begin very slowly."*

The nurse admits a client in order to rule out a brain tumor. When preparing the client for an MRI what question is of highest priority for the nurse to ask?

"When was the last time you had a bowel movement?" "Are you afraid of the dark?" *"Do you have any implanted hardware such as a pacemaker, orthopedic screws or rods, or metal plate?"* "When was the last time you ate or drank anything or took any medication?"

The nurse is caring for an adult client with poor urine output. The nurse would report to the RN if the client had urine output less than how many milliliters (mL) per hour for two consecutive hours?

*30 mLs* 150 mLs 300 mLs 700 mLs

Which disease processes are caused by gallstones?

*Cholecystitis* Fatty Liver Disease! *Pancreatitis* Hepatitis

The nurse caring for a client undergoing a hemodialysis procedure places high priority on monitoring the client frequently for what common complication during the treatment?

*Hypotension* Hyperglycemia Infection, fever Dialysis dementia

A client is hospitalized with a diagnosis of pneumonia. Which findings, based on the nurse's knowledge, are indicative of a deteriorating clinical state? State all that apply

*Increased respiratory rate* *Tachycardia* Agitation *Cyanosis* Increased urinary output

A 77-year-old client with a history of respiratory disease has undergone a hernia repair. Which of the following expected outcomes should be the nurse's priority focus for this client?

*The client has normal breath sounds.* The client rates his pain as 2 to 3 on a 10-point scale. The client ambulates 10 feet with assistance. The client tolerates a clear liquid diet.

Which client is most at risk for a cardiovascular accident (CVA)?

80-year-old female who is 10 pounds overweight. 32-year-old female who takes oral contraceptives. 45-year-old male who works on a farm *65-year-old male who has high blood pressure and smokes.*

Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia?

A client with a stroke. *A client with a spine injury.* A client with brain injury. A client with a herniated disc.

The nurse is caring for a 54-year-old client with a history of smoking one pack of cigarettes per day diagnosed with early stages of emphysema. What preoperative screening tests would the nurse anticipate this client will require? (Select all that apply.)

ALT, AST, LDH, and bilirubin. Urine culture and sensitivity. *Complete blood count.* *Chest x-ray.* *Electrocardiogram.*

For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?

Administering antibiotics as prescribed *Applying pressure to injection sites* Increasing nutritional intake Allowing complete independence of mobility

A client with jaundice is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?

Administering vitamin K subcutaneously Decreasing the client's dietary protein intake *Keeping the client's fingernails short and smooth* Applying pressure when giving I.M. injections

Which description would the nurse choose to explain cardiac output?

Afterload divided by stroke volume. Heart rate divided by diastolic blood pressure. *Stroke volume multiplied by heart rate.* Preload multiplied by weight in kilograms.

The nurse works in a facility that is performing a trial of new hand soap, and experiences a skin reaction on both hands that includes dry cracked skin and pruritus. While waiting for the skin to heal, the nurse takes care to:

Apply lotion. Wash the hands more frequently. Use the new soap frequently. *Wear gloves.*

The nurse is bathing a client who suddenly begins to display tonic-clonic muscle activity. The client does not have a history of seizures. Besides providing for the client's safety, what actions does the nurse take? Select all that apply

Assess vital signs. *Time the seizure.* Cover the client with a blanket. Finish the bath *Notify physician*

You will be reinforcing teaching and instructing the client on cardiac lifestyle. Which basic principle of teaching should you follow?

Assume that the patient knows little or nothing about the topic. *Sequence the instruction from the least complex to the most complex.* Tell the patient to call their significant other so you can instruct them. Use medically oriented terms so the patient will be able to speak with the doctor.

When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family?

Avoiding contact with blood-soiled clothing or dressing Keeping the client in complete isolation Forbidding the sharing of needles or syringes *Using good sanitation with dishes and shared bathrooms*

The nurse is evaluating a patient's knowledge regarding a low sodium, low fat cardiac diet. Which food choice indicates that the patient needs additional teaching?

Baked flounder. Angel food cake. *Canned tomato soup.* Baked potato with margarine.

When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function?

Breaks down protein into dipeptides and amino acids Triggers cholecystokinin to contract the gallbladder *Breaks down fat into fatty acids and glycerol* Transports fatty acids

A client was admitted to the ED with a thermal burn to the right arm and leg. Which data collected by the nurse requires immediate action?

Bright red skin with small blisters on the burn sites *Coughing and wheezing* Impaired Tissue Perfusion Thirst

The nurse is preparing the client for surgery. Identification of risk factors associated with delayed wound healing is done during a preoperative assessment. Which risk factor would the nurse identify?

Cardiac conditions. COPD. Epilepsy. *Steroid therapy.*

A brief episode of neurological deficit, such as loss of function in the left arm, followed by a return to normal function is commonly called which term?

Cerebral vascular accident. *Transient ischemic attack.* Brain attack. Bell's Palsy.

Which assessment finding indicates that bowel function has returned for the client who has undergone general anesthesia?

Client complains of hunger. Abdomen is flat. Client has stopped vomiting. *Presence of bowel tones.*

A client has herpes zoster on the right side of his face and scalp. Which would concern the nurse most?

Complaints of pain on the right side of the scalp *Complaints of pain in the right eye* Complaints of burning pain on the right side of the face Presence of fluid-filled vesicles on the right side of the face

You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? (Select all that apply)

Dark brown stool Bluish mucous membranes *Jaundice of the skin* Frothy light-colored urine *Dark brown urine Yellowing of the sclera*

Which term describes involuntary jerking, rhythmic movements of the eyes?

Diplopia Exopthalmos *Nystagmus* Oculogyric crisis

The nurse assesses the client's level of consciousness and finds he cannot arouse the client with deep pain or vigorous and continuous stimulation. How does the nurse document the level of consciousness?

Disoriented. Lethargic. Stuporous. *Comatose.*

What type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses?

Droplet Precautions. *Universal Precautions.* Airborne Precautions. Exposure Precautions.

Your patient with acute pancreatitis is scheduled for a test that will use a scope to assess the pancreas, bile ducts, and gallbladder. The patient asks you, "What is the name of the test I'm going for later today?" You tell the patient it is called:

EGD CT scan of the abdomen MRCP *ERCP*

Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?

Ecchymosis petechiae, and coffee-ground emesis Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration Jaundice, dark urine, and steatorrhea *Right upper quadrant pain radiating to the shoulder, nausea and vomiting*

The nurse is caring for a client that is comatose and directs care toward which most important priority?

Encouraging maximum independence. *Maintaining airway and supporting breathing.* Repositioning to prevent alterations in skin integrity. Minimizing complications.

Which client teaching topic should be emphasized during preoperative teaching of a client scheduled for a total laryngectomy?

Financial concerns. Type of anesthesia to be used. *Alternate form of communication.* Pain control methods.

The nurse caring for a client diagnosed with cirrhosis of the liver promotes a diet:

High in fat and vitamin K, low in protein. High in protein and carbohydrates. High in vitamin B and fats. *Low in protein, with vitamin K and B supplements.*

A client is newly diagnosed with myasthenia gravis. Client education would include which condition as the cause of this disease?

Inability of the basal ganglia to produce enough dopamine. Loss of the myelin sheath surrounding peripheral nerves. A postviral illness characterized by ascending paralysis. *Destruction of acetylcholine receptors, causing muscle weakness.*

Which intervention will the nurse include in the care plan for a client hospitalized with viral hepatitis?

Increase fluid intake to 3000 ml per day Bland diet Administer antibiotics as ordered *Ensure adequate bed rest*

Which instruction should the nurse include when teaching a client being discharged home with a prescription for a diuretic?

Increase salt intake. Take the medication prn for chest pain. Take the medication at hour of sleep (hs). *Rise slowly from a sitting to a standing position to avoid dizziness.*

The nurse admits a client with a newly diagnosed abdominal aortic aneurysm scheduled for surgery tomorrow. When examining the client, the nurse takes special care not to:

Increase the client's anxiety. *Palpate the abdomen.* Administer beta blockers. Elevate the feet and legs.

The nurse is caring for a preoperative client who will undergo surgery today. Which of the following would be an appropriate nursing diagnosis for this client?

Ineffective coping. Impaired gas exchange. Body image disturbance. *Anxiety and deficient knowledge*

The nurse enters the room in time to see the client fall on the floor and begin a generalized, tonic-clonic seizure. The client's teeth are clenched and he is incontinent of urine. What is the nurse's priority action in this situation?

Insert an oral airway. Get help to move the client onto the bed. Pad the side rails. *Move furniture out of the client's way.*

When the nurse cares for the client in the holding area prior to surgery, the client is in what phase of the surgical process?

Intraoperative. Perioperative Postoperative *Preoperative.*

The nurse is caring for a patient diagnosed with coronary artery disease who receives routine daily application of a nitroglycerin patch. Which assessment finding causes the nurse to hold the application of the nitroglycerin patch?

Irregular heart rate. Complaints of chest pain. *Systolic blood pressure below 90mm Hg.* Skin redness at site.

When explaining the disorder to a client with tinea corporis, the nurse should include which information about this skin disorder?

It is a malignant skin condition *It can be passed human to human* It should be exposed to sunlight It requires no treatment

The nurse is caring for a client scheduled for colon surgery. What information does the nurse provide the client regarding general anesthesia?

It is administered directly to the skin, or injected into a specific area. It allows the client to retain the ability to consciously maintain a patent airway. *It blocks awareness centers in the brain.* It produces minimal depression of the level of consciousness.

The physician has ordered sequential compression devices (SCDs) for a client returning from surgery. What is the best rationale for use of SCDs?

Keep the legs warm. Induce relaxation similar to a massage. *Prevent thrombus formation.* Maintain balanced fluid volume.

The nurse is reviewing the client's medical record, and reads in the provider's notes that the client has macules over the bridge of the nose and cheeks. The nurse assesses the client prepared to see which of the following on the client's nose and cheeks?

Leathery hardening and thickening Small, raised, blister-like lesions Butterfly rash consistent with systemic lupus erythematosus *Freckles*

The nurse is teaching the client about to receive a computed tomography scan (CT scan) of the head with contrast. Which instruction does the nurse give after the scan?

Lie flat for eight hours. Avoid dairy products. Remain awake and exercise. *Drink fluids.*

The physician order reads, "monitor for and report signs of increased intracranial pressure". Which assessment finding does the nurse report?

Lip smacking. Brief periods of blank staring. *Increased blood pressure and decreased heart rate.* Client complains of numbness and weakness in extremities.

When assessing a client diagnosed with left-sided heart failure, the nurse anticipates which of the following findings?

Liver enlargement Abdominal distention *Shortness of breath Edema of the feet and ankles

The nurse is preparing a client for surgery. Which function has preoperative teaching been shown to have?

Make client aware of need for extended assistance. Increases postoperative complications. *Decrease anxiety.* Increases the relationship between the nurse and the client's family.

The nurse is caring for a client diagnosed with acute pancreatitis and focuses the plan of care to: (Select all that apply.)

Manage care of the nasogastric tube. Prepare the client for surgery. *Meet nutritional needs.* *Reduce pain.* *Replace enzymes and hormones*

A client was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care?

Measuring serum potassium for hyperkalemia Assessing the client for hypervolemia Measuring the client's weight weekly *Documenting precise intake and output*

When providing education on antiviral medication for the client with herpes simplex, the nurse will emphasize that:

Medication will cure herpes simplex *Therapy is best initiated early* Viral shedding is increased Analgesics aren't needed

A client has suffered a transection of the spinal cord at T4-5. Which long term nursing intervention will the client need?

Monitoring of arterial blood gases. Neurovascular checks. Monitor pulse pressure. *Straight catheterization three times a day.*

A client has a spinal cord transection at the T4 level. The nurse can expect the client to have which symptom?

No deficits. Quadriplegia Autonomic dysreflexia *Paraplegia.*

The client is found to have a discolored spot that is not raised and less than a centimeter in size. the nurse documents this lesion as a:

Nodule Papule Cyst *Macule*

While cooking, a client couldn't feel the temperature of a hot oven. Which area of the brain would the nurse suspect to be dysfunctional?

Occipital lobe. Frontal lobe. Temporal lobe. *Parietal lobe.*

The client is admitted with a cerebral injury that has caused impaired speech and hearing. Which area has the client most likely experienced injury to?

Occipital lobe. Frontal lobe. *Temporal lobe.* Parietal lobe.

A client who is diagnosed with a right subarachnoid hemorrhage should be placed in which position?

On the left side. *With the head of the bed elevated.* On the right side. Flat in bed.

The nurse is preparing the client for a breast biopsy to determine if a lump found is cancerous. The nurse explains that the surgery is what type?

Palliative *Diagnostic.* Emergency. Ablative.

The nurse is teaching staff members about anatomy and physiology of the skin and explains that what layer of the dermis is responsible for providing the elasticity of the skin?

Papillary layer Appendage layer *Reticular layer* Stratum germinatvum

Which intervention describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

Perform Crede'maneuver to the lower abdomen before the client voids. Perform a straight catheterization every 12 hours while awake. Insert an indwelling catheter. *Schedule intermittent catheterization every 4hours.*

Which components contribute to coagulation? (Select all that apply)

Potassium *Platelets* *Calcium* *Vitamin K*

Your patient has a blood potassium level of 9.2 mEqL. What intervention should you anticipate for this patient?

Potassium supplementation *Kidney dialysis* Calcium supplementationu Answered Instruction on nutrition

The nurse admits a client to a medical unit who states that he is having chest pain of a 7 on a scale of 0 to 10. The patient has a history of angina. His skin is warm and dry. He does not appear to be short of breath. What additional priority assessment does the nurse make?

Presence of peripheral edema. Swallowing. Presence of bowel tones. *Blood pressure.*

A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will:

Prevent hypoglycemia. Remove bilirubin from the blood. Mobilize iron stores from the liver" *Prevent the absorption of ammonia from the bowel.*

What is the Goal of Treatment for Client with Increased ICP?

Prevent kidney failure *Reduce neurological deficits* Provide increased fluids Prevent blood clots

The nurse is caring for a client who had abdominal surgery and has a sutured wound that is healing well without signs of infection. How does the nurse describe the wound?

Purulent odor. Copious drainage. Red with swelling. *Incision clear, sutures intact.*

The nurse is caring for a client with increased intracranial pressure. Which order would the nurse question?

Raise head of bed 30 degrees. Raise head of bed 25 degrees. *Keep head of bed flat.* Raise head of bed 45 degrees.

The nurse is caring for a client with increased intracranial pressure. Which order would the nurse question?

Raise head of bed 30 degrees. Raise head of bed 25 degrees. *Keep head of bed flat.* Raise head of bed 45 degrees.

Which condition is a risk factor for hemorrhagic stroke?

Recent viral infection. *Hypertension.* Coronary artery disease. Diabetes.

The school nurse receives calls from several parents reporting that their children have lice. All of the children are in the same classroom. The nurse's priority action is to:

Require all students in the school to wear surgical caps until the outbreak of lice is contained Isolate the children in that classroom and keep them from the cafeteria, gymnasium, or anyplace where they will come in contact with others. Send all of the children in that class home with notes asking parents to take them to the pediatrician. *Assess all of the children in the classroom, and send notes home with all children in the school advising parents to check their children for lice*

The nurse looks up an antihypertensive drug in the Pearson Drug Guide that is described as having a negative chronotropic effect. What priority assessment does the nurse make before administering this drug?

Respiratory rate. Skin color and temperature. Oxygen saturation. *Apical heart rate.*

The nurse is preparing a client for surgery who will leave for the operating room in 60 minutes. Prior to administering the preoperative medication, what does the nurse instruct the client?

Review the signed preoperative consent. Bathe. Deep-breathe and cough. *Void.*

A client develops atopic dermatitis secondary to food allergies. An appropriate nursing diagnosis for this client would be which of the following?

Risk for Ineffective Thermoregulation Impaired Tissue Perfusion Imbalanced Nutrition: Less Than Body Requirements *Disturbed body image*

What would be the priority nursing diagnosis for the client with late stage Parkinson's disease?

Risk for injury. Knowledge deficit: food sensitivities. Impaired gas exchange. *Ineffective airway clearance.*

A client is given a prescription for Kwell lotion. The nurse knows the client will need instruction about treating:

Scabies or herpes zoster Scabies or eczema *Lice or scabies* Lice or psoriasis

A client's blood pressure continues to be elevated despite being prescribed an ACE Inhibitor for several weeks. Which action is most appropriate for the nurse at this time?

Schedule the client to have his blood pressure checked again in a week. *Ask if the client is taking the prescribed medication.* Suggest to the physician that another medication be added. Realize the client is anxious because of the diagnosis.

A postoperative elderly client with pneumonia has a nursing diagnosis of Ineffective airway clearance. Which intervention should the nurse include in the care plan?

Suction once per shift. *Monitor the need for suctioning every hour.* Suction every hour. Ask the physician for an order to suction.

The nurse is monitoring a client that is 24 hours post surgery.Which finding requires intervention?

Temperature 99.3 degrees Fahrenheit. BP 100/80. *24 hour urine output 300 mL/hr.* Pain rating 4 on scale 1 to 10.

For a client with a stoke, what criteria must be fulfilled before the client is fed?

The client swallows small sips of water without coughing. *Gag reflex returns.* Speech returns to normal. Client states that there is no numbness or tingling of the face.

The admitting vital signs were BP 146 over86, HR 88, RR 16. Thirty minutes later the client became short of breath with an increase in heart rate to 180 beats per minute. The client's blood pressure dropped to 82 over 48. How does the nurse best evaluate the change in vital signs?

The client's preload and afterload has increased. The client's stroke volume has increased along with the increase in heart rate. *The client's cardiac output decreased due to an increase in heart rate.* The client's cardiac output increased causing an increase in heart rate.

A hospitalized patient with a history of chronic stable angina complains of chest pain. Which rationale does the nurse base appropriate nursing interventions on?

The ischemia indicates that irreversible myocardial damage is occurring. Ischemia is frequently associated with vomiting and fatigue. The ischemia will always progress to myocardial infarction. *The ischemia should be relieved with rest, nitroglycerin, or both.*

Which area of the brain is primarily functioning to regulate thinking, planning, and affect?

The temporal lobe. The occipital lobe. The parietal lobe. *The frontal lobe.*

The nurse is observing the client's rhythm strip on the cardiorespiratory monitor when suddenly the P wave disappears. What does the nurse interpret this to mean?

The ventricle is no longer contracting. Only the left ventricle is contracting. The client's heart is no longer ejecting blood. *The atria are not contracting.*

A client admitted to the emergency department for head trauma is diagnosed with an epidural hematoma. Which would most likely cause this condition?

Venous bleeding from the arachnoid space. Rupture of the carotid artery. Thromboembolism from a carotid artery. *Laceration of meningeal artery.*

When does the nurse remove the postoperative client's sutures?

When all drainage from the wound ceases. When the wound is closed and scar tissue is seen. When the wound has visible scabs and is no longer edematous. *When the physician orders removal of sutures.*

The nurse is teaching a college class about the risk of skin cancer. One of them asks, "I know you can get skin cancer from lying in the sun, but tanning booths are different, right?" The nurse would include which of the following when responding?

While tanning booths are not as bad as the sun, they still increase the risk of skin cancer Tanning booths are worse that the sun because they emit more ultraviolet light! *Both tanning booths and the sun increase the risk of skin cancer, and should be avoided* Occasional use of tanning booths is unlikely to be harmful if time is limited

The postoperative client has an order for oxygen at 2 L

minute. How does the nurse set the oxygen flow meter? / The top of the ball should sit below the line marked 2. *The line marked 2 should cut the ball in half.* Any part of the ball should touch the line marked 2. The bottom of the ball should sit on top of the line marked 2.

The nurse is caring for an elderly client who fell down a flight of stairs and experienced a closed head injury. Secondary to loss of respiratory drive caused by increased intracranial pressure, the client had a tracheostomy placed. When the daughter visits, she asks the nurse, "Are you making sure Dad uses his CPAP at night? Because he has sleep apnea." What is the nurse's best response?

*"CPAP was prescribed to keep the airway open. Now his tracheostomy will do that, and he won't need it until the tracheostomy is closed."* I will inform the doctor and get an order for respiratory therapy to set up a machine before bed tonight." "He doesn't need his CPAP at night anymore, but I'll remind the doctor to order it just in case he has problems." "When a client is critically ill and monitored on the cardiorespiratory monitor, he doesn't need his CPAP, because we'll know if he stops breathing."

The nurse would assess the client's hydration status if the specific gravity was found to be outside what range?

*1.010 to 1.025* 1.000 to 1.005 1.025 to 1.030 1.030 to 1.050

What is the name of the section marked?

*Pulmonary Artery* Aorta Left Atrium Right Atrium

The nurse working in an outpatient clinic sees a mother run into the center holding a toddler by the ankles and pounding on his back while yelling, "Help me please! He's choking and I can't get it out." What is the nurse's priority intervention?

*Take the child from the mother and assess airway* Call 911 Call the doctor. Take the child from the mother and assess the child for a pulse

The nurse is caring for a client with increased intracranial pressure. How does the nurse reduce stimuli? (Select all that apply.)

*Teaching family to speak softly and minimize touching.* Placing a sign on the client's door that says "No visitors allowed." Providing all care quickly at one time to provide periods of rest. *Keeping the room dark and quiet.* Elevating the head of the bed.

The nurse is caring for a client who just had a bronchoscopy performed and is asking for a drink of water, reporting that his mouth feels very dry. The nurse:

*Tests the client's gag and swallow reflexes.* Gets the client a small glass of water to sip on. Informs the client he is not allowed to have water. Uses a lemon glycerine swab to moisten the oral cavity

A client is diagnosed with a severe nail fungus and is given a prescription for an oral antifungal medication. When looking over the client's daily meds, which one would cause concern?

*Warfarin* Estrogen Oral antidiabetic Antihypertensive

Which client is most at risk for a cardiovascular accident (CVA)?

32-year-old female who takes oral contraceptives. 80-year-old female who is 10 pounds overweight. *65-year-old male who has high blood pressure and smokes.* 45-year-old male who works on a farm.

After teaching the client about the thallium scan he is to undergo tomorrow, the nurse determines the client understood when he tells his wife the purpose of the test is to detect:

Abnormalities in electrical conduction in the heart. *Areas of the heart not getting adequate oxygenation.* Any flaws in the pulmonary circulation. Abnormalities in cardiac structure.

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order?

Administer IV fluids. *Encourage ambulation, maintain NPO status, and monitor intake & output.* Insert a nasogastric attached to intermittent suction. Encourage at least 3000 ml of fluids per day.

The nurse admits a client with a history of mitral valve stenosis who was admitted to the acute care facility for diagnostic testing related to a suspected diagnosis of prostate cancer. What physician's order would the nurse question?

Ambien (zolpidem) 10 mg PO h.s., p.r.n. n.p.o. after midnight. Erythromycin 1 gram IV 1 hour before procedure. *IV of D5W to infuse at 125 mL/hour.*

The nurse knows that a client has the most serious type of skin cancer when the diagnosis is:

Basal cell carcinoma Squamous cell carcinoma *Malignant melanoma* Multiple myeloma

Which classification of prn medication does the nurse choose for the client complaining of angina pain?

Beta Blocker. *Nitrate.* Diuretic. ACE Inhibitor.

Which document will most likely contain the patient's decision to not get cardiopulmonary resuscitation?

Healthcare proxy Healthcare proxyrrect! *Advance directives* Healthcare surrogacy

A patient diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which medication does the nurse expect the physician to prescribe in order to improve the patient's mentation?

NPH insulin Diazepam Potassium *Lactulose*

The nurse working in a physician's office admits a client with a history of transient ischemic attacks (TIA) who was advised to lose weight, change diet to lower cholesterol, and maintain treatment of hypertension. The client has chosen not to take this advice. This leads the nurse to conclude the client is at increased risk for which condition?

Myasthenia gravis. *Cerebrovascular accident.* Aneurysm. Vasovagal syndrome.

The nurse is caring for a client with a newly implanted permanent pacemaker who asks, "How do I change the battery?" What information will the nurse supply this client in answer to the question?

The battery doesn't need to be changed because it will last forever. *The battery generally lasts for 20 years or longer but will need to be surgically replaced when it wears out.* The battery is located in a small box the client can hang on your belt. There is a small cord the client connects to the pacemaker and that plugs into the wall.

The client with psoriasis asks the nurse if the plaque buildups can be scraped off to remove them. The nurse explains:

The client would require screening to see if he is a candidate for the procedure Surgical removal is considered plastic surgery, and is very costly Only very young chldren respond to that form of treatment *Plaque cannot be removed surgically*

The nurse is working in a clinic receives a call from a client who has begun treatment for a fungal skin infection two days ago. He is calling to report that the infection is not getting any better. The nurse's best response is:

"Are you following the directions you were given to treat it?" "You may have a different strain of fungus, and will require antibiotics. I will speak to the doctor and call you back with the orders received." *"Fungal infections can take up to three weeks to resolve, and at least a week before improvement is seen."* "I'll make an appointment for you to be seen today."

The patient asks the nurse about causes of metabolic syndrome. Which is the most accurate answer?

"Can be avoided by taking daily vitamins and drinking 64 fluid ounces of water daily." "Affects only older adults beyond the age of 65." *"Obesity, physical inactivity, and genetic factors may contribute to metabolic syndrome."* "Is not a concern for females unless they smoke."

The nurse is preparing a client for a lumbar puncture. Which statement made by the client indicates the need for further instruction?

"I will need to lie flat for 6 to 12 hours after the procedure." "I will need to curl my knees and head into my chest." "I will need to drink a lot of fluids after the procedure." *"I will be put to sleep for this procedure."*

A client has been diagnosed with eczema. Which statement made by the client indicates an understanding of its management?

"I will take daily baths and use strong antibacterial soaps to prevent skin infections." " I will wait 3 hours after bathing to apply lotion to my skin." *"I will avoid excessive use of soap and water and keep my skin well-hydrated with emollients."* "I will make sure to expose my skin to the sun at least 1 hour a day."

The nurse is providing care for a patient who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client?

"Jaundice is associated with pressure ulcer formation." "Jaundice impairs urea production, which produces pruritus." *"Jaundice produces pruritus (itching) due "to impaired bile acid excretion."* "Jaundice leads to decreased tissue perfusion and subsequent breakdown."

The nurse working in an outpatient clinic is caring for a client diagnosed with ringworm. The client says, "How in the world could I have been infected with a worm?"

"Most people ingest the worm through contaminated hands." *"Ringworm is actually a fungal infection, and it is not a worm."* "It can be the result of working in the dirt or come from an infected family pet." "Ringworm is actually a bacterial infection, and is not a worm."

Which description would the nurse choose to explain the concept of preload?

"Resistance in the pulmonary veins." "The amount of blood in the peripheral circulation." *"Myocardial stretch at the end of diastole."* "The amount of blood delivered in one contraction." (Stroke volume)

The nurse assisting the client with constructive pulmonary disease would use which of the following statements to explain why dyspnea occurs?

*"Your airways open wider on inspiration, and trap air on expiration."* "decreased surfactant causes many of your alveoli to collapse." "Your lung compliance is decreased." "You have difficulty breathing in enough air."

The nurse is reviewing the morning lab work for a client and knows that the normal sodium level in the body is:

*135 to 145 milliequivalents.* 135 to 145 microequivalents. 3 to 5 milliequivalents. 3 to 5 microequivalents.

Which condition is a common cause of pre-renal acute renal failure?

*Decreased cardiac output* Atherosclerosis Prostatic hypertrophy Rhabdomyolysis

The nurse assesses the client's urine and finds a specific gravity of 1.050, which the nurse concludes is consistent with the nursing diagnosis:

*Fluid volume deficit* Fluid volume excess Infection Urinary elimination, altered

What priority assessment will the nurse make prior to offering clear liquids to a postoperative client?

*Gag reflex.* Bowel tones. Orientation. Nutritional needs.

What assessment data does the nurse collect from an electrocardiogram (EKG)?

*Heart rhythm.* Amount of cardiac output. Amount of preload. Amount of afterload.

Which disease process is caused by inability of liver to detoxify ammonia to urea. Symptoms include impaired mental status and altered consciousness.

*Hepatic Encephalopathy* Pancreatitis Malabsorption Syndrome Cholecystitis

The primary nursing action when treating a client with an impetigo lesion would be to:

*Remove crusts and apply neomycin antibiotic ointment* Administer oral analgesics Apply a sterile dressing Remove the crust and apply an antifungal ointment

What is the most reliable diagnostic test for acute pancreatitis?

*Serum amylase, lipase levels.* Presence of jaundice White blood cell count Platelet count

How should the nurse position the client while undergoing a thoracentesis?

*Sitting* Sims' Prone Supine

The client comes to the office for a skin rash. Which question would the nurse include when obtaining a client history?

"Do you smoke?" "Do you have a family history of skin cancer?" *"Have you ever had a skin rash like this before?"* "How long have you had that mole on your left arm?"

The nurse teaches the client to cough and deep-breathe, and determines that the client understood teaching when which of the following statements is made?

"I should breathe in slowly through my mouth and out through my nose." *"I should hold a rolled pillow against my abdomen when I cough, to splint the incision."* "I should breathe in and cough as soon as I'm done inhaling." "I will begin coughing and deep-breathing the day after surgery."

The patient diagnosed with hypertension who smokes states, "I feel just fine and don't seem to be sick." How does the nurse best respond?

"Just come back to get your blood pressure checked in one week." *"Many people with hypertension feel fine, but are at risk for heart disease or a stroke."* "You are going to be really sick if you don't stop smoking." "Most people with hypertension don't feel well; you must only have a mild problem."

The nurse working in an outpatient surgical center admits a client who is to have a basal cell carcinoma removed from the left temple. While collecting data for the nursing history, the nurse assesses that the client understands the diagnosis. The client says, "I had a friend die from skin cancer, and I know this is probably fatal, but I'd like to treat it as aggressively as possible to improve my chances of survival." The nurse's best response is:

"You are scared, and that is a normal response to this diagnosis, but many people respond to chemotherapy." "You won't know what your likelihood of survival is until after the doctor removes the cancerous cells and examines them under a microscope." *"Basal cell carcinomas are generally slow-growing, and do not often spread. Your friend might have had malignant melanoma or squamous cell carcinoma."* "Tell me more about your friend's condition."

The daughter of an elderly man calls the physician's office to report that her father fell off of the bottom step in the basement and landed on the cement, bumping his head. The daughter asks the nurse what to do. What is the nurse's best response?

* Question the daughter in order to determine the man's current condition.* Instruct the daughter to take her father to the nearest Emergency Department. Instruct the daughter how to check pupils and perform a mental status examination. Instruct the daughter to call 911.

While the nurse is explaining the functioning of the urinary system, the client asks the nurse, "How much urine has to be in the bladder before I feel the urge to urinate?" The nurse's most accurate response is:

*"250-450 mL."* "At least 500 mL." "Around 1 liter" "About 750 mL"

The nurse is caring for a client admitted with a diagnosis of acute renal failure who asks, "Does this mean my kidneys are failing and I will need a kidney transplant?" The nurse explains:

*"Acute kidney failure can be reversed with prompt treatment, and usually will not destroy the kidney."* "Kidney transplantation is highly likely, and it would be a good idea to start talking to family." "When the doctor comes to see you, we can talk about whether you will need a transplant." "No, don't think like that. You're going to be fine."

The nurse working in the cardiologist's office receives a call from a client diagnosed with angina reporting that he is having chest pain. He has taken nitroglycerine three times, five minutes apart, and is still having chest pain. The nurse provides what instruction to the client?

*"Call 911 as soon as we hang up, and lie down until the ambulance arrives."* "Take two aspirin and rest, and call back if the pain does not improve." "Take three more nitroglycerine tablets at the same time." "Have your spouse bring you to the office immediately."

What discharge instructions is most appropriate for reducing the client's fatigue and shortness of breath during mealtimes?

*"Eat frequent, small meals to reduce energy use."* "Eat simple carbohydrates for quick energy." "Eat fatty foods to get maximum caloric intake." "Eat the largest meal late at night before sleep."

The parents of a teenager with bronchiolitis asks the nurse why the room has a sign on the door that says "contact precautions," and ask why the nurses all wear gowns and gloves when they enter the room. What is the nurse's best response?

*"Extra precautions prevent the virus from spreading to other patients."* "Your child is very ill, we don't want to have another person catch what he has." "It's because we need to protect your son from other illnesses." "we always wear gowns when patients are coughing."

Which statement made by a client who has chronic renal failure and is on hemodialysis indicates the need to reinforce teaching?

*"I comply with salt restrictions in my diet using salt substitutes."* " I will report any increase in my weight of 5 pounds in a 2-day period "I take my prescribed antihypertensive drugs daily "I am careful to take precautions in the arm with the AV fistula."

Which statement by a female client indicates that instruction in ways to prevent urinary tract infection (UTI) was understood?

*"I should avoid tub baths and take showers instead."* *"I should dring 8 to 10 glasses of fluid per day."* "I should only wear nylon underpants." "I should void every 6 hours while I am awake." "I should use powder or talc to aid in keeping the perineal skin dry."

Before discharge, the client with emphysema tells the nurse, "This disease makes me a prisoner in my own home." What nursing response is best?

*"I'm not sure what you mean by being a prisoner."* "There are lots of things you can still do." "You're just having a bad day today." "Why are you being so negative?"

The nurse admits a 14-month-old infant with a history of prematurity, born at 25 weeks' gestation, to the pediatric unit. The mother reports that the infant has had several episodes of sudden respiratory distress with coughing, shortness of breath, circumoral cyanosis, and retractions. When the client is diagnosed with asthma, the mother asks the nurse, "Will this be a problem he'll have for the rest of his life?" The nurse's best response is:

*"It's possible this could be a lifelong problem, or he could outgrow it as he grows."* "Yes, but there are ways to reduce the frequency of episodes." "Everyone is different, so it's hard to predict what will happen. " "He will probably always be asthmatic because he was born prematurely."

The nurse working in a plastic surgeon's office admits a client for a consult about possible liposuction. The client states, "I am so sick of dieting, it would be much easier to just have this fat surgically removed." The nurse responds most accurately by saying:

*"Liposuction should not be considered a replacement for dieting, because remaining fat cells can expand if excess calories are taken in."* "While liposuction will reduce the need for dieting, it will not fully eliminate it." "Now you will be able to eat what you want so long as you don't eat excessive numbers of calories." "You will need to diet even more carefully after liposuction, because you will be at greater risk for fat cell production."

The nurse is caring for a client who received spinal anesthesia. The client calls the nurse into the room, saying, "Come quick! I can't feel my legs!" Which is the best response for the nurse?

*"Loss of feeling is normal and will subside as the anesthesia wears off."* "Did this occur suddenly, or have you noticed this ever since surgery?" "Have you fallen or injured yourself in any way since surgery?" Answered "I will call the doctor immediately."

The client with cellulitis is being discharged from the hospital. What statement should the nurse include in discharge instructions to the client?

*"Monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site."* "Drainage from the site is an expected finding and is of no cause for concern." "If pustules develop, squeeze the lesions gently each day to remove the pus." "If the lesion looks healed, stop taking the antibiotic so you will not develop resistance."

A client with chronic renal failure asks the nurse why he is anemic. What response by the nurse is best?

*"There is decreased production by the kidneys of the hormone erythropoietin."* "The decreased metabolic waste products in your body depress the bone marrow." "We will need to review your dietary intake of iron-rich foods "It is most likely that you have hereditary traits for the development of anemia.

A client with urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). Which instruction would the nurse reinforce with the client?

*"Your urine may turn reddish orange and may cause staining of your clothes."* "This drug will take care of the infection causing your symptoms." "Take the drug before meals to minimize GI symptoms." "Always keep this drug and use it at the first symptom of a UTI."

The nurse prepares to administer oxygen by nasal cannula to the client with chronic obstructive pulmonary disease (COPD) who is experiencing compromised breathing What oxygen flow rate is most appropriate for this client?

*2L/minute* 5L/minute 8L/minute 10L/minute

The nurse tests the clean-catch urine specimen using a dipstick and finds protein, blood, white cells and bacteria. The nurse suspects the client might have:

*A urinary tract infection* Contaminated the urine specimen during collection Diabetes Mellitus Fluid volume deficit

The nurse is caring for a client diagnosed with a glioblastoma who has just returned from surgery to remove as much of the tumor as possible. When gathering data on this client which assessments will be the nurse's priority to monitor? (Select all that apply.)

*Ability to respond to commands and bilateral muscle strength.* *Orientation to time, place, and person.* *Pupil response to light.* *Ability to speak.* Coping mechanism.

For the hospitalized client, which manifestation would the nurse recognize as a symptom of pulmonary embolism?

*Abrupt onset of dyspnea and apprehension* Slow increase in heart rate and respiratory rate Slight anxiety Significant bilateral wheezing

A male client who presents to the emergency department with coffee-colored urine and edema states he had a bad sore throat a few weeks ago. His BP is elevated, and urinalysis shows blood and protein in the urine. The nurse interprets that this clinical picture is consistent with which developing health problem?

*Acute glomerulonephritis* Urinary tract infection Urinary calculi Acute prostatitis

The nurse is preparing to administer respiratory medications to a client hospitalized with asthma. By which most frequently used route will the medication be administered?

*Aerosol* Intravenous Subcutaneous Oral

Which conditions are a known cause of cirrhosis of the liver? (Select all that apply)

*Alcohol consumption* *Obesity* *Hepatitis C* *Blockage of the bile duct*

What nursing explanation identifies the primary rationale for administering aminophylline?

*Aminophylline dilates the bronchial airways* Aminophylline releives persistent coughing Aminophylline reduces sputum production Amiophylline thins respiratory secretions.

The nurse is preparing to administer oxygen as ordered by the physician via a face mask to a client admitted with hypothermia secondary to exposure to the elements. What important nursing intervention will the nurse perform specific to the needs of this client?

*Apply a heated humidifier* Turn the oxygen flow to 15 liters per minute Suction the oropharynx before placing the face mask Pad the sides of the mask.

The nurse is caring for a postoperative client and gathers the following data: temperature 36.2°C, pulse 104, respirations 8, oxygen saturation 92%, pain level of 2, dressing is clean and dry, breath sounds reveal fine rales in the bases bilaterally. What is the nurse's priority intervention?

*Ask the client to deep-breathe and cough.* Administer narcotic analgesic for pain. Notify the doctor of the client's need for increased fluids. Administer oxygen.

Which nursing intervention should be included in preparing a client for an electroencephalogram?

*Ask the physician if antidepressants and sedatives should be withheld before the test* Shave the scalp in three round 6 cm areas. Keep the client NPO status 6 hours before the test. Force fluids the day before the test.

A patient enters the emergency department complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this patient includes which nursing action?

*Aspirin 325 mg orally and oxygen.* Open heart surgery. Foley catheter insertion. Heparin 100 units subcutaneously.

The nurse notices that a patient's recent laboratory results reveal increased liver enzymes. Which medication order does the nurse question?

*Atorvastatin (Lipitor).* Niacin (Nicobid). Clonidine (Catapress). Furosemide (Lasix).

When doing discharge teaching to a client with chronic liver cirrhosis, why is it important to put emphasis on bleeding precautions?

*Because of the cirrhosis, the liver is unable to produce clotting factors.* The increased production of bile decreases clotting factors. The required medications reduce clotting factors. The low protein diet will result in reduced clotting factors.

A client newly diagnosed with asthma has infrequent acute episodes. The nurse should reinforce which teaching concept regarding the medication that is most effective for providing quick relief in acute episodes?

*Beta-agonist via metered-dose inhaler* Corticosteroid via metered-dose inhaler Anti-inflammatory via metered dose-inhaler Daily use of a bronchodilator inhaler

Before discharging a client with fractured ribs from the emergency department, what instruction is most important for the nurse to provide?

*Breathe deeply several times every hour* Breathe shallowly to avoid pain Breathe rapidly to promote ventilation Breathe into a paper bag every 3 hours

When assessing the client with an arteriovenous fistula used for hemodialysis, the nurse notes absence of bruit and thrill. The nurse's priority action is to:

*Call the physician and notify him of these findings* Do nothing, this is a normal finding Compare the BP readings in both arms Have the client exercise and do a reassessment

A client with renal calculi is advised to restrict calcium in the diet. The nurse determines that the client understands the restrict when the client states to avoid which types of foods?

*Chocolate, smoked fish, and low-fat milk* Chicken, beef, and salmon Green vegetables, fruit and legumes Eggs, meat, and poultry

What are Symptoms of Parkinson's Disease?

*Cognitive changes (sometimes dementia)* *Gait difficulties (ataxia)* *Tremors (increase with stress and anxiety)* *Rigidity, jerking motions* Increased pulse pressure

What intervention should the nurse identify as the priority for the client with a nursing diagnosis of Ineffective Airway Clearance related to tumor mass?

*Coughing, deep breathing, and hydration maintenance* Provision of supplemental oxygen Keep the head of the bed elevated Preparation of a tracheostomy tube

The nurse instructs the client on the procedure for collecting a 24-hour urine specimen. When the client demonstrates understanding, the nurse's first action is to:

*Discard the first void and begin collecting the 24-hour urine specimen* Determine the specific gravity of the first voided specimen Instruct the client to begin collecting urine with the first voided urine Test the urine for glucose

The nurse is caring for a client who is producing abnormally large amounts of urine and calls the physician to notify her that the client is demonstrating:

*Diuresis* Oliguria Anuria Polydipsia

The nurse is reinforcing discharge teaching for a client admitted with a diagnosis of pylonephritis who will continue antibiotics after discharge. The nurse stresses the importance of:

*Drinking at least 2,000 mL of fluid daily* Daily weights Straining all urine Recording intake and output

Which assessment finding for a patient with cirrhosis of the liver would indicate a need for Vitamin K?

*Ecchymosis* Dyspnea Fatigue Ascites

The nurse is caring for a client with papules and vesicles in patches all over the body, some of which have been ruptured and left a yellow crusty exudate. There are tiny cracks in the involved areas with very dry skin. The client went to the clinic because of concerns about possible food allergies. the nurse anticipates which diagnosis?

*Eczema* Ringworm Mycosis fungoides Impetigo

A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis? (Choose all that apply)

*Elevated liver enzymes* *Elevated serum bilirubin level* Elevate hemoglobin level Decreased erythrocyte sedimentation rate

Which instructions will help prevent infection with Lyme Disease? Select all that apply

*Eliminate mosquito breeding places.* Wear sunscreen when outdoors. Avoid going barefoot at home. *Avoid exposure to deer ticks.*

A client with a urinary diversion device has the nursing diagnosis Risk for Impaired Skin Integrity. Which interventions will the nurse use with this client? Select all that apply

*Empty the bag reservoir every 2 hours* *Ensure appliance wafer is not more than 1/8 inch larger than stoma* Change urine collection device daily Reinforce teaching of self-catheterization technique Monitor for foul-smelling urine

The nurse delegates bathing the client with hemiparesis to the unlicensed assistive personnel (UAP) and provides which specific direction?

*Encourage the client to bathe the affected side.* Avoid moving the extremities on the affected side. Avoid bathing the unaffected side. Teach the client how to provide self-care after discharge.

The nurse delegates bathing the client with hemiparesis to the Certified Nursing Assistant and provides which specific direction?

*Encourage the client to bathe the affected side.* Teach the client how to provide self-care after discharge. Avoid moving the extremities on the affected side. Avoid bathing the unaffected side.

The nurse is caring for a client who just had a lumbar puncture performed. What nursing intervention is a priority of care for this client?

*Ensure the client lies flat for 6-12 hours.* Administer laxatives for 2-3 days following the procedure. Have the client cough, deep-breathe, and turn frequently. Apply pressure to the insertion site for 5-10 minutes.

The nurse is caring for a client with emphysema. When the nurse enters the client's room, the spouse asks for the oxygen to be increased, because the client is having trouble breathing. The nurse's best intervention is to:

*Explain that increased oxygen will decrease respirations and make him more SOB.* Call the physician for an order to increase the oxygen delivered. Increase the oxygen and monitor oxygen saturation. Tell the spouse that increasing oxygen is not possible.

A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would be expected in this client?

*Flank pain on the affected side* Hypertension Pain that radiates toward the unaffected side No tenderness with deep palpation over the angle of Henle

How does the nurse explain ascites to the client?

*Fluid accumulation in the abdomen* Enlargement of the liver Calcium stone obstructing the Gall Bladder Kinking of the large bowel

A patient with coronary heart disease wants to change his lifestyle. Which risk factors can the patient work to change? (Choose All that Apply)

*High blood pressure* *Cigarette smoking* *Obesity* *Elevated blood lipids.* Heredity

Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which medication-related side effects?(Choose all that apply)

*Hyperkalemia* Tachycardia *Thrombocytopenia* Jaundice

The nurse enters the client's room to collect a urine culture when the client asks why it is needed. The nurse explains the purpose of a urine culture is to determine:

*If microorganisms are present in the urine* The presence of occult blood in the urine Urine concentration Urine glucose level

The nurse is preparing to admit a client with urge incontinence. In reviewing the care plan, the nurse identifies interventions that target which manifestation?

*Inability to inhibit urine flow long enough to reach the toilet* Involuntary loss of urine without a warning or stimulus Loss of urine when coughing or sneezing Inability to empty bladder

During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings?

*Increased ammonia level* Increased calcium level Increased creatinine leveled Decreased magnesium level

The nurse admits a client who prefers naturopathic remedies whenever possible and who is reporting rhinorrhea, chest congestion with dry cough, and low-grade fever. The physician diagnosed a common cold, and prescribes over-the-counter palliative treatment. What recommendation can the nurse make in keeping with the client's beliefs?

*Increased water intake for cough.* Take acetaminophen for fever. Pseudoephedrine for rhinorrhea Inhale cold air to open airways

A physician has ordered a condom catheter for a client. The nurse cleans the client's perineal area before application of the condom catheter and sees irritation, excoriation, and swelling of the penis. Which nursing intervention should be the nurse's priority?

*Informing the charge nurse of the findings* Twisting the condom after application Applying the condom with adhesive tape Rolling the condom down securely over the tip of the penis

How does the explain autonomic dysreflexia?

*It is a vasoconstrictive problem produced by excessive sympathetic nervous system stimulation.* It is a cardiovascular problem produced by decreased cardiac output secondary to bradycardia. It is a parasympathetic nervous system problem resulting from unopposed vasodilation. It is a spastic disorder that limits mobility.

What nursing action is most appropriate before transporting the client to have x-rays taken after a chest tube insertion?

*Keep the drainage system below the insertion sites* Clamp the chest tubes before leaving the room Attach a portable suction machine to the chest tubes Provide mechanical ventilation during transport

The nurse anticipates an order for fluid restriction when admitting a client with a medical diagnosis of:

*Kidney failure* Urinary tract infections Renal calculi Diabetes

The nurse working in the Emergency Department admits a client requiring surgical repair of a laceration on the hand, and anticipates what type of anesthesia?

*Local.* General. Topical. Spinal.

Entry of pathogens into the respiratory system is inhibited by what protective mechanisms? (Select all that apply.)

*Lymphoid tissue in the pharynx* *Nasal filtration* Mucus production in the alveoli Fluid in the parietal pleura Saliva in the oral cavity

A client is scheduled for a MRI of the head. Which area is essential to assess before the procedure?

*Metal fillings, prosthesis, or a pacemaker* The presence of carotid artery disease. Food or drink intake within the past 8 hours. Voiding before the procedure.

The client is admitted to a medical surgical unit from the emergency department four hours after a motorcycle accident. He has a spinal cord injury at the level of T12. Which medication would be used to control edema of the spinal cord?

*Methylprednisolone.* Furosemide. Sodium bicarbonate. Acetazolamide.

A client is admitted to the hospital with a medical diagnosis of viral pneumonia. the nurse needs to monitor for which of the following most frequent manifestations? Select all that apply

*Nonproductive cough* *Normal or near normal white blood cell count* High fever that is intermittent Profuse pleural diffusion on chest x-ray

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70 over 53, skin is cool&clammy. Which action does the nurse take?

*Notify the MD.* Continue to monitor the patient. Obtain an EKG. Check the patient's blood glucose.

The nurse does which of the following to prepare to collect a creatinine clearance urine test?

*Obtain a 24-hour collection bottle for urine* Check for a signed informed consent Assess the client for allergies to shellfish Insert a Foley catheter with a big drainage bag

A patient walks into the emergency department after being bitten by a deer tick. The patient is nervous about Lyme disease. What instruction does the nurse give to the client? Select all that apply.

*One should monitor for a bullseye rash* Lyme disease should be treated with antivirals immediately. Blood tests should be done immediately *Blood tests are not reliable until 6 to 8 weeks after exposure.* You cannot get Lyme disease from deer ticks.

A client with AIDS develops severe itching with skin lesions that ulcerate and become infected. The physician diagnoses Mycosis fungoides, which is a (n):

*Opportunistic illness, also called T-cell lymphoma* Skin cancer similar to basal cell carcinoma Indication tht the AIDS virus is now attacking the skin Fungal skin infection that leads to skin cancer

The nurse is caring for a client post CVA with right side paralysis, on a rehabilitation unit. How does the nurse know to describe the purpose of the client's treatment?

*Optimal function.* Promote ambulation. Bathing self. Promote self-feeding.

What are possible side effects of a beta blocker?

*Orthostatic hypotension and bradycardia.* Dizziness and hypertension. Hypertension and tachycardia. Palpitation and tachycardia.

The nurse is teaching a client who is being started on the ACE Inhibitor, Enalapril (Vasotec). Which is the most common side effect complaint from patients who routinely take this medication?

*Persistent cough.* Sore throat. Increased thirst. Reduced urine output.

How does Diabetes increase a client's risk for complications?

*Predisposes the client to wound infection and delayed healing.* Increases blood coagulation time and increases risk of hemorrhage. Predisposes the client to postoperative lung infections. Impairs excretion of drugs and other toxins.

The client presents to the physician's office complaining of sudden onset of fever, chills, vomiting, right flank pain, urinary frequency and dysuria. The nurse suspects a diagnosis of:

*Pyelonephritis* Acute renal failure Polycystic kidney disease Glomerulonephritis

The nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen saturation. The client's respiratory rate is 26, and oxygen saturation is 89%. What actions can the nurse take independently to support respirations and reduce hypoxia?

*Raise the head of the bed.* Apply oxygen Administer a bronchodilator Insert an oral airway.

The nurse attaches a spacer to the metered-dose inhaler for a client What is the purpose of the spacer?

*Reduces the risk for oral yeast by depositing medicine more deeply into the airways* Makes the device look less intimidating to a client Concentrates the medication in the upper respiratory tract Makes it unnecessary to shake the inhaler before administering the drug

The nurse is caring for an elderly client with stress incontinence. While bathing the client, the nurse learns which of the following factors that might have contributed to this condition?

*She has 9 children, all delivered at home* Her mother had incontinence after age 50 She regularly performs Kegel exercises She tries to drink six glasses of water daily

The nurse admits a client with a diagnosis of pneumonia with moderate respiratory distress requiring oxygen by nasal cannula. What diagnostic test does the nurse anticipate will be ordered to confirm the cause of the infection?

*Sputum culture* CBC with differential ELISA Biopsy

The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicion of a spontaneous pneumothorax of the left lung? (Select all that apply.)

*Subcutaneous emphysema palpable on the left side of the chest.* *Absent breath sounds on the left side of the chest.* *Tachycardia and tachypnea.* Diminished breath sounds in the bases bilaterally, with rhonchi in the left lower lobe. Trachea is at midline.

A client with burn injury asks the nurse what the term "full thickness" means. the nurse should respond that burns classified as full thickness involve tissue destruction down to which level?

*Subcutaneous tissue* Dermis Epidermis Internal organs

The nurse is preparing a client for elective surgery. Which description is appropriate for this type of surgery?

*Surgery that is performed to improve the client's life.* Surgery that is performed immediately to preserve function. Surgery that normally involves little risk. Surgery that involves a high degree of risk.

The client, diagnosed with benign prostatic hypertrophy (BPH), asks the nurse why he has to void so frequently. The nurse explains that the enlarged prostate:

*Surrounds and applies pressure to the urethra, preventing complete emptying of the bladder* Surrounds and applies pressure on the ureter, preventing urine from entering the bladder Surrounds and applies pressure to the Cowper's glands, preventing urine production Invades the epididymis, causing decreased sperm and urine production

The nurse administers the first dose of an ACE Inhibitor to an elderly client with hypertension. Which priority intervention does the nurse choose?

*Take the blood pressure before and 1 hour after drug administration.* Instruct the patient to drink 3 liters of fluid per day. Auscultate heart tones before drug administration. Place the client in Trendelenburg to facilitate blood flow to heart.

The physician orders two puffs of albuterol sulfate twice a day as needed using a metered dose inhaler. After administering the first puff of medication, what client action demonstrates proper use of the inhaler?

*The client holds his or her breath for up to 10 seconds before exhaling* the client depresses the canister a second time before exhaling The client cleans the mouthpiece with a clean paper tissue or cloth The client bends from the waist to increase the exhaled volume

For a client in hepatic coma, which outcome would be the most appropriate?

*The client is oriented to time, place, and person.* The client exhibits increased serum albumin level. The client increases oral intake to 2,000 calories/day The client exhibits no ecchymotic areas.

After having a transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

*The client reports bladder spasms and the urge to void* The urine in the drainage bag appears red to pink The normal saline irrigation is infusing at the rate of 50 gtt/minute About 1,000 mL of irrigant have been instilled, and 1,200 mL of drainage have been returned

A client underwent a thoracentesis a few hours earlier. What finding should the nurse report immediately to the Doctor?

*The onset of crepitus* Slight oozing of blood from the puncture site Slight fever Slightly elevated blood pressure

The client with a closed head injury must be carefully monitored by the nurse because she could stop breathing or have inadequate respiratory effort due to what?

*The respiratory control mechanism is in the brain and increased cerebral edema could damage its function.* The accident that injured the head might also have injured the chest. The client's reduced level of consciousness might cause the tongue to block the airway. Closed head injuries mainly occur in very young children whose airways are very narrow and easily occluded.

The nurse is caring for a client in the physician's office who wishes to quit smoking. The client asks the nurse, "If I quit smoking, will my risk of lung cancer be the same as a non-smoker's?" The nurse's best response includes which of the following?

*The risk of lung cancer will decline if he quits, but it will be higher than for someone who never smoked.* The risk of lung cancer will return to the same level as that for a person who never smoked. The client's risk for lung cancer will never drop[, because the damage has already been done. No one knows for sure what the risk is for someone who quits smoking.

What assessment finding indicates that air is leaking into the tissue around the victim's chest tube insertion site?

*The skin crackles when touched* The tissue appears pale or colorless The client is tired The client has a fever

Select all of the risk factors that are associated with deep vein thrombosis.

*The use of oral contraceptives* Type B and O blood *Obesity* Rh negative blood

The nurse working in an urgent care clinic admits a 38-year-old woman with report of chest pain radiating to the jaw, diaphoresis, cool extremities, and nausea. While waiting for the doctor to see the client, what is the nurse's priority intervention?

*To administer oxygen.* To draw blood for cardiac enzymes. To obtain a signed operative consent. Administration of nitroglycerine.

What assessment technique is essential before allowing a client food or fluids after a bronchoscopy?

*Touch the arch of the palate with a tongue blade.* Listen to the abdomen for active bowel sounds Check the temperature of the client Palpate the throat while the client swallows

A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which nursing interventions are appropriate to prevent skin breakdown? (Select all that apply.)

*Turn and reposition every 2 hours* *Alternating air pressure mattress* Sit in chair for 30 minutes each shift Range of motion every 4 hours Abdominal and foot massages every 2 hour

The nurse, working in a physician's office, is caring for a woman who has had recurrent urinary tract infections. The client asks why women get more UTIs than men. The nurse explains it is because of the difference in the size of men's versus women's:

*Urethra* Ureters Glomeruli Renal pelvis

A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to:

*Use a condom during sexual intercourse* Follow a low-protein, moderate-carbohydrate, moderate-fat diet Avoid alcohol for the first 3 weeks Have family members get an injection of immunoglobin

Is Atrial fibrillation or Ventricular fibrillation more serious?

*Ventricular fibrillation (v-fib for short) is the most serious cardiac rhythm disturbance. The lower chambers quiver and the heart can't pump any blood, causing cardiac arrest.* Atrial fibrillation is more serious because the client loses 1/3 of their cardiac output.

The LVN is preparing a client for surgery. Which responsibility does the LVN have with the preoperative consent?

*Witnessing the client's signature.* Signing the consent for the client who is not clear about the procedure. Medicating the client prior to signing the form. Encouraging the client to read about the procedure so it is understood.

What should the nurse reinforce regarding health maintenance strategies to the client with chronic obstructive pulmonary disease (COPD)? Select all that apply

*Yearly influenza immunizations* *Immunization against pneumonia* *Adequate oral intake* Limitation of physical activity Oral fluid restriction

The nurse who is explaining the pathophysiology of chronic obstructive pulmonary disease (COPD) to a client includes the fact that the alveolar destruction results in which manifestation? Select all that apply

*decreased surface area* *Airway collapse related to loss of elasticity* Increased dead space air Development of pulmonary emboli Chronic dilation of bronchioles

The nurse is caring for a client admitted for control of unstable angina. The nurse answers the call bell and the client reports severe pain (10 on a 1-10 scale, with 10 being worst) in the left leg. The nurse assesses the left leg and finds it cold, pale, and pulseless, with no popliteal, dorsalis pedis, or posterior tibial pulse by palpation or Doppler. What is the nurse's priority intervention?

Administer an analgesic to control pain. Have the client walk to improve circulation. Elevate the leg and apply heat. *Notify the RN or physician immediately.*

The client with history of seizures is prescribed phenytoin (Dilantin). What is the mechanism of action of this drug?

Block the enzyme cholinesterase. Relax the muscles. Increase levels of dopamine. *Decrease excitability of neurons.*

What is an Aneurysm?

Blood Clot in the parietal lobe Frequent cause of concussion *Abnormal outpouching or dilation of cerebral artery that develops secondary to a weakness in the arterial wall.* A normal part of the Circle of Willis

The nurse working in a long-term care facility is talking with a client diagnosed with congestive heart failure, diabetes, hypertension, and chronic renal failure, and notes mild edema of the ankles while the client is sitting in the chair. Breath sounds are clear with good chest excursion, and the client denies any feeling of shortness of breath. The nurse reviews the medical record and sees no significant change in the client's daily weights over the last week. What are the nurse's priority interventions for this client? (Select all that apply.)*

Review the client's diet to determine sodium intake. *Encourage the client to elevate her feet when sitting.* Review the client's BUN and creatinine. Call the doctor for an order to increase the client's diuretic. *Apply antiembolism stockings.*

The nurse is ambulating a client with a history of angina in the hall and notices the client has become very short of breath. Which nursing action(s) does the nurse choose first?

Walk the client back to his bed and apply oxygen. *Ask another nurse to bring portable oxygen, in order to apply prn oxygen, and a wheelchair.* Administer 1 nitroglycerin immediately and walk the patient back to his room. Get a prn angina electrocardiogram (EKG) immediately.

The nurse is assessing a client scheduled for reconstructive surgery when the client states, "I can't wait to have this procedure done. I'm going to have a wonderful life once my appearance is improved." The nurse interprets this comment as an indication that the client:

Is excited about how the surgery will improve his life Recognizes the importance of physical appearance Is attempting to reduce anxiety *Has an unrealistic expectation*

The nurse is caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are:

Pancreatic cancer and obesity History of diabetes and smoking High cholesterol and alcohol abuse *Gallstones and alcohol abuse*

The nurse is assessing the client, and anticipates which as early sign of meningitis?

Seizures and paralysis. Negative Babinski sign. Chills. *Nuchal rigidity. (stiff neck)*

The nurse teaches a patient with angina about taking Nitroglycerin tablets. Which instruction does the nurse include?

Take the tablet with a large amount of water. *Lie or sit down when placing one tablet under the tongue.* If one tablet does not relieve chest pain, call 911. If the tablet causes cough and headache, stop the medication and notify the physician.

When does the nurse know that a client has mastered the technique needed to correctly use an incentive spirometer?

The client blows quickly and hard into the mouthpiece. *The client inhales slowly and deeply through the mouthpiece.* The client inhales slowly and deeply through the nose. The client inhales quickly and deeply through the mouthpiece.

The nurse is caring for a postop client who has had a skin graft. Which of the following are possible reasons for a skin graft? Select all that apply

The client had scabies, ringworm, and impetigo *A large area of skin was missing due to a burn8 The client had wrinkles, freckles, or any skin discoloration the client wants repaired *Trauma to the skin destroyed the stratum germinativum* *A wound would not heal and had to be grafted closed*

Five minutes after administering 1 nitroglycerin sublingual (sl), the nurse takes the client's blood pressure and it is 156 over 84. The client states that he is having chest pain of 5 on a scale of 0 to 10. What is the significance of the client's blood pressure and chest pain?

The client should have swallowed the nitroglycerin tablet. The nitroglycerin did not work and prn morphine sulfate IV should be given by the Registered Nurse. The blood pressure is too high and is causing the chest pain. *It is safe to administer another prn sublingual (sl) nitroglycerin as ordered.*

The nurse comes upon a person who has just witnessed a devastating event. The client's pupils are dilated, heart and respiratory rate are increased, and the client's hands are trembling. How does the nurse explain these symptoms?

The client's central nervous system was stimulated by the event and is producing the symptoms. The client's parasympathetic nervous system was stimulated by the event and is producing the symptoms. *The client's sympathetic nervous system was stimulated by the event and is producing the symptoms.* The client may be using an illegal stimulant producing the symptoms.

The nurse is preparing a client for a palliative procedure. Which of the following is an appropriate description for the nurse to use to describe the purpose of the surgery?

This procedure will establish the diagnosis for further treatment This procedure will replace the malfunctioning nerve. *This procedure will relieve pressure on the nerve causing the pain.* This procedure will restore function from the previous procedure.

Stool softeners would be given to a client after a repair of a cerebral aneurysm for which reason?

To prevent the Valsalva maneuver, which may lead to bradycardia. To prevent constipation when osmotic diuretics are used. To stimulate the bowel because of loss of nerve innervation. *To prevent straining, which increases intracranial pressure (ICP).*

A client with subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which reason?

To raise the client's blood pressure. To prevent seizures. To decrease the client's restlessness. *To promote osmotic diuresis to decrease intracranial pressure (ICP).*

When feeding a client who has suffered a left-sided CVA, what interventions does the nurse choose? (Choose all that apply)

Turn to the right side before feeding. *Place the food on the unaffected side.* *Sit the client upright in a chair.* Encourage the client to cough after several bites of food.

The nurse working in an ED outpatient clinic admits a diabetic client with an irregularly shaped red area on the calf of the leg that is hot to the touch, painful, and edematous with red streaks found traveling from the red area up the back of the thigh. The nurse anticipates what diagnosis?

Venous stasis ulcer *Cellulitis* Peripheral vascular disease Gangrene

The nurse sees this rhythm on the heart monitor. What label does the nurse give to this rhythm?

Ventricular Fibrillation Normal Sinus Rhythm Atrial Fibrillation Ventricular Tachycardia

This image labels the different parts of 1 beat on a heart rhythm strip. What does the p wave represent?

Ventricular depolarization that causes the contraction of the ventricle S4 *Depolarization of the atria.* Repolarization of the ventricles.