GI
A healthcare provider prescribes 250 mg of an antibiotic intravenous piggyback (IVPB). A vial containing 1 gram of the powdered form of the medication must be reconstituted with 2.8 mL of diluent to form a volume of 3 mL. How many mL of the solution should the nurse administer? Record your answer using one decimal place and leading zero if applicable. __mL
0.3
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? 1 Sodium and chloride levels 2 Bicarbonate and sulfate levels 3 Magnesium and protein levels 4 Calcium and phosphate levels
1
The nurse reviews the medical records of four male clients. Which client will the nurse assess most closely for developing prostate cancer? 1 Black 55-year-old 2 White 45-year-old 3 Asian 55-year-old 4 Hispanic 45-year-old
1
The primary healthcare provider prescribed medications to four clients with osteoporosis. Which client is instructed to remain upright for 30 minutes after medication administration? 1 Client A 2 Client B 3 Client C 4 Client D
1
What is the main reason a nurse raises three of the four side rails on the bed of an 83-year-old client who had surgery for a fractured hip? 1 As a safety measure because of the client's age 2 Because clients older than 60 years of age should use side rails 3 To be used as handholds to facilitate the client's ability to move in bed 4 Because all older adults are disoriented for several days after anesthesia
1
Which is the first line treatment for Paget disease? 1 Oral alendronate 2 1500 mg of calcium 3 Intravenous pamidronate 4 Intravenous zoledronic acid
1
A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record your answer using a whole number. ______ mL/hr
167
A client has had a below-the-knee amputation of the leg. What is important for the nurse to consider when providing postoperative care for a client who had an amputation of a lower extremity? 1 Strict bed rest is maintained for at least several days. 2 The residual limb should not be elevated for the first 24 hours. 3 Hemorrhage rarely occurs during the early postoperative period. 4 Primary healthcare providers usually change the dressing on the residual limb within 48 hours.
2
A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? 1 Snack daily in the evenings 2 Divide food into four to six meals a day 3 Eat the last of three daily meals by 8:00 PM 4 Suck a peppermint candy after each meal
2
A nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? 1 Client A 2 Client B 3 Client C 4 Client D
2
A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately 3 months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. Which stage should the nurse determine the client is in at this time?
2
A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately 3 months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. Which stage should the nurse determine the client is in at this time? 1 Primary 2 Secondary 3 Latent 4 Tertiary
2
An obese client asks the nurse how to lose weight. What should the nurse include in the response that explains when long-term weight loss occurs best? 1 Fats are limited in the diet. 2 Eating patterns are altered. 3 Carbohydrates are restricted. 4 Exercise is a major component.
2
Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____
2
Which structure protects a client's internal organs, supports blood cell production, and stores minerals? 1 Joints 2 Bones 3 Muscles 4 Cartilages
2
While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention? 1 To promote bone density 2 To prevent further edema 3 To reduce pain perception 4 To increase muscle strength
2
A nurse receives a telephone report from the postanesthesia care unit for a client status following a colon resection with anastomosis. Place the nursing actions in order of priority when the nurse receives this client from the postanesthesia care unit. 1. Monitor respiratory rate and quality 2. Assess the client's level of consciousness 3. Check the abdominal dressing 4. Assess airway 5. Obtain the heart rate and blood pressure
2, 4, 1, 5, 3
A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply. 1 Adhering to a low-carbohydrate diet 2 Avoiding aspirin and aspirin-containing products 3 Limiting alcohol consumption to two drinks weekly 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement
2, 4, 5
To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply. 1 Eggs 2 Liver 3 Cheese 4 Salmon 5 Shellfish
2, 5
A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply. 1 Jaundice 2 Boardlike abdomen 3 Abdominal tenderness 4 Decreased bowel sounds 5 Rapid decrease in coagulation ability
2. 3. 4.
A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. What should the plan of care include immediately after surgery? 1 Changing the client's pressure dressing as necessary 2 Inviting a member of Reach to Recovery to visit the client 3 Placing the client in the semi-Fowler position with the left arm elevated 4 Waiting for a cessation of drainage before the client resumes any activity
3
A client develops gastric bleeding and is hospitalized. Which area should the nurse assess most closely during the history? 1 Usual dietary pattern 2 Recent travel to other countries 3 Medications taken routinely or recently 4 A change in the status of family relationships
3
A client has been diagnosed with anemia. Which decreased hormone level may be the cause? 1 Bradykinin 2 Prostaglandin 3 Erythropoietin 4 Activated vitamin D
3
A client is being considered for bariatric surgery. Which client health problem does the nurse identify as consistent with morbid obesity? 1 Dumping syndrome 2 Compartment syndrome 3 Hypoventilation syndrome 4 Inappropriate antidiuretic hormone syndrome (ADH)
3
A nurse is assessing a client for the potential for osteoporosis. Which factor in the client's history increases the risk for this disorder? 1 Estrogen therapy 2 Hypoparathyroidism 3 Prolonged immobility 4 Excessive calcium intake
3
A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? 1 Low-residue, bland diet 2 Fluid intake below 500 mL 3 Small, frequent feeding schedule 4 Low-protein, high-carbohydrate diet
3
A nursing student assesses a client with abdominal pain. Which action performed by the nursing student needs correction? 1 Assessing the factors that worsen the pain 2 Asking the client about his or her sleeping patterns 3 Assessing the client for tenderness and dimpling 4 Asking the client about the time and type of pain
3
After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1 Observing the suprapubic dressing for drainage 2 Maintaining the client in the semi-Fowler position 3 Monitoring for bright red blood in the drainage bag 4 Encouraging fluids by mouth as soon as the gag reflex returns
3
Among which group of women are breast cancer death rates the lowest? 1 Hawaiian 2 Puerto Rican 3 Asian American 4 African American
3
The nurse is performing an assessment of a female client's reproductive system. Which action should the nurse take? 1 Maintain friendly demeanor with the client during assessment 2 Ask about sexual practices at the beginning of assessment 3 Ask about menstrual history at the beginning of assessment 4 Maintain gender-specific terms while questioning during assessment
3
The nurse is providing care to a client who has had a transurethral resection of the prostate (TURP). Which goal is the priority? 1 Maintain patency of the cystostomy tube. 2 Prevent wound hemorrhage and infection. 3 Maintain patency of the indwelling catheter. 4 Prevent the abdominal dressing from draining.
3
What should the nurse consider as the goal of therapy when administering allopurinol to a client with gout? 1 Increase bone density 2 Decrease synovial swelling 3 Decrease uric acid production 4 Prevent crystallization of uric acid
3
Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1 Thermography 2 Plethysmography 3 Duplex venous doppler 4 Somatosensory evoked potential
3
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1 Pouring warm water over the perineum 2 Ensuring the patency of the catheter 3 Removing the catheter within 24 hours 4 Cleaning the catheter insertion site
3
Which medication should the nurse question when it is prescribed for a client with acute pancreatitis? 1 Ranitidine 2 Cimetidine 3 Meperidine 4 Promethazine
3
Which test helps to identify fibroids, tumors, and fistulas while performing a reproductive tract examination? 1 Mammography 2 Ultrasonography 3 Hysterosalpingography 4 Computed tomography
3
A nurse is caring for a client with tertiary syphilis. Which body system should the nurse monitor most closely? 1 Respiratory 2 Reproductive 3 Integumentary 4 Cardiovascular
4
A nurse is instructing a group of clients in the community about food preparation. Which statement indicates a client is at an increased risk for contracting botulism? 1 "I do not usually brush my teeth after I finish eating a meal." 2 "Sometimes I eat grapes before I have a chance to wash them." 3 "Utensils that I use to cut up chicken are put into the dishwasher." 4 "I save money when I buy the slightly damaged cans of vegetables."
4
A nurse is performing a health history and physical assessment of a client with cholelithiasis and obstructive jaundice. Which clinical finding should the nurse expect this client to exhibit? 1 Hematuria 2 Bloody stools 3 Straw-colored urine 4 Pain in the right upper quadrant
4
A nurse is reviewing the laboratory reports of four clients. Which client most likely has rheumatoid arthritis? 1 Client A 2 Client B 3 Client C 4 Client D
4
A nurse is reviewing the treatment charts of four clients. Which treatment chart needs revision? 1 Client A 2 Client B 3 Client C 4 Client D
4
A nurse is teaching a client with a non-weight-bearing long leg cast. Which statement indicates the need for the nurse to reinforce discharge teaching? 1 "The cast can be wrapped in plastic when I take a shower." 2 "I called my office to let them know I will be back at work next week." 3 "The physical therapist is going to teach me how to walk with crutches." 4 "I am going to give myself a pedicure with red nail polish when I get home."
4
A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? 1 "I can drink beer with this, but not wine." 2 "I need to limit my intake of acetaminophen to 650 mg a day." 3 "I should take an emetic if I accidentally overdose on the acetaminophen." 4 "I have to be careful about which over-the-counter cold preparations I take when I have a cold."
4
Which disorder of the foot is caused by continual pressure over bony prominences? a. Corn b. Plantar wart c. Hammer toe d. Hallux rigidus
a
Which structure indicated in the figure is the primary reproductive organ of the female? 3204932525 A B C D
a
A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. The nurse should insert the catheter in what location in the illustration? 3142352560 a b c d
b
After a prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. Which nursing goal will best achieve prevention? a. Increase coagulability of the blood. b. Increase velocity of the venous return. c. Increase effectiveness of internal respiration. d. Increase oxygen-carrying capacity of the blood.
b
A client is to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is most important for the nurse to obtain? 1 Infusion pump 2 Tall intravenous (IV) pole 3 Clamp taped at the bedside 4 Infusion set delivering 60 drops/mL
1
The nurse is reviewing the laboratory reports of a group of elderly clients. Which client has an age-related impairment in thirst mechanism? 1 Client A 2 Client B 3 Client C 4 Client D
1
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
A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply. 1 Bone pain 2 Convulsions 3 Muscle spasms 4 Tingling of extremities 5 Depressed deep tendon reflexes
1, 5
While assessing a client, the nurse suspects that the client has acute osteomyelitis. Which symptoms in the client support the nurse's suspicion? Select all that apply. 1 Foot ulcer 2 Temperature of 102° F 3 Erythema of the affected area 4 Tenderness of the affected area 5 Drainage from the affected area
2, 3, 4
A client expresses a complete lack of interest in food. How should the nurse document this finding in the client's medical record? 1 Apathy 2 Aphasia 3 Adactyly 4 Anorexia
4
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
Why is Phalen's test performed in a client? 1 To diagnose atrophy 2 To diagnose bone tumor 3 To detect rotator cuff injuries 4 To detect carpal tunnel syndrome
4
A healthcare provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL
0.5
A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1 Lactase 2 Sucrase 3 Maltase 4 Amylase
1
A client has a body mass index (BMI) of 35 and verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by changing which dietary habits? 1 Decrease portion size and fat intake 2 Increase protein and vegetable intake 3 Decrease carbohydrate and fat intake 4 Increase fruits and limit fluid intake
1
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? 1 Use a pillow to keep the legs abducted. 2 Elevate the client's affected limb on a pillow. 3 Turn the client using the log-rolling technique. 4 Place a trochanter roll along the entire extremity.
1
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
A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? 1 Works at a plumbing business 2 Works in a hemodialysis unit at a hospital 3 Works as a dishwasher at a local restaurant 4 Works at an occupational arsenic compound business
1
A client who has just been transferred to the inpatient unit following surgery for oral carcinoma indicates to the nurse that the client's spouse is the only person who is allowed to visit. To support the client at this time, which action should the nurse take? 1 Comply with the client's wishes 2 Ask the client why other visitors should be restricted 3 Have the spouse explain to the client that everything will be okay 4 Promote communication to find out how the client really feels
1
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? 1 Monitor the client's vital signs. 2 Increase the client's fluid intake. 3 Improve the client's nutritional status. 4 Determine the client's reasons for drinking.
1
A client with rheumatoid arthritis arrives in the clinic stating, "I don't take any medications because they are too expensive." The client reports that family members are arranging for the medications to be obtained from another country. What is the nurse's best response? 1 Discuss alternative solutions with the client. 2 Encourage the client to use any method possible to obtain the medications. 3 Contact the primary healthcare provider immediately to discuss the client's plan. 4 Explain that medical regimens must be followed to continue to receive care in the clinic.
1
A client with rheumatoid arthritis is in the convalescent stage of an exacerbation. The client states, "The only time I am without pain is when I lie perfectly still." Considering the client's statement, what should the nurse encourage the client to do? 1 Participate in active joint flexion and extension exercises. 2 Perform flexion exercises three times a day. 3 Do range-of-motion (ROM) exercises once a day. 4 Refrain from exercising until remission occurs.
1
A primary health care provider prescribes 1000 mL total parenteral nutrition (TPN) to be infused over 12 hours via a central venous access device. What is most important for the nurse to obtain when preparing the equipment? 1 An infusion pump 2 A steady intravenous (IV) pole 3 An infusion set delivering 60 gtts/mL 4 A set of hemostats to be taped at the bedside
1
A rubella vaccination is ordered for a client. Which statement made by the client is cause for concern? 1 " I have been trying to conceive a baby for a few months." 2 "I have plans to have a baby by next year." 3 "I have no history of rubella in childhood." 4 "I have plans to get married by the next year."
1
After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? 1 Prepare the client for surgery. 2 Administer oxygen per nasal catheter. 3 Place in the supine position, with legs elevated. 4 Ask the client if there have been any black stools.
1
After interacting with a client, a nurse finds that a 23-year-old client has never undergone a Papanicolaou (Pap) test. What should the nurse suggest to the client? 1 Schedule a Pap test immediately 2 Schedule a Pap test during menses 3 Schedule a Pap test every five years 4 Schedule a Pap test and human papillomavirus test
1
Despite receiving 2900 mL intake for 2 days, the client's urine output has progressively diminished. The nurse identifies that the urinary output is less than 40 mL/hr over the past 3 hours. What action will the nurse take? 1 Assess breath sounds and obtain vital signs. 2 Decrease the intravenous flow rate and increase oral fluids. 3 Insert an indwelling catheter to facilitate emptying of the bladder. 4 Check for dependent edema by assessing the lower extremities.
1
Following surgery, total parenteral nutrition is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, what is the next action the nurse should take? 1 Check the serum glucose level. 2 Obtain an oxygen saturation level. 3 Administer a prescribed analgesic. 4 Prepare the client for immediate surgery for possible bowel obstruction.
1
The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? 1 Monitor for nonverbal cues of pain 2 Check the pressure dressing for bleeding 3 Assist the client to ambulate around his room 4 Irrigate the client's nasogastric tube with sterile water
1
The school nurse is attending to a student athlete who reports muscle pain after a practice session. Which should the nurse identify as a cause of this pain when providing instruction to the student? 1 Lactic acid 2 Acetoacetic acid 3 Hydrochloric acid 4 Beta-hydroxybutyric acid
1
What would be the drug of choice in an adolescent who is diagnosed with syphilis during the first trimester of pregnancy? 1 Penicillin G 2 Doxycycline 3 Tetracycline 4 Erythromycin
1
Which musculoskeletal system change is associated in older adult clients? 1 Decreased in height 2 Decreased neck rigidity 3 Increased fine-motor dexterity 4 Increased range of motion (ROM)
1
A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. 1 Ascites 2 Hunger 3 Pruritus 4 Jaundice 5 Headache
1, 3, 4
The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear
1, 3, 4
A client has received instructions to take 650 mg aspirin every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply. 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to acetaminophen if tinnitus occurs. 5 Report persistent abdominal pain.
1, 3, 5
A client with osteomyelitis has a slow rate of healing. Which factors can contribute to reduced healing in the client? Select all that apply. 1 Diabetes 2 Cataract 3 Smoking 4 Dermatitis 5 Alcoholism
1, 3, 5
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor
1, 4, 5
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.
A client with gastroesophageal reflux is to receive metoclopramide 15 mg orally before meals. The concentrated solution contains 10 mg/mL. How much solution should the nurse administer? Record your answer using one decimal place. _____ mL
1.5
A healthcare provider prescribes an intravenous (IV) infusion of ampicillin 375 mg every 6 hours. The drug is supplied as 500 mg of powder in a vial. The directions are to mix the powder with 1.8 mL of diluent, which yields 250 mg/mL. How much prepared solution should the nurse administer? Record your answer using one decimal place. ___ mL
1.5
A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile, because she has been trying to become pregnant unsuccessfully for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The primary healthcare provider diagnoses the condition polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important? 1 Consoling the client over her inability to have children 2 Discussing weight loss, exercise, and a balanced low-fat diet 3 Providing information to the client on how to prepare for surgery 4 Informing the client that there are no long-term complications of PCOS
2
A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to which factor? 1 Urate crystals in the synovial tissue 2 Inflammation in the joint's synovial lining 3 Formation of bony spurs on the joint surfaces 4 Deterioration and loss of articular cartilage joints
2
A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for what reaction? 1 Hypertensive crisis 2 Hypovolemic shock 3 Abdominal distention 4 Tenting of the integument
2
A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client? 1 Nausea 2 Blood in the stool 3 Food intolerances 4 Hourly urinary output
2
A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? 1 Observe the client for signs of respiratory distress. 2 Percuss the client's abdomen and listen for dull sounds. 3 Palpate the lower extremities over the tibia and observe for edema. 4 Listen for decreased or absent bowel sounds while auscultating the abdomen.
2
A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystostomy tube is in place."
2
A client reports an absence of menstruation to the nurse. Which condition does the nurse suspect? 1 Gonorrhea 2 Amenorrhea 3 Dysmenorrhea 4 Ectopic pregnancy
2
A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. What should the nurse assess for in this client? 1 Melena 2 Anal itching 3 Constipation 4 Ribbon-shaped stools
2
A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority? 1 Turn the client to the side-lying position. 2 Take the client's pedal pulse in the affected extremity. 3 Instruct the client to wiggle the toes of the right foot. 4 Ask the client if numbness or tingling is present in the right foot.
2
A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? 1 Increased secretion of bile salts 2 Increased pressure in the portal vein 3 Increased interstitial osmotic pressure 4 Increased production of serum albumin
2
A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. What should the nurse be prepared to administer? 1 A low-residue diet 2 Intravenous therapy 3 Total parenteral nutrition 4 An oral electrolyte solution
2
A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? 1 Drink a glass of milk before retiring. 2 Elevate the head of the bed on blocks. 3 Eliminate carbohydrates from the diet. 4 Take antacids, such as sodium bicarbonate.
2
A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? 1 Femoral pulse 2 Toes for mobility 3 Condition of the pin 4 Range of motion of the knee
2
A nurse is reviewing a newly admitted client's medication administration record (MAR). Which element, if missing, makes the record incomplete? 1 Height 2 Allergies 3 Vital signs 4 Body weight
2
A nurse is teaching a client about colostomy care. To be most effective when teaching colostomy care to a client, what should the nurse do first? 1 Wait until a family member is present 2 Assess barriers to learning colostomy care 3 Begin with simple written instructions concerning the care 4 Wait until the client has accepted the change in body image
2
A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary healthcare provider immediately if the client experiences which manifestation? 1 Slight stiffness of the fingers 2 Increasing pain at the injury site 3 Small amount of dark, bloody drainage on the cast 4 Bounding radial pulse in the affected extremity
2
According to the Centers for Disease Control and Prevention, compared to Caucasians, the syphilis rates among Hispanics are two times higher in 2011. What may be the reason for this? 1 Equitable access to health care support 2 Difference in the status of health literacy 3 Availability of health care facilities 4 Genetic predisposition in Hispanic patients
2
An 85-year-old client has a three-day history of nausea, vomiting, and diarrhea. The client develops weakness and confusion and is admitted to the hospital. To best monitor the client's rehydration status, what should the nurse assess? 1 Skin turgor 2 Daily weight 3 Urinary output 4 Mucous membranes
2
An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse considers that a comminuted fracture has what characteristics? 1 Bone protrudes through a break in the skin. 2 The bone has broken into several fragments, and the skin is intact. 3 The bone is broken into two parts, and the skin may or may not be broken. 4 Splintering has occurred on one side of the bone and bending on the other.
2
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1 Decreased blood supply 2 Impaired neural functioning 3 Perforation of the bowel wall 4 Obstruction of the bowel lumen
2
On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? 1 Assist the client to ambulate. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Encourage using the incentive spirometer.
2
The registered nurse is evaluating the actions of a nursing student who is providing emergency care to a client with an extremity fracture. Which action of the nursing student does the registered nurse think needs a correction? 1 Keeping the client warm 2 Removing the shoes of the client 3 Immobilizing the affected extremity 4 Allowing the client to lie in supine position
2
The x-ray report of a client shows the presence of greenstick fracture. What is greenstick fracture? 1. A fracture with more than two fragments 2. An incomplete fracture with one side bent 3. A spontaneous fracture at the site of bone disease 4. A fracture that extends across the longitudinal axis of the bone shaft
2
Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma? 1 Apply liberal amounts of Vaseline for 3 inches (7.6 centimeters) around the stoma 2 Wash the area with soap and water and then apply a protective ointment 3 Pour saline over the stoma and rub the area to remove hard fecal matter 4 Rinse the area with peroxide before applying fresh gauze bandages
2
Which clinical indicator should the nurse identify before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP)? 1 Urine output 2 Bilirubin level 3 Blood pressure 4 Serum glucose
2
Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? 1 Carelessness 2 Fragility of bone 3 Sedentary existence 4 Rheumatoid diseases
2
Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? 1 Calcium of 9.5 mg/dL (2.375 mmol/L) 2 Potassium of 7.02 mEq/L (7.02 mmol/L) 3 Bicarbonate of 22.8 mEq/L (22.8 mmol/L) 4 Phosphorus of 4.1 mg/dL (1.3243 mmol/L)
2
While caring for a female client, the nursing student feels tenderness and a lump in the client's breast. The nursing student tells the registered nurse, "I think this client has breast cancer." Which statements of the registered nurse would be appropriate in accordance with the knowing element of Swanson's theory? Select all that apply. 1 "Try to comfort the client." 2 "Avoid making assumptions." 3 "Assess the client thoroughly." 4 "Check for other signs of breast cancer." 5 "Try to provide support and care to the client."
2, 3, 4
A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. 1 Provide a low-fat diet 2 Administer analgesics 3 Teach relaxation exercises 4 Encourage walking in the hall 5 Monitor cardiac rate and rhythm 6 Observe for signs of hypercalcemia
2, 3, 5
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. 1 High protein diet 2 Low sodium diet 3 Daily abdominal girth measurements 4 Encourage increased by mouth fluid intake 5 Daily weights
2, 3, 5
The registered nurse is evaluating the actions of a nursing student who is providing care to a client with compartment syndrome. Which action of the nursing student does the registered nurse think needs correction? Select all that apply. 1 Bivalving the cast 2 Applying cold compresses 3 Loosening the bandage applied 4 Evaluating the client's level of pain 5 Elevating the extremity above heart level
2, 5
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which unique clinical indicator can help the nurse identify a fat embolus? 1 Anxiety 2 Restlessness 3 Pinpoint red spots on the chest 4 Decreased arterial oxygen level
3
A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? 1 Ripe bananas 2 Milk products 3 Green vegetables 4 Creamed potatoes
3
A client reports pain, weakness, and numbness in the neck, back, and shoulders after working long hours at a computer. Which condition will the nurse most likely observe in the client's electronic medical record? 1 Bursitis 2 Meniscus injury 3 Repetitive strain injury (RSI) 4 Carpal tunnel syndrome (CTS)
3
A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? 1 "Why did you sign the consent form originally?" 2 "I can understand why you changed your mind." 3 "Can you tell me your reasons for refusing the procedure?" 4 "You must be afraid about something concerning the procedure."
3
A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate? 1 Nasotracheal suction 2 Mechanical ventilation 3 Naloxone administration 4 Cardiopulmonary resuscitation
3
A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. How can the nurse best implement the plan? 1 Offering a firm-bristled toothbrush 2 Providing an antiseptic mouthwash 3 Using a gentle spray of normal saline 4 Swabbing the mouth with a moistened gauze square
3
A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? 1 Stimulation of the liver to produce an excess quantity of bile pigments 2 Inability of the liver to remove normal amounts of bilirubin from the blood 3 Increased destruction of red blood cells during the acute phase of the disease 4 Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
3
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
After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. Which is an expected outcome for this client? 1 Only when pain free, begin exercising as part of a formal activity program. 2 Avoid exercising when there is a moderate amount of discomfort. 3 Exercise and be active unless the discomfort becomes too great. 4 Walk and exercise even when the pain is severe.
3
An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the healthcare provider will most likely prescribe? 1 Increase intake of dietary roughage quickly 2 Avoid oral feedings for a prolonged period 3 Resume small, easily digested feedings gradually 4 Limit intake to self-selection of personally preferred foods
3
Before a client with syphilis can be treated, what should be determined? 1 Portal of entry 2 Size of chancre 3 Existence of allergies 4 Names of sexual contacts
3
Following surgery, a client asks the nurse to help with measuring intake and output. What is the best nursing response? 1 Determine the client's willingness to really help 2 Identify the client's reason for wanting to do this task 3 Assess the client's ability to measure the intake and output 4 Explain that measuring intake and output is the responsibility of the nurse
3
The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? 1 Acute gastritis 2 Diabetes mellitus 3 Partial gastrectomy 4 Unhealthy dietary habits
3
The nurse is caring for a client who had surgery for a total hip replacement. Which action by the unlicensed assistive personnel (UAP) (continuing care assistant [CCA]) will cause the nurse to follow up? 1 Places the client in supine position 2 Places the client in lateral position 3 Places the client in orthopneic position 4 Places the client in semi-Fowler position
3
A 76-year-old male client asks the nurse about the chances of getting osteoporosis like his wife. Which is the best response by the nurse? 1 "This is only a problem for women." 2 "Exercise is a good way to prevent this problem." 3 "You are not at risk because of your small frame." 4 "You might think about having a bone density test."
4
A client has a colostomy after surgery for cancer of the colon. Which postoperative nursing intervention maximizes skin integrity? 1 Empty the colostomy bag when it is three fourths full 2 Allow one half inch between the stoma and the appliance 3 Help the client to remove the appliance on the first postoperative day 4 Apply stoma adhesive around the stoma and then attach the appliance
4
A client in a debilitated state is admitted for palliative treatment following a terminal diagnosis of liver cancer. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition? 1 Description of the client's pain 2 Assessment of hunger 3 Inspection of bowel patterns 4 Record of daily weights
4
A client is diagnosed with condyloma acuminatum. Which finding in the client supports the diagnosis? 1 Macules on the penis 2 Pus-filled ulcers on the penis 3 Swollen penis with tight foreskin 4 Moist, fleshy projections on the penis
4
A client who had a severe weight loss is told the importance of eating more protein to provide the essential amino acids. The client asks the nurse why these substances in protein foods are "essential." How should the nurse respond? 1 "They will give you the added energy you need." 2 "They contain the necessary nitrogen you need for healing." 3 "They are essential for rebuilding your body tissue protein." 4 "They must come from your food because your body cannot make them."
4
A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, when does the nurse advise the client to take the prescribed as-needed oxycodone? 1 Just as a last resort 2 Before going to sleep 3 As the pain becomes intense 4 When the discomfort begins
4
A client who recently immigrated to the United States (Canada) has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1 Vitamin A is an integral part of the retina's pigment called melanin. 2 It is a component of the rods and cones, which control color visualization. 3 Vitamin A is the material in the cornea that prevents the formation of cataracts. 4 It is a necessary element of rhodopsin, which controls responses to light and dark environments.
4
A client who was admitted with severe abdominal pain and vomiting states, "I know I am very sick. Do you think I have cancer?" What is the best response by the nurse? 1 "You must be upset to think that you have cancer." 2 "Did you receive information about what therapy will be prescribed?" 3 "Your primary healthcare provider will need to talk with you about that." 4 "What are your feelings about the diagnosis of cancer?"
4
A client with a fractured head of the right femur and osteoporosis is placed in Buck extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1 Remove the weights from the traction every 2 hours to promote comfort. 2 Turn the client from side to side every 2 hours to prevent pressure on the coccyx. 3 Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction. 4 Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.
4
A client with a history of food intolerance has abdominal pain, abdominal distention, and a feeling of fullness. The client is admitted to the hospital for diagnostic testing. What specific information should the nurse collect when performing the nursing admission history and physical? 1 Client's food preferences 2 Presence of clay-colored stools 3 Amount of splinting by the client 4 Detailed characteristics of the pain
4
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? 1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy 4 Limited water reabsorption caused by removal of intestine
4
A nurse in the women's health clinic is counseling clients about the signs of gynecologic problems. Teaching by the nurse would be deemed effective if the clients stated that which early manifestation of cervical cancer should prompt them to seek professional care? 1 Abdominal heaviness 2 Pressure on the bladder 3 Foul-smelling discharge 4 Bloody spotting after intercourse
4
A nurse is caring for a client who underwent a cervical biopsy. The nurse finds that the client has a body temperature of 100° F, increased abdominal pain, and increased drainage that is foul-smelling. Which action is priority? 1 Administer analgesics to the client 2 Place the client in the lithotomy position 3 Ask the client to douche the perineal area 4 Report the client's condition to the primary healthcare provider
4
A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? 1 Tingling of the fingertips and toes 2 Dry and sticky mucous membranes 3 Abdominal cramping and irritability 4 Muscle weakness and cardiac dysrhythmias
4
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
Discharge teaching for a client with hypercholesterolemia includes nutritional instructions for a diet low in saturated fat. Which items included by the client on a list of foods to avoid support the nurse's conclusion that teaching is effective? 1 High-fiber foods 2 Canned vegetables 3 Citrus fruits and juices 4 Whole milk and hard cheeses
4
For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? 1 Liver abscess 2 Intestinal obstruction 3 Perforation of the duodenum 4 Hemorrhage from esophageal varices
4
The healthcare provider prescribes finasteride for a client with benign prostatic hyperplasia. What information does the nurse provide to the client? 1 Male pattern baldness can occur. 2 Results can be expected in 4 to 6 weeks. 3 The medication relaxes the muscles in the bladder neck, making it easier to urinate. 4 Protection should be worn during intercourse with a pregnant female.
4
The nurse instructs the client with a new colostomy to avoid foods and drinks and produce large amount of gas, specifically to avoid the intake of what? 1. Milk 2. Cheese 3. Coffee 4. Cabbage
4
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? 1 Oxygen therapy 2 Cardiac monitoring 3 Nutrition supplements 4 Venous thromboembolism (VTE) prevention
4
The nurse prepares a client for a Papanicolaou test (Pap test). What should the nurse instruct the client before conducting the test? 1 Empty the bladder 2 Douche the vagina with soap 3 Avoid scheduling a Pap test to be performed during menses 4 Avoid sexual intercourse for at least 24 hours before the test
4
Which condition should be reported immediately to the primary healthcare provider? 1 Pelvic pain immediately after colposcopy 2 Light vaginal bleeding for 1 to 2 days following a hysterosalpingogram 3 Rectal bleeding for 2 days after prostate biopsy 4 Body temperature of 102° F with vaginal discharge 48 hours after cervical biopsy
4
A nurse is caring for a client after a total knee replacement who is requesting hydrocodone/acetaminophen in addition to the patient-controlled analgesia (PCA). The client reports having taken two hydrocodone/acetaminophen tablets every 4 hours for several weeks before surgery. If each tablet contains 500 mg of acetaminophen, how much acetaminophen had the client been ingesting per day? Record your answer using a whole number with no punctuation. ___ mg
6,000
Which dietary selection by the client leads the nurse to determine that teaching about a low-residue diet is understood? a. Baked fish, macaroni with cheese, strained carrots, fruit gelatin, milk b. Stewed chicken, baked potato with butter, peas, white bread, plain cake, milk c. Lean roast beef, buttered white rice with egg slices, white bread with jelly, tea with sugar d. Creamed soup with crackers, omelet, mashed potatoes, bran muffin, orange juice, coffee with milk
c
