Med Surg Exam Final Study Guide
The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventative actions should the nurse recommend? Select all that apply. Select one or more: a.Regular exercise b.Calcium and vitamin D supplementation c.Weight loss d.Smoking cessation e.High-protein diet
A C D
An emergency department nurse is preparing to inspect and palpate the head and scalp of an older adult who experienced a fall. A member of which group would most likely consider this examination as a violation of norms? Select one: a.Jewish b.Asian c.African d.Islamic
B
Convert the following temperature as indicated. 18° C = _____ ° F (round to nearest tenth) Select one: a. 65.4 F b. 64.4 F c. 32.0 F d. 103.0F
B
The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. This pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address what health problem? Select one: a.Intermittent claudication b.Coronary artery disease (CAD) c.Arterial embolus d.Raynaud disease
A
The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? Select one: a.Hemorrhage b.Difficulty ambulating c.Infrequent swallowing d.Bradycardia
A
The school nurse is working with a female high school junior whose BMI is 31. When planning this girl's care, the nurse should identify what goal? Select one: a.Increase in exercise and reduction in calorie intake b.Continuation of current diet and activity level c.Possible referral to an eating disorder clinic d.Increase in daily calorie intake
A
Write the equivalent indicated. 1 kg = _____ lb Select one: a. 2.2 b. 2.0 c. 2.1 d. 0.22
A
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? Select one: a.Arterial blood gas (ABG) measurement b.Incentive spirometry c.Pulse oximetry d.Peak flow measurement
A C
A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. Select one or more: a.Chest tightness b.Bradypnea c.Wheezing d.Cough e.Crackles
A C D
A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response? Select one: a."A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." b."You have no need to worry. Your pressure is probably elevated because you are being tested." c."Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." d."We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."
A
A client has a newly diagnosed heart murmur. During the nurse's subsequent health education, he asks if he can listen to it. What would be the nurse's best response? Select one: a."If you would like to listen to your murmur, I'd be glad to help you and to show you how to use a stethoscope." b."Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur." c."Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction." d."Listening is called palpation, and I would be glad to help you to palpate your murmur."
A
A community health nurse has scheduled a hypertension clinic in a local shopping mall in which shoppers have the opportunity to have their blood pressure measured and learn about hypertension. This nursing activity would be an example of which type of prevention activity? Select one: a.Secondary prevention b.Disease prevention c.Primary prevention d.Tertiary prevention
A
A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns? Select one: a."It's been found that using computers improves our clients' care and improve communication." b."You'll find that all the hospitals are doing this now, and that writing information with a pen is rare." c."We have found that it is easier to keep track of our clients' information this way rather than with pen and paper." d."The government is telling us we have to do this, even though most people, like yourselves, are opposed to it."
A
A hospice nurse is caring for a client who is dying of lymphoma. According to Maslow hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying client? Select one: a.Physiologic b.Emotional c.Social d.Spiritual
A
A nurse is conducting a health assessment of an adult client when the client asks, "Why do you need all this health information and who is going to see it?" What is the nurse's best response? Select one: a."It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place." b."Your health information is placed on secure websites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care." c."Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over." d."Please do not worry. It is safe and will be used only to help us with your care. It's accessible to a wide variety of people who are interested in your health."
A
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital? Select one: a.A physical assessment in the community consists of largely the same techniques as are used in the hospital. b.A physical assessment made in the community requires that the client be made more comfortable than would be necessary in the hospital setting. c.A physical assessment made in the community does not require the privacy that a physical assessment made in the hospital setting requires. d.A physical assessment made in the community varies in technique from that conducted in the hospital setting by being less structured.
A
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of what health problem? Select one: a.Peripheral arterial occlusive disease (PAD) b.Chronic venous insufficiency c.Raynaud phenomenon d.Venous thromboembolism
A
During a health assessment of an older adult with multiple chronic health problems, the nurse is utilizing multiple assessment techniques, including percussion. What is the essential principle of percussion? Select one: a.To create vibration in a body wall b.To create sound over dead spaces in the body c.To assess the sound created by the body d.To strike the abdominal wall with a soft object
A
Professor Marsh was recently diagnosed with Asthma. Professor has been experiencing intermittent symptoms of asthma 2-3 times per week but not daily. Based on your nursing assessment, what category/zone would best describe his asthma? Select one: a.Mild Intermittent b.Severe Persistent c.Moderate Persistent d.Mild Persistent
A
The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? Select one: a."A PFT measures how much air moves in and out of your lungs when you breathe." b."A PFT measures how much energy you get from the oxygen you breathe." c."A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood." d."A PFT measures how elastic your lungs are."
A
The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her pain management? Select one: a.There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug. b.The dose range is higher with cancer clients, and the medical team will be very careful to prevent addiction. c.The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. d.Frequently, female clients and younger clients need higher doses of opioids to be comfortable.
A
The nurse caring for an older adult client with osteoarthritis is reviewing the client's chart. This client is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this client? Select one: a.Drug interactions b.Inadequate pain control c.Depression d.Chronic illness
A
The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? Select one: a.A barrel chest b.Chronic chest pain c.Long, thin fingers d.Signs of oxygen toxicity
A
The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? Select one: a.Lipids and fibrous tissue b.Lipoproteins c.White blood cells d.High-density cholesterol
A
The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain? Select one: a.Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain. b.Use the services of a translator each time you assess the client so you can document the client's pain rating. c.Ask the client to write down a number according to the 0-to-10 point pain scale. d.Use the Visual Analog Scale (VAS).
A
The nurse is preparing a discharge teaching session with an Asian client to evaluate the client's ability to change a dressing. The client speaks and understands minimal English. What would be the best way to promote understanding during the teaching session? Select one: a.Use an interpreter during the teaching session b.Ask the client to repeat the instructions carefully c.Write the procedure out for the client in simple language d.Have the client demonstrate the dressing change
A
The nurse is preparing to administer warfarin to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the client's warfarin is at therapeutic levels? Select one: a.International normalized ratio (INR) between 2 and 3 b.Partial thromboplastin time (PTT) within normal reference range c.Prothrombin time (PT) 8 to 10 times the control d.Hematocrit of 32%
A
The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain? Select one: a.The elderly may require lower doses of medication and are easily confused with new medications. b.The elderly may require a higher initial dose of pain medication followed by a tapered dose. c.The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. d.The elderly may have altered absorption and metabolism, which prohibits the use of opioids.
A
The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal? Select one: a.Less than 120/80 mm Hg b.Less than 140/90 mm Hg c.Less than 129/89 mm Hg d.Less than 130/90 mm Hg
A
Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing? Select all that apply. Select one or more: a.Ensuring privacy and confidentiality of genetic information b.Notifying individuals and family members of the results of genetic testing c.Assessing and analyzing family history data for genetic risk factors d.Providing a written report on genetic testing to an insurance company e.Identifying individuals and families in need of referral for genetic testing
A C E
Professor Lilly has a chronic history of asthma and was recently started on a new LABA inhaler. She is reporting you that she has been experiencing daily symptoms and asthma exacerbations 2-3 times per week. Based on your assessment, which would be categorize Professor Lilly's asthma? Select one: a.Severe Persistent b.Moderate Persistent c.Mild Persistent d.Mild Intermittent
B
The emergency department (ED) nurse is caring for an adult client who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain is the nurse addressing with this client? Select one: a.Osteopenic b.Acute c.Chronic d.Intermittent
B
The future of transcultural nursing care lies in finding ways to promote cultural competence in nursing students. How can this goal be best accomplished? Select one: a.By requiring students to care primarily for clients from other ethnic groups b.By offering multicultural health studies in nursing curricula c.By screening applicants according to their cultural competence d.By enhancing the content of community nursing classes
B
The home health nurse is developing a plan of care for a client who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the client teaching? Select one: a.Dependence and health b.Self-care and safety c.Autonomy and need d.Health promotion and exercise
B
A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? Select one: a.Laryngeal cancer b.Obstructive sleep apnea c.Adenoiditis d.Chronic tonsillitis
B
A client was diagnosed with rheumatoid arthritis one year ago, but has achieved adequate symptom control with Ibuprofen-NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? Select one: a.Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord b.Inhibiting transduction by blocking the formation of prostaglandins in the periphery c.Blocking modulation by limiting the reuptake of serotonin and norepinephrine d.Distorting the action potential that is transmitted along the A-delta (δ) and C fibers
B
A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Select one: a.Non-rebreather air mask b.Venturi mask c.Tracheostomy collar d.Face tent
B
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize? Select one: a.Increasing fluids to maintain BP b.Rising slowly from a lying or sitting position c.Taking medication first thing in the morning d.Stopping medication if dizziness persists
B
A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension: Select one: a.has a more gradual onset than primary hypertension. b.has a specific cause. c.does not normally cause target organ damage. d.does not normally respond to antihypertensive drug therapy.
B
A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? Select one: a.Drowsiness or lethargy b.Increased urine output c.Decreased heart rate d.Mild agitation
B
A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? Select one: a.Gradually increase levels of physical exertion b.Take prescribed medications as scheduled c.Change filters on heaters and air conditioners frequently d.Avoid goose-down pillows
B
A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize that which of the following medications is incompatible with warfarin? Select one: a.Vitamin A b.Vitamin K c.Alprazolam d.Furosemide
B
A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effects should the nurse be sure to address in client teaching? Select one: a.Nausea and vomiting b.Thrush c.Temporarily increased respiratory secretions d.Decreased level of consciousness
B
A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? Select one: a.The client should be preliminarily screened for surgery. b.Symptom management is the main focus of medical and nursing care. c.The focus of care is resting the voice to prevent chronic hoarseness. d.Teaching focuses on safe and effective use of antibiotics.
B
A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? Select one: a.Administer inhaled anticholinergics b.Administer an inhaled beta-adrenergic agonist c.Utilize a peak flow monitoring device d.Administer corticosteroids by metered dose inhaler
B
An elderly client is admitted with a diagnosis of community-acquired pneumonia. During admission the client states, "I have a living will." What implication of this should the nurse recognize? Select one: a.This document is binding for the duration of the client's life. b.This document specifies the client's wishes before hospitalization. c.This document is always honored, regardless of circumstances. d.This document has been drawn up by the client's family to determine DNR status.
B
The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures? Select one: a.Do a complete assessment, and give pain medication based on the client's report of pain. b.Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged. c.Use a pain scale to assess the client's pain, and let the client know ibuprofen is available every 6 hours if she needs it. d.Provide medication as per client request and offer relaxation techniques to promote comfort
B
The nurse is assessing a client new to the clinic. Records brought to the clinic show that the client's hypertension has not improved. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? Select one: a.Possibility of medication interactions b.Lack of adherence to prescribed drug therapy c.Progressive target organ damage d.Possible heavy alcohol use or use of recreational drugs
B
The nurse is beginning a shift on a medical unit and is performing assessments appropriate to each client's diagnosis and history. When assessing a client who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the client's neck? Select one: a.Inspection b.Palpation c.Percussion d.Auscultation
B
The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Select one: a.Bronchoscopy b.Incentive spirometry c.Intermittent positive-pressure breathing (IPPB) d.Positive end-expiratory pressure (PEEP)
B
The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs? Select one: a.Simple mask b.Nasal cannula c.Partial-rebreathing mask d.Non-rebreathing mask
B
The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax? Select one: a.Sudden loss of consciousness b.Diminished or absent breath sounds on the affected side c.Paradoxical chest wall movement with respirations d.Muffled heart sounds
B
The nurse is conducting an assessment of a client in her home setting. Your client is a 91-year-old woman who lives alone and has no family members living close by. What should the nurse be aware of to aid in providing care to this client? Select one: a.What the client's financial status is b.What resources are available to the client c.How many children this client has d.Where the closest relative lives
B
The nurse is creating a nursing care plan for a client with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of clients who live with chronic pain should be integrated into care planning? Select one: a.They often have an increased tolerance of pain. b.They can experience acute pain in addition to chronic pain. c.They are typically more comfortable with underlying pain than clients without chronic pain. d.They often have a lower pain threshold than clients without chronic pain.
B
The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? Select one: a.Reddened extremities with muscle atrophy b.Unequal peripheral pulses between extremities c.Numbness and tingling in the distal extremities d.Visible clubbing of the fingers and toes
B
The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The client is 34 weeks' gestation and does not want this procedure but the physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle? Select one: a.Nonmaleficence b.Autonomy c.Veracity d.Beneficence
B
Two clients have recently returned to the postsurgical unit after knee arthroplasty. One client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the clients' different perceptions of pain? Select one: a.One of the clients is exaggerating their sense of pain. b.Endorphin levels may vary between clients, affecting the perception of pain. c.One of the clients may be experiencing opioid tolerance. d.The clients are likely experiencing a variance in vasoconstriction.
B
While assessing a client the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment finding? Select one: a.Encourage the client to increase intake of foods high in vitamin K b.Implement interventions relevant to arterial narrowing c.Assess the client's use of over-the-counter dietary supplements d.Adjust the client's activity level to accommodate decreased coronary output
B
A client with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities? Select one: a.Perform passive range-of-motion exercises once per shift b.Closely monitor the client's serum albumin and prealbumin levels c.Ensure that the client's heels are protected and supported d.Perform gentle massage of the client's lower legs, as tolerated
C
A client is asking for a breakthrough dose of analgesia. The pain-medication prescriptions are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? Select one: a.To eliminate the potentially adverse effects of the opioid b.To eliminate the need for additional medication during the night c.To achieve better pain control than with one medication alone d.To prevent respiratory depression from the opioid
C
A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? Select one: a.Hypertensive emergency b.Glaucoma c.Retinal blood vessel damage d.Cranial nerve damage
C
A client's intractable neuropathic pain is being treated using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the client, the nurse has returned to assess the client and finds the client unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? Select one: a.Celecoxib b.Acetylcysteine c.Naloxone d.Acetylsalicylic acid
C
A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Select one: a.Lie in a low Fowler or supine position. b.Increase activity. c.Increase oral fluids unless contraindicated. d.Call the nurse for oral suctioning, as needed.
C
A home health nurse has been assigned to the care of an 82-year-old woman who has been discharged home following hip replacement surgery. At what level of care is this nurse most likely practicing? Select one: a.Primary prevention b.Secondary prevention c.Tertiary prevention d.Preventative care
C
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the client reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this client? Select one: a.The likelihood that heavy alcohol intake is a significant risk factor for PAD. b.The lack of exercise, which is the main cause of PAD. c.Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. d.Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
C
A nurse is assessing a new client who is diagnosed with PAD. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment? Select one: a.Apply a tourniquet for 3 to 5 minutes and then reassess b.Have the primary provider prescribe a CT c.Use Doppler ultrasound to identify the pulses d.Elevate the extremity and attempt to palpate the pulses
C
A nurse is leading a community health clinic. What should the nurse emphasize in order to promote disease prevention? Select one: a.It is best achieved by reducing psychological stress. b.It is best achieved by being an active participant in the community. c.It is best achieved by exhibiting behaviors that promote health. d.It is best achieved through attending self-help groups.
C
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the client has a BMI of 45. What does this indicate? Select one: a.The client is of normal weight. b.The client is mildly obese. c.The client is extremely obese. d.The client is overweight.
C
During discussion with the client and the client's husband, the nurse discovers that the client has a living will. How does the presence of a living will influence the client's care? Select one: a.The client is legally unable to refuse basic life support. b.Power of attorney may change while the client is hospitalized. c.The client may nullify the living will during her hospitalization if she chooses to do so. d.The physician can override the client's desires for treatment if desires are not evidence based.
C
Personal space and distance are culturally dependent and can impact nurse-client interactions significantly. What is the best way for the nurse to interact with a client who has a different cultural perspective on space and distance? Select one: a.Realize that sitting close to the client is an indication of warmth and caring b.Position yourself 10 to 12 ft from the client to accommodate the most common cultural preferences c.Allow the client to adopt a position that is comfortable for him or her d.Remember not to intrude into the personal space of the elderly
C
The "eight rights" of medication administration are: Select one: a. RIGHT: medication, solution, doctor, shift, time, documentation, patient, response b. medication, client, dose, time, unit, documentation, reason, assessment. c. RIGHT: client, medication, dosage, route, time, documentation, reason, response d. RIGHT: medication, order, signature, time, route, documentation, response
C
The nurse is admitting a client who is a recent immigrant from China and who has a diagnosis of adenocarcinoma. During the client's admission assessment, the client speaks of her beliefs related to health care and indirectly references the yin/yang theory. Based on her cancer diagnosis and her yin/yang beliefs, which meal will the client most likely order for lunch? Select one: a.Chef's salad, bread, and water b.Fruit smoothie and granola bar c.Chicken noodle soup with crackers, fruit crisp, and hot tea d.Turkey sandwich, small tossed salad, and iced tea
C
The nurse is caring for an acutely ill client who is on anticoagulant therapy. The client has a comorbidity of renal insufficiency. How will this client's renal status affect heparin therapy? Select one: a.Heparin may be given subcutaneously, but not IV. b.Warfarin will be substituted for heparin. c.Lower doses of heparin are required for this client. d.Heparin is contraindicated in the treatment of this client.
C
The nurse is performing a dietary assessment with a client who has been admitted to the medical unit with community-acquired pneumonia. The client wants to know why the hospital needs all this information about the way he eats, asking you, "Are you asking me all these questions because I am Middle Eastern?" What is the nurse's best response to this client? Select one: a."We always try to abide by foreign-born clients' dietary preferences in order to make them comfortable." b."We wouldn't want to feed you anything you only eat on certain holidays." c."We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these." d."We know that clients who grew up in other countries often have unusual diets, and we want to accommodate this."
C
The nurse is preparing to suction a client with an endotracheal tube. What should be the nurse's first step in the suctioning process? Select one: a.Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask. b.Explain the suctioning procedure to the client and reposition the client. c.Assess the client's lung sounds and SaO2 via pulse oximeter. d.Turn on suction source.
C
The nurse is teaching a client with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this client about preventing possible drug interactions? Select one: a.Consult the internet before selecting an OTC medication. b.Use only one pharmacy so the pharmacist can check drug interactions. c.Read drug labels carefully before taking OTC medications. d.Prescription medications can be safely supplemented with OTC medications.
C
The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this client? Select one: a.The client will likely benefit more from distraction than pharmacologic interventions. b.It is difficult to control chronic pain, so this is an inevitable part of the disease process. c.Medication should be taken when pain levels are low so the pain is easier to reduce. d.Pain medication can be increased when the pain becomes intense.
C
When assessing venous disease in a client's lower extremities, the nurse knows that what test will most likely be prescribed? Select one: a.Radiography b.Echocardiography c.Duplex ultrasonography d.Positron emission tomography (PET)
C
A client has been brought to the ED by the paramedics. The client is suspected of having acute respiratory distress syndrome (ARDS). What intervention should the nurse first anticipate? Select one: a.Setting up oxygen at 5 L/minute by nasal cannula b.Performing deep suctioning c.Setting up a nebulizer to administer corticosteroids d.Preparing to assist with intubating the client
D
A client has been diagnosed as being prehypertensive. What should the nurse encourage this client to do to aid in preventing a progression to a hypertensive state? Select one: a.Avoid excessive potassium intake b.Eat less protein and more vegetables c.Limit morning activity d.Exercise on a regular basis
D
A client has been diagnosed with small cell lung cancer. The client has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy. This client is demonstrating which ethical principle in making his decision? Select one: a.Justice b.Confidentiality c.Beneficence d.Autonomy
D
A client is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the client's prescriptions specify an initial bolus dose. What is the nurse's priority assessment? Select one: a.Assessment for paradoxical increase in pain b.Assessment for decreased level of consciousness (LOC) c.Assessment for fluid overload d.Assessment for respiratory depression
D
A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action? Select one: a.Perform postural drainage. b.Apply a cold pack to the affected area. c.Apply heat to the forehead. d.Increase fluid intake.
D
A client with migraines does not know whether she is receiving a placebo for pain management or the new drug that is undergoing clinical trials. After discussing the client's distress, it becomes evident to the nurse that the client did not fully understand the informed consent document that she signed. Which ethical principle is most likely involved in this situation? Select one: a.Confidentiality b.Sanctity of life c.Fidelity d.Veracity
D
A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? Select one: a.Determining whether the incident was managed effectively b.Determining if individuals responded appropriately during the incident c.Educating survivors on potential coping strategies for future disasters d.Providing individuals with education about recognizing stress reactions
D
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Select one: a.Administration of prophylactic antibiotics b.Obtaining culture and sensitivity swabs from all newly admitted clients c.Administration of antiretroviral medications to clients over age 65 d.Administration of pneumococcal vaccine to vulnerable individuals
D
A medical nurse has obtained a new client's health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the client. Which of the following is the most important rationale for documenting the client's care? Select one: a.It verifies appropriate staffing levels. b.It creates a teaching log for the family. c.It keeps the client fully informed. d.It provides continuity of care.
D
A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)? Select one: a.5 mm induration b.4 mm erythema c.10 mm wheal d.15 mm induration
D
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? Select one: a.Administer an inhaled glucocorticoid. b.Obtain a peak flow reading. c.Determine the cause of the acute exacerbation. d.Administer a short-acting ß2 -agonist (SABA).
D
A nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the client's aneurysm? Select one: a.New onset of hemoptysis b.Sudden increase in blood pressure and a decrease in heart rate c.Cessation of pulsating in an aneurysm that has previously been pulsating visibly d.Sudden onset of severe back or abdominal pain
D
A nurse is teaching a client how to perform flow type incentive spirometry prior to scheduled thoracic surgery. What instruction should the nurse provide to the client? Select one: a."When you're ready, blow hard into the spirometer for as long as you can." b."Hold the spirometer at your lips and breathe in and out like you normally would." c."Take a deep breath and then blow short, forceful breaths into the spirometer." d."Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
D
An adult client has requested a "do not resuscitate" (DNR) order in light of his recent diagnosis with late-stage pancreatic cancer. The client's son and daughter-in-law are strongly opposed to the client's request. What is the primary responsibility of the nurse in this situation? Select one: a.Temporarily withhold nursing care until the physician talks to the family b.Perform a "slow code" until a decision is made c.Contact a social worker or mediator to intervene d.Honor the request of the client
D
An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize? Select one: a.The need to work closely with the occupational and physical therapists b.The fact that TB is self-limiting, but can take up to 2 years to resolve c.The fact that the disease is a lifelong, chronic condition that will affect ADLs d.The importance of adhering closely to the prescribed medication regimen
D
An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients? Select one: a.Teaching clients to utilize alternative therapies in asthma management b.Ensuring that clients keep their immunizations up to date c.Encouraging clients to carry a corticosteroid rescue inhaler at all times d.Educating clients about recognizing and avoiding asthma triggers
D
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation? Select one: a.Pancreas b.Gall bladder c.Intestines d.Thyroid gland
D
The home health nurse is caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the client at your visit today. The family members will be taking care of the client. What would your priority nursing interventions be for this visit? Select one: a.Provide psychosocial family support during this emotional experience. b.Teach the family the theory of pain management and the use of alternative therapies. c.Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance. d.Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication.
D
The nurse has just taken report for the shift and is performing the initial assessments of clients. One of the clients asks if an error has been made in her medication. The nurse knows that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the client's antibiotic. Which of the following principles would apply when the nurse gives an accurate response? Select one: a.Confidentiality b.Respect c.Justice d.Veracity
D
The nurse is caring for a client who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the client is hypoxemic? By monitoring the client's: Select one: a.hemoglobin, hematocrit, and red blood cell levels. b.extremities for signs of cyanosis. c.level of consciousness (LOC). d.oxygen saturation level.
D
The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status? Select one: a.The client's serum glucose level b.The client's understanding of pain physiology c.The client's white blood cell count d.The client's rating of her pain
D
The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? Select one: a.Administer prophylactic antibiotics. b.Perform soap and water decontamination. c.Survey the victims using a radiation survey meter. d.Irrigate victims' open wounds.
c