Med Surg: Final review PREPU: ODD

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A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: 1 instruct the client to drink at least 2 L of fluid daily. 2 maintain the client on bed rest. 3 administer anxiolytics, as ordered, to control anxiety. 4 administer pain medication as ordered.

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? 1- Allows for the nurse to facilitate the grieving process 2- Allows for the nurse to take the client through in the appropriate order 3- Allows for the nurse to understand when the grieving process should be concluded 4- Allows the nurse to express his or her feelings

The statements below reflect interventions to address a person's needs. Arrange each need based on Maslow's hierarchy from most basic to highest level. 1 Providing nasogastric tube feedings 2 Explaining a new procedure 4 Encouraging a patient to start a hobby that he or she has always wanted to try 3 Referring a patient to a cancer support group

1,2,3,4

A client with a terminal illness has feelings of rage toward the nurse. According to Kubler-Ross, the client is in which stage of dying? 1- Denial 2- Anger 3- Bargaining 4- Depression

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks? 1- Preparing the patient for a septoplasty 2- Applying nasal packing 3- Administering nasal lavage 4- Applying steroidal nasal spray

After teaching nursing students about the health-illness continuum, the instructor determines that teaching was successful when the students state which of the following? 1- "A patient's care must be focused on treating the disease." 2- "A person can be both healthy and ill at the same time." 3- "A patient with a disease typically falls on the far end of the continuum." 4- "A patient with a chronic illness is considered ill."

According to Maslow's hierarchy of human needs, which of the following is the highest level of need(s)? 1- Safety and security 2- Physiological needs 3- Self-actualization 4- Sense of belonging

Which of the following does not coincide with Kübler-Ross's stages related to a dying client? 1- Clients don't always follow the stages in order. 2- Some client regress, then move forward again. 3- The dying client usually exhibits anger first. 4- The client may be in several stages at once.

Which is a sign of approaching death? 1- Increase in urinary output 2- Clear sensorium 3- Insomnia 4- Irregular breathing patterns

During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate? A "I would make arrangements to have all your children present for the death vigil." B "Make sure you have made previous arrangements with the funeral home for burial arrangements." C "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." D "Have you thought about what you will do when you find your spouse after he has died?"

A nurse is aware that crackles, non-contiguous breath sounds, are assessed for a patient with: 1- Asthma 2- Chronic bronchitis 3- A collapsed alveoli 4- Pulmonary fibrosis

Based on Maslow's hierarchy of needs, when prioritizing a patient's plan of care, what would be the nurse's first priority? 1- Allowing the family to see a newly admitted patient 2- Ambulating the patient in the hallway 3- Administering pain medication 4- Teaching the patient to self-administer insulin

The nurse is using a teaching plan with a client. When will the implementation phase of the teaching-learning process end? A upon starting the written teaching plan B when teaching strategies have been completed C when the extent to which goals have been achieved has been documented D upon documentation of the teaching plan

According to Maslow's hierarchy of needs, which of the following is the lowest-level need? 1- Physiological needs 2- Safety and security 3- Sense of belonging and affection' 4- Esteem and self-respect

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound? 1- Count the sponges. 2- Label the tissue specimen. 3- Prepare the necessary sutures. 4- Hand equipment to the surgeon as needed.

Which of the following is a leading cause of chronic obstructive pulmonary disease (COPD) exacerbation? 1 Bronchitis 2 Pneumonia 3 Common cold 4 Asthma

A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need?1- Esteem and self-respect 2- Safety and security 3- Physiologic needs 4- Belongingness and affection

An occupational nurse is working with patients at a construction site. According to Maslow's Hierarchy of Needs, what dimension of care should the nurse make the highest priority in working with these clients? 1- Spiritual 2- Esteem 3- Physiologic 4- Safety

The nurse caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia would assess for the most common early sign of: 1- Hypertension (BP >130/90). 2- Tachypnea (>35 breaths/min). 3- Oliguria (urinary output <400 mL/day). 4- Tachycardia (HR >150 bpm).

A client who has no health insurance asks if there is any chance that they will benefit from healthcare reform. What should the nurse tell the client about the goal of the Patient Protection and Affordable Care Act? 1- The goal of the Patient Protection and Affordable Care Act is to provide affordable healthcare to U.S. citizens who previously had no access to health insurance .2- The Patient Protection and Affordable Care Act applies only to people who are eligible for Medicaid, so it will not apply to the client's situation. 3- The Patient Protection and Affordable Care Act applies only to people who are eligible for Medicare, so it will not apply to the client's situation. 4- The goal of the Patient Protection and Affordable Care Act is to provide affordable healthcare to U.S. citizens who have at least three dependents.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? 1- The client is displaying early signs of shock. 2- The client is showing signs of a medication reaction. 3- The client is displaying late signs of shock. 4- The client is showing signs of an anesthesia reaction.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? 1- Circulating nurse 2- Scrub nurse 3- Surgeon 4- Registered nurse first assistant

According to Maslow, which category of needs represents the most basic on the hierarchy? 1- Physiologic needs 2- Self-actualization 3- Safety and security 4- Sense of belonging

An emergency department (ED) nurse is assessing a 20-year-old gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. What should the ED nurse suspect? 1- Fracture of the cribriform plate 2- Potential loss of consciousness 3- Abrasion of the soft tissue 4- Fracture of the nasal septum

As a circulating nurse, what task are you solely responsible for? 1- Keeping records. 2- Estimating the client's blood loss. 3- Handing instruments to the surgeon. 4- Counting sponges and needles.

Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following? 1- Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups 2- Nursing care directed to specific client groups with identified needs, usually related to illness 3- Provision of primary care services, often with care being provided to underserved populations 4- Nursing care of clients with complex needs who are discharged from acute care institutions early in the recovery process

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? 1- Encourage the family members to express their feelings and listen to them in their frank communication. 2- Encourage conversations about the impending death of the client. 3- Be a silent observer and allow the client to communicate with the family members. 4- Encourage the client's family members to spend time with the client.

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? 1- Avoid sports activities for 6 weeks. 2- Decrease the amount of daily fluids. 3- Take aspirin for nasal discomfort. 4- Administer normal saline nasal drops as ordered.

Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening? 1- Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles 2- Pulse 72 beats/minute, irregular; client confused and agitated 3- Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor 4- Pulse 60 beats/minute, blood pressure 90/42mm Hg, difficult to arouse

After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options. 1 Alter smooth muscle tone 2 Reduce airway obstruction 3 Decrease alveolar ventilation 4 Increase oxygen distribution

1, 2, 4

The sounds of breathing, including terminal bubbling, at the time of death may be distressing for families to hear. When the nurse hears these sounds, she should do which of the following? Select all that apply. 1- Reposition the patient in an attempt to move secretions out of the oropharynx. 2- Educate the family about what they are hearing and that the sound does not mean that the patient is in any distress. 3- Suction the patient deeply and often to rid the oropharynx of the build-up of secretions. 4- Suggest to the provider that now is the time for an anticholinergic drug (such as glycopyrrolate).

1, 2, 4

The nurse is practicing in a community-based setting. What outcomes may be achieved by the nurse's community interventions? (Select all that apply.) 1- Promote wellness. 2- Reduce the spread of disease. 3- Improve the health status of the community. 4- Prevent hospital-acquired illness. 5- Promote the financial health of the community.

1, 2,3,

Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. 1- Maintaining client comfort 2- Arranging plans for after death 3- Supporting family members 4- Providing personal care 5- Completing a head-to-toe assessment 6- Encouraging fluids

1, 3, 4

Place the following nursing actions in sequence in the nursing process. 2 Establishing expected outcomes 4 Identifying learning needs and etiology 5 Putting the teaching plan into action 3 Identifying alterations that need to be made to the teaching plan 1 Determining what the patient wants to learn

1, 4, 2, 5, 3,

In which statements regarding medications taken by a client diagnosed with COPD do the the drug name and the drug category correctly match? Select all that apply. 1 Albuterol is a bronchodilator. 2 Dexamethasone is an antibiotic. 3 Cotrimoxazole is a bronchodilator. 4 Ciprofloxacin is an antibiotic. 5 Prednisone is a corticosteroid.

1, 4,5

A patient near the end of life is experiencing anorexia-cachexia syndrome. What characteristics of the syndrome does the nurse recognize? (Select all that apply.) 1- Alterations in carbohydrate, fat, and protein metabolism 2- Endocrine dysfunction 3- Anemia 4- Neurologic dysfunction 5- Bladder incontinence

1,2,3 Anorexia-Cachexia syndrome patient losses appetite and muscle mass

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? 1- Denial 2- Anger 3- Bargaining 4- Acceptance

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: 1- lie supine with his neck extended. 2- sit upright, leaning slightly forward. 3- blow his nose and then put lateral pressure on his nose. 4- hold his nose while bending forward at the waist.

A hospice nurse performs a follow-up telephone call to the spouse of a client who died about 1 year ago. The spouse tells the nurse, "I'm always feeling so sad. Life just doesn't feel worth living." Further conversation reveals that the spouse is having trouble sleeping and eating since her husband's death and that the spouse is "drinking more since he died." The nurse identifies which nursing diagnosis as the priority? 1- Ineffective coping 2- Complicated grieving 3- Grieving 4- Stress overload

A nurse is caring for a patient who is experiencing fear, anxiety, and feelings of powerlessness after receiving a diagnosis of cancer. The nurse develops a teaching plan focusing on the patient's diagnosis and treatment options to promote the patient's sense of control over the situation. Using Maslow's Hierarchy of Human Needs, which of the following categories is the nurse attempting to meet? 1- Esteem and self-respect 2- Safety and security 3- Physiology 4- Belongingness and affection

A patient is nearing death from metastatic cancer and is receiving hospice care in the home. The home care nurse visits. The patient's family caregiver states that the patient has not eaten well for the last several days and rarely wishes to drink, only sucking on ice now and then. The caregiver thinks that it is cruel to let the dying patient starve to death, or die from dehydration. What would the nurse's best response be? 1- "I think it is cruel, too. If this were my mother, I would not let her die like that." 2- "Tell me why you feel that way?" 3- "It's okay, because this may hasten death and relieve suffering." 4- "This is what happens when people die."

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? 1- Pulmonary hypotension 2- Hypercapnia 3- Systemic hypotension 4- Increased smooth muscle contractility

Nursing has evolved from the hospital or home care of the individual during illness to caring for individuals, communities, and populations across the health care continuum. Which of the following necessitated changes in models of nursing care?1- Fewer individuals with chronic disease 2- Increased aging population 3- Fewer inpatient settings 4- Lengthened hospital stays

The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response? 1- CPAP allows a higher percentage of oxygen to be used 2- CPAP prevents the collapse of the patient's airway 3- CPAP eliminates the need for oxygen supplementation during the day 4- CPAP alters alveolar perfusion

The hospice nurse understands that many factors directly or indirectly affect how a person dies. Which of the following is a changeable factor that can be influenced by the nurse when dealing with the dying patient? 1- Cultural attitude toward death 2- Relationship with the health care providers 3- Disease progression 4- Previous experiences with illness

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? 1- Rhonchi in the bronchial region 2- Audible stridor without using a stethoscope 3- Crackles in the bases of the lungs 4- Diminished breath sounds throughout

The nurse is providing care for a number of patients who are receiving treatment for health problems that have a respiratory etiology. Which of the following patients is most likely to benefit from the administration of a PO or IV diuretic? 1- A patient who presents with a barrel chest 2- A patient who has crackles on auscultation 3- A patient who has a sibilant wheeze 4- A patient who has recently complained of chest pain

Using the concept of the wellness-illness continuum, what would the nurse include in the development of a nursing care plan for a chronically ill patient? 1- Educate the patient about every possible complication associated with the specific illness. 2- Encourage positive health characteristics within the limits of the specific illness. 3- Limit all activities because of the progressive deterioration associated with all chronic illnesses 4- Recommend activity beyond the scope of tolerance to prevent early deterioration.

Which of the following best describes the health-illness continuum? 1- A person with chronic illness is at the far end of the continuum reflecting illness. 2- A person may be considered neither completely healthy or completely ill. 3- A person with high-level wellness is free of any disease or infirmity. 4- A person on the continuum remains at the point based on his or her initial state of health.

Which term is used to describe the personal feelings that accompany an anticipated or actual loss? 1- Bereavement 2- Grief 3- Mourning 4- Spirituality

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: 1- verapamil (Isoptin) 2- dantrolene sodium (Dantrium) 3- potassium chloride 4- an acetaminophen suppository

2 Signs of Malignant Hypertherma

A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply.Strengthen the diaphragm Prevent airway collapse Control the rate and depth of respirations Condition the inspiratory muscles Release air trapped in the lungs

2, 3, 5

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. 1- Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. 2- Check for any unusual changes in breathing during the first 48 hours. 3- Observe for any clear drainage from either nostril. 4- Keep the nasal packing in place for 72 hours to help reshape the form of the nose. 5- Elevate the head of the bed for sleeping during the first week. 6- Restrict from sports activities for 6 weeks.

2, 3,5,6

A nurse is developing a teaching plan for a terminally ill client and his family about about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? 1- Each client experiences each of the stages. 2- Typically, the stages occur in succession. 3- The stages are applicable to any loss. 4- Most clients reach acceptance by the time of death

A nurse is preparing a presentation for a local community group addressing the influences on health care delivery. Which of the following would the nurse include in presentation when describing disease patterns? 1- Most infectious diseases have been controlled or eradicated. 2- The prevalence of chronic illness is decreasing due to the emphasis on healthy living. 3- Obesity along with conditions associated with it has become a major health concern. 4- People with acute illnesses are considered the largest group of health care consumers.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? 1 Respiratory alkalosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Metabolic acidosis

As the moment of death approaches, which of the following does the nurse encourage the family to do? 1- Have the family sit in front of the client so they can be seen. 2- Rub the client's hand and arm to comfort the client. 3- Speak to the client in a calm and soothing voice. 4- Lie next to the client and hold the client.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and is now performing discharge teaching with this patient. What should the nurse include in the teaching about breathing techniques? 1 Make inhalation longer than exhalation. 2 Exhale through a wide open mouth. 3 Use diaphragmatic breathing. 4 Use chest breathing.

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? 1- A workshop on caring for the dying client 2- Use evidence-based practice in daily care regimen. 3- Explore own feelings on mortality and death and dying. 4- Participate in a support group to learn clients' feeling on care.

Using Maslow's hierarchy of needs, place the following problems in their order of priority. 1Loneliness 2Fear 3Constipation 5Low self-concept 4Failure to achieve potential

3, 2, 1, 5, 4

A client in hospice has end-stage renal failure. The client states that, of late, he has lost his appetite and feels like everyday situations have become more stressful. The client reports feeling restless. In addition, the client's spouse notices that the client is becoming more confused. What is the most important nursing intervention that needs to be carried out at this point? 1- Make arrangements for the client to receive nutritional counseling. 2- Immediately administer drug therapy to restore renal function. 3- Make arrangements with the physician to administer immunosuppressants. 4- Provide the spouse with an emergency kit that contains small doses of oral morphine liquid.

A client is at risk for emphysema. When reviewing information about the condition with the client, which would the nurse emphasize as the most important environmental risk factor for emphysema? 1Air pollution 2 Allergens 3 Infectious agents 4 Cigarette smoking

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to 1- Apply an ice pack to the nose. 2- Reassure the client that the nose is not fractured. 3- Administer prescribed oral ibuprofen (Motrin). 4- Check the clear fluid for glucose.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: 1- The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP 2- The importance of participating in daily physical exercise when using CPAP on a regular basis 3- The need to have continuous pulse oximetry in place while the CPAP machine is in use 4- The importance of complying with CPAP despite the inconvenience associated with its use

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder? 1Asthma 2 Bronchiectasis 3 Cystic fibrosis 4 Emphysema

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that: 1- inserting a Foley catheter can decrease fluid retention. 2- administering I.V. antibiotics can prevent pneumonia. 3- this client may need intubation. 4- it may be necessary to raise the head of this client's bed.

After teaching a group of students about health, wellness and illness, a nursing instructor determines that additional instruction is necessary when the students identify which of the following as a component of wellness? 1- Performing to the best of one's ability 2- Reporting a feeling of well-being 3- Adjusting to varying situations 4- Feeling together about one part of life

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 1- 4 seconds with 2 episodes/hour. 2- 6 seconds with 3 episodes/hour. 3- 8 seconds with 4 episodes/hour. 4- 10 seconds with 5 episodes/hour.

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern? 1- Anesthesiologist 2- Circulating nurse 3- Registered nurse first assistant 4- Surgeon

The client is 45 years old and has a family history of breast cancer. The client was diagnosed with breast cancer 2 months ago. During a routine visit, the physician prescribes dexamethasone to be taken over a 3-week period. Which symptom would prompt the physician to add dexamethasone to the client's treatment plan? 1- Frequent bloody discharge from the breast 2- Massive swelling in the arm 3- Coarse skin around the breast 4- An 8-lb (3.6-kg) weight loss

The home health nurse is assisting a patient and his family in planning the patient's return to work after an extensive illness. On which level of Maslow's hierarchy of basic needs does the patient's need for self-fulfillment fit? 1- Physiologic 2- Safety and security 3- Love and belonging 4- Self-actualization

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? 1- Pulse rate of 110 beats/min 2- Respiratory rate of 18 breaths/min 3- Blood pressure of 104/62 mm Hg 4- Temperature of 102.5°F (39°C)

Today, increasing emphasis is placed on health, health promotion, wellness, and self-care. Which of the following activities in the care of a female patient with a recent diagnosis of diabetes mellitus is most congruent with the philosophy of health promotion? 1- Providing the patient with a new glucometer and test strips which have been recently brought to market 2- Introducing the patient to a diabetes educator who is in charge of a diabetes support group in the community 3- Helping the patient to schedule hemoglobin A1C testing at an outpatient laboratory 4- Teaching the patient about measures that she can take to minimize the long-term health effects of her disease

When applying Maslow's hierarchy of needs to patient care, the nurse determines that the patient has reached the ultimate goal indicating integrated human functioning and health when which level is met? 1- Safety and security 2- Belongingness and affection 3- Esteem and self-respect 4- Self-actualization

A nurse is teaching a client on the proper technique of using a metered dose inhaler. In the middle of the teaching the client states, "This is so hard! I'm nervous I'm going to do this wrong!" To facilitate learning for the client, what statement will the nurse use in response to the client's concern? A "Why do you feel it is too hard?" B "Let me re-read the teaching material to you." C "What is it that you don't understand?" D "Let me break it down in smaller steps."

B The client is experiencing anxiety, which is common when learning something new. The nurse should recognize this and use simple explanations and instructions in order to alleviate the anxiety. Asking the client what they don't understand or what they feel is too hard is putting more pressure on the client and may worsen the anxiety

A nurse is exploring various barriers to adult learning in order to promote and enhance learning readiness and comprehension. Which situation does the nurse recognize as being a potential experiential barrier to learning? A An adult who lacks motivation B An older adult experiencing acute pain C An adult with no formal education D An adolescent from another culture

C Experiential readiness refers to past experiences that influence an individual's ability to learn. The adult with no formal education has an experiential barrier to learning. The adult experiencing acute pain has a physical barrier to learning. A client from another culture has a cultural barrier to learning. A client who lacks motivation has a learning readiness barrier to learning.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: 1- blood pressure. 2- hemoglobin level. 3- temperature. 4- heart rate.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? 1- Appendicitis 2- Pancreatitis 3- Cholecystitis 4- Peptic ulcer

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? 1- BUN: 28 mg/dL 2- K+: 5.0 mEq/L 3- Na+: 145 mEq/L 4- Ca: 9 mg/dL

Which of the following is a clinical manifestation of hypothyroidism? 1- A pulse rate below 60 beats/minute. 2- An elevated systolic blood pressure. 3- Systolic murmurs 4- Exophthalmos

Which of the following is a strategy to promote urinary continence? 1- Void regularly, 5 to 8 times a day 2- Take diuretics after 4 PM 3- Use caffeine in moderation 4- Implement a low fiber diet

Which of the following is a sympathetic nervous system effect? 1- Decreased peristalsis 2- Decreased blood pressure 3- Constricted pupils 4- Constricted bronchioles

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors? 1- Mourning 2- Grief 3- Bereavement 4- Spirituality

Which of the following is the analgesic of choice for burn pain? 1- Morphine sulfate 2- Fentanyl 3- Demerol 4- Tylenol with codeine

Which of the following is the gold standard for herpes simplex virus (HSV) diagnosis? 1- Culture 2- Shave biopsy 3- Excisional biopsy 4- Punch biopsy

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? 1- Bleeding 2- Headache 3- Increased intracranial pressure (ICP) 4- Hypertension

Which of the following is the most common symptom of bladder cancer? 1- Painless gross hematuria 2- Pelvic pain 3- Back pain 4- Altered voiding

Which of the following is the overall aim of glaucoma treatment? 1- Prevent optic nerve damage 2- Optimize the patient's remaining vision 3- Reverse optic nerve damage 4- Reattach the retina

Which of the following is the preferred IV fluid for burn resuscitation? 1- Lactated Ringer's (LR) 2- Normal saline (NS) 3- D5W 4- Total parenteral nutrition (TPN)

Which of the following is the primary function of the small intestine? 1- Absorption 2- Digestion 3- Peristalsis 4- Secretion

Which of the following medications are used to suppress viral load of the HSV-2 infection? 1- Acyclovir (Zovirax) 2- Penicillin 3- Metronidazole (Flagyl) 4- Clindamycin (Cleocin)

Which of the following medications is used in the treatment of diabetes insipidus to control fluid balance? 1- Desmopressin (DDAVP) 2- Thiazide diuretics 3- Ibuprofen 4- Diabinese

Which of the following nursing instructions is most important for the nurse to emphasize to the client with a new HSV-2 diagnosis? 1- You must inform all sexual partners. 2- Keep lesions dry with alcohol or peroxide. 3- Wear loose underwear to promote air circulation. 4- Use a condom during sexual activity.

What measurement should the nurse report to the physician in the immediate postoperative period? 1- A systolic blood pressure lower than 90 mm Hg 2- A temperature reading between 97°F and 98°F 3- Respirations between 20 and 25 breaths/min 4- A hemoglobin of 13.6

Which of the following sexually transmitted infections (STIs) could be transmitted perinatally? 1- Herpes simplex 2- Chlamydia 3- Gonorrhea

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? 1- Dantrolene sodium 2- Fentanyl citrate 3- Naloxone 4- Thiopental sodium

What part of the brain controls and coordinates muscle movement? 1- Cerebellum 2- Cerebrum 3- Midbrain 4- Brain stem

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? 1 Respiratory rate of 22 breaths/minute 2 Dilated and reactive pupils 3 Urine output of 40 ml/hour 4 Heart rate of 100 beats/minute

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are 1- normal. 2- hypoactive. 3- sluggish. 4- absent.

When caring for a client with diabetes insipidus, the nurse expects to administer: 1- vasopressin. 2- furosemide. 3- regular insulin. 4- 10% dextrose.

A nurse is reading a journal article about the morbidity and mortality associated with burn injury. The nurse demonstrates understanding of the article by identifying which population as having the highest mortality and morbidity rates? 1- older adults 2- children 3- adolescents 4- young adults

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? 1- escharotomy 2- debridement 3- allograft 4- silvadene application

Petechiae are associated with which of the following disorders? 1- Thrombocytopenia 2- Deep vein thrombosis 3- Pulmonary emboli 4- Acute respiratory distress syndrome (ARDS)

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? 1- Hepatic encephalopathy 2- Esophageal varices 3- Hepatitis C 4- Portal hypertension

Which of the following glands is considered the master gland? 1- Pituitary 2- Thyroid 3- Parathyroid 4- Adrenal

A client and their loved ones are in the grieving period of the client's dying, and the nurse wants to offer the best possible support to them in the process. Which is the best intervention the nurse could perform during the grieving period? 1- Avoid criticism or giving advice. 2- Spend time with client. 3- Provide palliative care. 4- Allow a period of privacy.

A client diagnosed with AIDS develops pneumocystis pneumonia (PCP). When planning the care for the client, which medication would the nurse anticipate being prescribed? 1- trimethoprim-sulfamethoxazole (TMP-SMZ) 2- pentamidine 3- clarithromycin 4- acyclovir

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms? 1- atrial fibrillation 2- atrial flutter 3- heart block 4- bundle branch block

A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose? 1- supraventricular tachycardia 2- sinus tachycardia 3- heart block 4- atrial flutter

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel? 1- All options are correct. 2- fluid shift 3- fluid loss 4- hypotension

A 37-year-old male patient presents at the emergency department complaining of nausea and vomiting and severe abdominal pain. While the nurse is assessing the patient, the patient's wife informs the nurse that the patient ingested 24 ounces of vodka last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. What is the patient exhibiting signs of? 1- Pancreatitis with possible peritonitis 2- Acute cholecystitis 3- Obstruction of the bowel 4- Acute appendicitis

A 44-year-old man with a longstanding diagnosis of AIDS has been admitted to the hospital with an absolute neutrophil count (ANC) of 385/mm3. When planning the patient's care, what action should the nurse prioritize? 1- Placing the patient on protective isolation precautions 2- Obtaining the patient's blood type and cross-match in anticipation of transfusion 3- Providing the patient with supplementary oxygen by simple face mask 4- Padding hard surfaces on the patient's bed to reduce the risk of injury

A 45-year-old man with diabetic nephropathy is now in renal failure and is starting dialysis. He asks for information about hemodialysis. What would the nurse include in the teaching for this patient? 1- Hemodialysis is a treatment option that is required three times a week. 2- Hemodialysis is a treatment option that is required daily. 3- The patient will have surgery and a catheter will need to be inserted into the abdomen. 4- Hemodialysis is a treatment that is used for a few months until the patient's kidneys heal

A 60-year-old woman has begun a course of oral antibiotics for the treatment of a urinary tract infection (UTI). The patient's nurse should recognize that the causative microorganisms most likely originated from: 1- Fecal contamination from the patient's perineum 2- Colonization of the patient's urethra from bloodborne pathogens 3- Proliferation of normal microbiotic flora 4- Ingested microorganisms

A 60-year-old woman has just been diagnosed with hypothyroidism after a diagnostic workup. What sign or symptom most likely motivated the woman to originally seek care? 1- Lethargy and apathy 2- Abnormal hair growth and excessive perspiration 3- Flushed skin and pruritus 4- Aggression and increased appetite

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms? 1- impaired cerebral circulation 2- cardiac disease 3- diabetes insipidus 4- hypertension

A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer? 1- Painless, gross hematuria 2- Deep flank and abdominal pain 3- Muscle spasm and abdominal rigidity over the flank 4- Decreasing kidney function associated with fever and hematuria

A 77-year-old female patient who is recovering in the hospital from a total knee replacement has rung her call bell and told the nurse that she needs pain medication. When assessing the patient's pain, what principle should the nurse bear in mind? 1- Older adults tend to have a blunted pain sensation, so complaints should be followed-up promptly. 2- Older adults frequently confuse pain with other tactile sensations. 3- Pain in older adults is often unrelated to physical harm or pathophysiological processes. 4- The sensation of pain increases with age, so older adults typically feel more pain for a longer period than younger patients.

A 79-year-old woman with a complex medical history has recently moved to a long-term care facility. The nurse reads in the woman's documentation that she has a history of atrial fibrillation and hypertension. The nurse should presume that this patient will likely be taking which of the following medications? 1- Warfarin (Coumadin) 2- Furosemide (Lasix) 3- Levothyroxine (Synthroid) 4- Calcium carbonate

A client has been diagnosed with atrial fibrillation and has been prescribed warfarin therapy. What should the nurse prioritize when providing health education to the client? 1- The need to have regular blood levels drawn 2- The importance of taking the medication 1 hour before or 2 hours after a meal 3- The need to sit upright for 30 minutes after taking the medication 4- The importance of adequate fluid intake

A client has been experiencing a decrease in serum calcium. After diagnostics, the physician proposes the calcium level fluctuation is due to altered parathyroid function. What is the typical number of parathyroid glands? 1- four 2- three 3- two 4- one

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure? 1- Colonoscopy 2- Barium enema 3- ERCP 4- Upper gastrointestinal fibroscopy

A client has just had a left radical mastectomy, and the nurse is providing information on complications that may arise due to removing the axillary lymph nodes. Which would not be included? 1- All would be included in the discussion. 2- reduced range of motion 3- tissue necrosis 4- infection

A client has suffered from several autoimmune disorders over the last 25 years, and lately has developed a new set of symptoms. The client's healthcare provider suspects Addison's disease. Which symptom would the nurse not expect to see? 1- weight gain 2- hypoglycemia 3- depression 4- hypotension

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? 1- Take daily weights. 2- Reposition the client frequently. 3- Assess for pupillary response frequently. 4- Assess vital signs frequently.

A client informs the nurse that he is having a difficult time coping with seasonal allergies and has taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies? 1- Elevated eosinophils 2- Elevated basophils 3- Elevated monocytes 4- Elevated neutrophils

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: 1- water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 2- a decreased serum phosphate level secondary to kidney failure. 3- an increased serum calcium level secondary to kidney failure. 4- metabolic alkalosis secondary to retention of hydrogen ions.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? 1- Relieving abdominal pain 2- Preventing fluid volume overload 3- Maintaining adequate nutritional status 4- Teaching about the disease and its treatment

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? 1- Hypertension causes the heart's chambers to enlarge and weaken. 2- Hypertension causes the heart's chambers to shrink. 3- Heart failure occurs when blood pressures drops. 4- Hypertension in older males regularly leads to heart failure.

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not include when teaching the client and family information about managing the disease? 1- If you have problems with a medication, you may stop it until your next physician visit. 2- Avoid sunlight and ultraviolet radiation. 3- Pace activities. 4- Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

A client is being screened for a thyroid disorder. The nurse would anticipate that the client would most likely undergo which test? 1- TSH (thyroid-stimulating hormone) 2- T4 3- T3 4- needle aspiration

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments? 1 Oxygen through nasal cannula at 2 L/minute 2 Intravenous methylprednisolone (Solu-Medrol) 120 mg 3 Ipratropium bromide (Alupent) by metered-dose inhaler 4 Vancomycin 1 gram intravenously over 1 hour

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: 1- shivering in hypothermia can increase ICP. 2- hypothermia is indicative of severe meningitis. 3- hypothermia is indicative of malaria. 4- hypothermia can cause death to the client.

A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia does the client have? 1- sinus bradycardia 2- atrial bradycardia 3- heart block 4- none

A client is examined due to recent vision changes and is diagnosed with myopia. What is the cause of this client's vision change? 1- elongated eyeballs 2- shortened eyeballs 3- irregularly shaped corneas 4- unequal curvatures in the cornea

A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate? 1- Donors are selected from compatible living donors. 2- Donors must be relatives. 3- Donors with hypertension may qualify. 4- The client is placed on a transplant list at the local hospital.

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? 1- "An allograft is a temporary wound covering obtained from cadaver skin." 2- "An allograft is a permanent wound covering taken from a donor site in your body." 3- "An allograft is a temporary wound covering obtained from pig skin." 4- "An allograft is an expensive sheet of skin obtained from a culture."

A client is scheduled to undergo a bone marrow aspiration and biopsy. The nurse understands that which site would most likely be used? 1- posterior iliac crest 2- sternum 3- rib 4- femur

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? 1- A liver biopsy 2- A CT scan 3- A prothrombin time 4- Platelet count

A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect? 1- Hyperkalemia 2- Hypokalemia 3- Hypernatremia 4- Hyponatremia

A client is very concerned about possibly having breast cancer, especially after caring for a close family member who recently died from the disease. The nurse informs the client that the primary and most common sign of breast cancer is a: 1- painless mass in the breast, most often in the upper outer quadrant. 2- painful mass in the breast, most often in the upper outer quadrant. 3- painless mass in the breast, most often in the lower quadrant near the nipple. 4- painful mass in the breast, most often in the lower quadrant near the nipple.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? 1- Tissue tearing away from supporting structures 2- Incision of the skin with well-defined edges, usually long rather than deep 3- Skin tear with irregular edges and vein bridging 4- Denuded skin

A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms? 1- electrocardiogram 2- electroencephalogram 3- echocardiogram 4- electrocautery

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? 1- vasodilation 2- vasoconstriction 3- hypertension 4- increased PaO

A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to 1- avoid caffeinated beverages. 2- request sublingual nitroglycerin. 3- apply supplemental oxygen. 4- lie down and elevate the feet.

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? 1- Confusion 2- Pale, warm, dry skin 3- Heart rate of 110 beats/minute 4- Urine output of 30 ml/hour

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? 1- inflammatory 2- neuroendocrine 3- intravascular fluid excess 4- hypertension

A client who has come to the clinic for an evaluation is diagnosed with glaucoma. The client asks the nurse, "What is this disease?" Which information would the nurse most likely include in the response? 1- Increased pressure in the eye causes damage to the optic nerve. 2- The lens becomes cloudy, causing vision to be impaired. 3- The retina separates from the sensory layers of the eye. 4- The conjunctiva becomes inflamed and irritated.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? 1- Risk for Impaired Gas Exchange 2- Acute Pain 3- Risk for Infection 4- Alteration in Tissue Perfusion

A client with HIV has recently completed a 7-day regimen of antibiotics. She reports vaginal itching and irritation. In addition, the client has a white, cheeselike vaginal discharge. Which condition is the client most likely experiencing? 1- Vulvovaginal candidiasis 2- Bacterial vaginosis 3- Trichomonas vaginalis vaginitis 4- Human papillomavirus

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? 1- Related to bone demineralization resulting in pathologic fractures 2- Related to exhaustion secondary to an accelerated metabolic rate 3- Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces 4- Related to tetany secondary to a decreased serum calcium level

A client with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The client's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of 1- embolic stroke. 2- myocardial infarction. 3- heart failure. 4- renal failure.

Which of the following inhibits bone resorption and promotes bone formation? 1- Calcitonin 2- Estrogen 3- Parathyroid hormone 4- Corticosteroids

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? 1- Decerebrate posturing and loss of corneal reflex 2- Loss of gag reflex and mental confusion 3- Complaints of headache and lack of pupillary response 4- Mental confusion and pupillary changes

A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? 1- Excessive urine output and decreased urine osmolality 2- Oliguria and decreased urine osmolality 3- Oliguria and serum hyperosmolarity 4- Excessive urine output and serum hypo-osmolarity

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this? 1- Tetany related to hypocalcemia 2- Muscle spasm related to hypokalemia 3- Muscle pain related to referred pain manifestations 4- Tetany related to hypercalcemia

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? 1- visual disturbances. 2- taste and smell alterations. 3- dry mouth and urine retention. 4- nocturia and sleep disturbances.

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate? 1- An inspiratory-expiratory (I:E) ratio of 2:1 2- A transverse chest diameter twice that of the anteroposterior diameter 3- An oxygen saturation of 99% 4- A respiratory rate of 12 breaths/minute

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? 1- Weight loss 2- Diarrhea 3- Fatigue 4- Hypertension

A client with heart failure is prescribed an angiotensin converting enzyme (ACE) inhibitor. When teaching the client about this medication, the nurse would explain that this class of medications are effective because they: 1- cause vasodilation to reduce the heart's workload. 2- lead to a reduction in sodium and water retention. 3- cause an increase in myocardial contraction. 4- result in an increase in the oxygen demand.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? 1- Scale 2- Crust 3- Ulcer 4- Scar

A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client? 1- "This medication will relieve your pain." 2- "This medication should be taken at bedtime." 3- "This medication will prevent re-infection." 4- "This will kill the organism causing the infection."

A commonly prescribed methylxanthine used as a bronchodilator is which of the following? 1- Theophylline 2- Levalbuteral 3- Terbutaline 4- Albuteral

A community health nurse is well-aware that the incidence and prevalence of chronic renal failure (CRF) has increased significantly in recent years. In a recent strategic planning meeting, the nurse has proposed health promotion activities to address this problem. Which of the following health promotion campaigns addresses the most common cause of CRF? 1- Teaching individuals with diabetes to manage their disease 2- Promoting smoking cessation 3- Encouraging adults to know their family history of CRF 4- Screening for CRF among adults age 70 and older

A critical care nurse is providing care to a client being mechanically ventilated. The low pressure alarm sounds. The nurse would assess for which situation? 1- disconnection from the ventilator 2- biting of the endotracheal tube 3- kinking of the tubing 4- evidence of bronchospasm

A female patient tells the nurse that she thinks she has a vaginal infection because she has noted inflammation of her vulva and a yellow-green discharge. The nurse recognizes that the clinical manifestations described are typical of what vaginal infections? 1- Trichomonas vaginalis 2- Candidiasis 3- Gardnerella 4- Chlamydial infection

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first? 1- Further investigate the initial complaint. 2- Explain that fatty foods can mimic chest pain. 3- Call for an immediate electrocardiogram. 4- Administer an over-the-counter antacid tablet.

A group of students are reviewing the anatomy and physiology of the breasts. The students demonstrate understanding of breast structure when they identify the tail of Spence as an extension of which quadrant? 1- Upper outer 2- Upper inner 3- Lower outer 4- Lower inner

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? 1- Attach a cardiac monitor 2- Insert a Foley urinary catheter 3- Assist with endotracheal intubation 4- Administer inotropic drugs

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: 1- acute cholecystitis 2- hepatitis A 3- hepatitis B 4- pancreatitis

A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC? 1- By assessing according to the Glasgow Coma Scale (GCS) 2- By eliciting the patient's response to a question requiring judgment 3- By engaging the patient in a conversation, if possible 4- By observing the patient's interactions with caregivers

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? 1- Facial erythema, pericarditis, pleuritis, fever, and weight loss 2- Photosensitivity, polyarthralgia, and painful mucous membrane ulcers 3- Weight gain, hypervigilance, hypothermia, and edema of the legs 4- Hypothermia, weight gain, lethargy, and edema of the arms

A nurse completes a shift assessment on a client admitted to the telemetry unit with a diagnosis of syncope. The client's heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The client is also experiencing dizziness and shortness of breath. Which medication will the nurse anticipate administering to the client based on these clinical findings? 1- Atropine 2- Lidocaine 3- Pronestyl 4- Cardizem

A nurse educator is teaching a chapter on "The Function of the Endocrine System." Which hormone would not be included as one of the six hypothalamic hormones? 1- prolactin 2- corticotropin-releasing hormone 3- thyrotropin-releasing hormone 4- gonadotropin-releasing hormone

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? 1- Tetany 2- Hemorrhage 3- Thyroid storm 4- Laryngeal nerve damage

A nurse is assessing a client with suspected bladder cancer. Which finding would the nurse most likely expect to assess? 1- painless hematuria 2- urgency 3- pelvic pain 4- dysuria

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? 1- tachycardia and tachypnea 2- tachycardia and bradypnea 3- bradycardia and bradypnea 4- bradycardia and tachypnea

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? 1- "How did this happen? I've been faithful my entire marriage." 2- "I'll be very careful when preparing food for my family." 3- "I'll wash my hands often." 4- "I'll take all my medications as ordered."

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect? 1- Decreases resting heart rate 2- Decreases cholesterol level 3- Increases cardiac output 4- Decreases platelet aggregation

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia? 1- Atropine 2- Dobutamine 3- Amiodarone 4- Lidocaine

A nurse is caring for a client with Cushing's syndrome. Which would the nurse not include in this client's plan of care? 1- Provide a high-sodium diet. 2- Examine extremities for pitting edema. 3- Report systolic BP that exceeds 139 mm Hg or diastolic BP that exceeds 89 mm Hg. 4- Administer prescribed diuretics.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? 1- "I sleep on three pillows each night." 2- "My feet are bigger than normal." 3- "My pants don't fit around my waist." 4- "I don't have the same appetite I used to."

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? 1- Hemorrhage 2- Blood transfusion reaction 3- Shock 4- Splintering of bone fragments

A nurse is conducting a neurological assessment of a patient who has just been admitted to the unit. In preparation for assessing the patient for pronator drift, what instructions should the nurse provide to the patient? 1- "Please hold your arms straight out with your palms pointing up to the ceiling." 2- "Please close your eyes and then walk a few steps with one foot directly in front of the other." 3- "Please close your eyes and then touch the tip of your nose with one index finger and then the other." 4- "Please lift one leg a few inches off the bed and hold it as still as possible."

A nurse is developing a teaching plan for a client diagnosed with hyperparathyroidism that explains this condition. When describing the underlying problem, the nurse would most likely include a discussion about which mineral? 1- calcium 2- sodium 3- potassium 4- magnesium

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? 1- VIII 2- X 3- III 4- VII

A nurse is providing care to a client in the critical care unit who has been on prolonged bed rest. When assessing the client, the nurse notes that the client is unable to lift the anterior surface of the foot and toes upward. The nurse documents this as: 1- footdrop 2- contracture 3- ICU-acquired weakness 4- nitrogen wasting

A nurse is providing care to a client who is critically ill. The client has an indwelling urinary catheter inserted to evaluate urine output hourly. Which strategy would be most important to reduce the client's risk for catheter-associated urinary tract infection? 1- removing the catheter as soon as possible 2- keeping the catheter drainage bag above the bladder 3- dIsconnecting the catheter from the bag to clean it 4- empyting the drainage bag once per shift

A nurse is providing care to a client who is to receive a tube feeding. A nasogastric tube has been inserted. Which method would the nurse anticipate as being used to confirm placement? 1- radiography 2- pH determination of gastric aspirate 3- auscultation of instilled air over stomach 4- evaluation of marking on tube

A nurse is reviewing a laboratory order for a client who is scheduled to be tested for a suspected endocrine disorder. The client was recently seen in the office for bronchitis, and you note that he is still taking cough medication. The nurse explains to the client that he will not be able to get his lab testing done today. Why has the testing been postponed? 1- The client is being tested for a thyroid disorder 2- The client is being tested for a parathyroid disorder 3- The client is being tested for an adrenal disorder 4- The client is being tested for a parathyroid disorder 5- The client is being tested for a pituitary disorder

A nurse is teaching a client with an endocrine disorder how the nervous system and endocrine system are linked. Which structure would the nurse identify as the link between the two systems. 1- hypothalamus 2- brain 3- medulla oblongata 4- pancreas

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1- Thrombolytic therapy has a time window of only 3 hours. 2- A ruptured intracranial aneurysm must quickly be repaired. 3- Intracranial pressure is increased by a space-occupying bleed. 4- A ruptured arteriovenous malformation will cause deficits until it is stopped.

A nurse practitioner assessed a patient's complaints about a vaginal discharge and prescribed Flagyl. The nurse was able to diagnose bacterial vaginosis because of this defining characteristic, a discharge that: 1- Has a fish-like odor. 2- Is burning and itching. 3- Is accompanied by vulvitis. 4- Is yellow-green and frothy.

A nurse provided health teaching to a patient with a STI. The nurse advised her patient that transmission of the organism was by three routes: sexual, percutaneous, and perinatal. Choose the STI that was diagnosed. 1- Herpes simplex 2- Chlamydia 3- Gonorrhea 4- Trichomoniasis

A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next? 1- Begin cardiopulmonary resuscitation 2- Prepare for endotracheal intubation 3- Provide electrical cardioversion 4- Administer intravenous epinephrine

A nurse reviews the ECG strip of a patient who has a history of premature atrial complexes (PACs). The strip shows a number of premature beats. The nurse expects to find: 1- PR interval >0.12 seconds. 2- Consistent P waves. 3- Prolonged QRS durations. 4- Regular rhythm.

A nurse who is contributing to the care of a patient with burns recognizes that the patient's injuries are associated with severe and debilitating pain at nearly all stages of treatment and recovery. What pharmacological intervention is most commonly used in the treatment of burn pain? 1- Intravenous morphine 2- Intravenous hydromorphone (Dilaudid) 3- Oral oxycodone 4- Oral codeine

A nursing student asks the instructor why the pituitary gland is called the "master gland." What is the best response by the instructor? 1- "It regulates the function of other endocrine glands." 2- "It is the gland that is responsible for regulating the hypothalamus." 3- "The gland does not have any other function other than to cause secretion of the growth hormones." 4- "It regulates metabolism."

A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to 1- Age 2- Dietary intake of fat 3- Cigarette smoking 4- Presence of diabetes mellitus

A patient admitted for the treatment of a nondepressed skull fracture has been leaking clear fluid from his nose, and glucose testing confirms that it is cerebrospinal fluid (CSF). This development necessitates what nursing action? 1- Elevating the head of the bed to 30 degrees 2- Performing gentle nasal suctioning at 20 to 30 mm Hg 3- Insertion of a nasogastric (NG) tube to low suction 4- Positioning the patient side-lying

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has? 1- Calcium 2- Magnesium 3- Phosphorus 4- Sodium

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? 1- Liver 2- Stomach 3- Large intestine 4- Kidneys

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? 1- Ensure a patent airway and that the patient is receiving 100% oxygen. 2- Send the patient for a chest x-ray. 3- Send the patient to the hyperbaric chamber. 4- Draw labs for a chemistry panel.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? 1- Bronze 2- Yellow 3- Gray 4- Orange-green

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? 1- Superficial 2- Full-thickness 3- Superficial partial-thickness 4- Deep partial-thickness

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? 1- Fluid status 2- Risk of infection 3- Body image 4- Anxiety

A patient has been admitted to an acute medical unit with a diagnosis of diabetes insipidus with a neurogenic etiology. When planning this patient's care, what diagnosis should be the nurse's most likely priority? 1- Fluid volume deficit related to increased urine output 2- Acute confusion related to alterations in electrolytes 3- Altered nutrition: less than body requirements related to decreased intake 4- Risk for injury related to decreased level of consciousness

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? 1- Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis 2- Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis 3- Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis 4- Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved? 1- Decrease in central venous pressure (CVP) 2- Increase in CVP 3- Decrease in blood pressure 4- Absence of cough

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged uncontrolled hypertension is at risk for developing what health problem? 1- Renal failure 2- Right ventricular hypertrophy 3- Glaucoma 4- Anemia

A patient who is receiving treatment for hyperthyroidism is being monitored closely by the care team. When observing this patient for signs and symptoms of thyroid storm (thyrotoxicosis), the nurse should prioritize which of the following assessments? 1- Temperature and heart rate 2- Deep tendon reflexes and peripheral pulses 3- Pain and level of consciousness (LOC) 4- Assessment for visual and auditory disturbances

A patient with osteoarthritis is taking up to 4 grams of acetaminophen daily. The nurse knows to obtain periodic: 1- Liver enzyme results. 2- Creatinine levels. 3- Electrocardiograms. 4- Complete blood counts.

A patient's thyroid gland has secreted T3 and T4 into the bloodstream. This occurs in response to the stimulation of a hormone originating in the: 1- Anterior pituitary gland 2- Adrenal cortex 3- Parathyroid gland 4- Pancreas

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: 1- combat inflammation. 2- prevent infection. 3- prevent platelet aggregation. 4- promote diuresis.

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? 1- Heparin sodium 2- Dexamethasone (Decadron) 3- Methyldopa (Aldomet) 4- Phenytoin (Dilantin)

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? 1- Frontal 2- Occipital 3- Parietal 4- Temporal

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms? 1- retinal detachment 2- angle-closure glaucoma 3- eye trauma 4- chalazion

After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? 1- Decreased cardiac output and decreased systolic and diastolic blood pressure 2- Decreased blood pressure with reflex tachycardia 3- Increased cardiac output and increased systolic and diastolic blood pressure 4- Decreased peripheral vascular resistance

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment? 1- Genital herpes 2- Syphillis 3- Gonorrhea 4- Chlamydia

Although not designated as endocrine glands, several organs within the body secrete hormones as part of their normal function. Which organ secretes hormones involved in increasing blood pressure and volume and maturation of red blood cells? 1- kidneys 2- cardiac atria 3- brain 4- liver

An adult patient is experiencing a temporary decrease in serum levels of T3 and T4. What physiological response is this state likely to result in? 1- Increased release of TSH 2- Increased resorption of T3 and T4 in the renal tubules 3- Release of sequestered T3 and T4 by the spleen 4- Compensatory release of T5 by the parathyroid

An intensive care nurse recognizes that there are numerous factors that contribute to a risk of unstable blood glucose levels in the acutely ill patient. When planning care for patients in the ICU, what goal for blood glucose levels is appropriate for the majority of patients? 1- 80 to 110 mg/dL 2- 95 to 115 mg/dL 3- 105 to 130 mg/dL 4- 20 to 145 mg/dL

Which of the following is a cause of a calcium renal stone? 1- Excessive intake of vitamin D 2- Gout 3- Neurogenic bladder 4- Foreign bodies

An older adult patient has been admitted to the intensive care unit with urosepsis. As a consequence of this infection, the patient is experiencing low levels of cortisol. What sequela of low cortisol should the nurse anticipate when planning this patient's care? 1- Low body temperature 2- Confusion 3- Hypertension 4- Increased intracranial pressure

An older adult patient with a number of comorbidities has opted to begin peritoneal dialysis rather than hemodialysis. A nephrology nurse has been coordinating his care from the insertion of the dialysis catheter to the application of his first few dialysis treatments. To closely monitor the patient for complications of this procedure, the nurse should prioritize which of the following assessments? 1- Assessing the patient for signs and symptoms of infection 2- Assessing the patient's pain levels and cardiac status 3- Assessing the patient's gastrointestinal function and bowel motility 4- Assessing the patient for evidence of hyperkalemia

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? 1- Myopia 2- Astigmatism 3- Hyperopia 4- Emmetropia

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? 1- Providing intensive insulin therapy 2- Allowiing a clear liquid diet during the acute phase 3- Administering oral analgesics around the clock 4- Maintaining a high-Fowler's position

Beta-blockers are used in the treatment of hyperthyroidism to counteract which of the following effects? 1- Sympathetic 2- Parasympathetic 3- Gastrointestinal effects 4- Respiratory effects

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: 1- stasis. 2- coagulation. 3- hyperemia. 4- hypotension.

During a client education session, the nurse describes the mechanism of hormone level maintenance. What causes most hormones to be secreted? 1- decrease in hormonal levels 2- increase in hormonal levels 3- hormonal overproduction 4- hormonal underproduction

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? 1- Iron deficiency anemia 2- Long-standing cardiopulmonary disease 3- Fungal infection 4- Poor circulation

During physical examination of a client with a suspected endocrine disorder, the nurse assesses the body structures. The nurse gathers this data based on the understanding that it is an important aid in which of the following? 1- Detecting evidence of hormone hypersecretion. 2- Detecting information about possible tumor growth. 3- Determining the presence or absence of testosterone levels. 4- Determining the size of the organs and location.

Frequently, what is the earliest symptom of left-sided heart failure? 1- dyspnea on exertion 2- anxiety 3- confusion 4- chest pain

HIV is harbored within which type of cell? 1- Lymphocyte 2- Platelet 3- Erythrocyte 4- Nerve

In a client with burns on the legs, which nursing intervention helps prevent contractures? 1- Applying knee splints 2- Elevating the foot of the bed 3- Hyperextending the client's palms 4- Performing shoulder range-of-motion exercises

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis

In consultation with her care team, a woman with a diagnosis of cancer has had a continent urinary diversion (Indiana pouch) created. The patient is discussing the advantages and disadvantages of this procedure with her nurse. The nurse should be aware of which of the following advantages of an Indiana pouch? 1- The patient does not have to wear an external collection bag. 2- The procedure can be performed on an outpatient basis. 3- The procedure allows for the spontaneous resumption of normal genitourinary function. 4- The patient does not require medical follow-up after the procedure.

It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine 1- increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. 2- decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. 3- increases the heart rate, constricts arterioles, and increases the heart's ability to eject blood. 4- decreases circulating blood volume.

One of the most frequently occurring complications (55% occurrence) of primary hyperparathyroidism is: 1- Kidney stones. 2- Pancreatitis. 3- Pathologic fractures. 4- Peptic ulcer.

Over the past 2 months, a client has been receiving treatment for multiple ear infections and tonsillitis. The client reports a curdy white vaginal discharge and burning with urination. What is the most likely cause of these symptoms? 1- Candida albicans 2- Trichomonas vaginalis 3- Gardnerella vaginalis 4- None of the options is correct.

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through: 1- ophthalmic examination. 2- using a sphygmomanometer. 3- laboratory tests. 4- an MRI.

Parathyroid hormone (PTH) has which effects on the kidney? 1- Stimulation of calcium reabsorption and phosphate excretion 2- Stimulation of phosphate reabsorption and calcium excretion 3- Increased absorption of vitamin D and excretion of vitamin E 4- Increased absorption of vitamin E and excretion of vitamin D

Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications? 1- Ectopic pregnancy 2- Bacteremia 3- Thrombophlebitis 4- Inguinal lymphadenopathy

Students are reviewing information about orbital and ocular tumors. They demonstrate understanding of the material when they identify which of the following as the most common malginant tumor of the eyelid? 1- Basal cell carcinoma 2- Squamous cell carcinoma 3- Malignant melanoma 4- Rhabdomyosarcoma

The initial sign of increasing intracranial pressure (ICP) includes 1- decreased level of consciousness. 2- herniation. 3- vomiting. 4- headache.

The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? 1- The client has had a mastectomy on the right side 2- The client has hypertension 3- The client has a fluid volume restriction 4- The client has a history of falls

The intensive care unit nurse is caring for a client who has severe brain injury with no neurolgical drive to breathe. This client would receive which type of mechanical ventilation? 1- Controlled mandatory ventilation (CMV) 2- Assist control (AC) 3- Synchronized intermittent mandatory ventilation 4- High-frequency ventilation (HFV)

The nurse assesses a patient who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease? 1- Potassium of 6.0 mEq/L 2- Sodium of 140 mEq/L 3- Glucose of 100 mg/dL 4- A blood pressure reading of 135/90 mm Hg

The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? 1- Hemodialysis 2- Peritoneal dialysis 3- Continuous arteriovenous hemofiltration (CAVH) 4- Continuous venovenous hemofiltration (CVVH)

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder? 1- pH 7.20, PaCO2 36, HCO3 14- 2- pH 7.31, PaCO2 48, HCO3 24- 3- pH 7.47, PaCO2 45, HCO3 33- 4- pH 7.50, PaCO2 29, HCO3 22-

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? 1- Delirium 2- Pain 3- Anxiety 4- Fever

The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? 1- Crackles are audible on chest auscultation. 2- The patient's blood pressure (BP) is 144/99. 3- The patient has put out 600 mL of dilute urine over the past 8 hours. 4- Blood glucose testing reveals a glucose level of 158 mg/dL.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to 1- refrain from eating or drinking for now. 2- have their spouse bring in the client's glasses. 3- wear any hearing aids while in the hospital. 4- use the walker when walking.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? 1- Pulmonary edema 2- Pneumonia 3- Congestive heart failure 4- Panic attack

The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? 1- Hypokalemia 2- Alkalosis 3- Hypovolemia 4- Bradycardia

The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication? 1- With food 2- 2 hours before meals 3- 2 hours after meals 4- At bedtime with 8 ounces of fluid

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should 1- check the client's heart rate. 2- check the client's serum K+ level. 3- check the client's urine output. 4- weigh the client.

The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client? 1- Dyspnea, fatigue, and weakness 2- Dizziness, syncope, and palpitations 3- Orthopnea, angina, and pulmonary edema 4- Dry cough, wheezing, and hemoptysis

The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of? 1- Psoriasis 2- Vitiligo 3- Diabetes 4- Melanoma

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? 1- Providing sufficient oxygen to improve oxygenation 2- Avoiding the use of oxygen to decrease the hypoxic drive 3- Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise 4- Increasing pH

The nurse is aware that the clinical symptoms of a patient with hypoparathyroidism are the result of the initial physiologic response of: 1- Hypocalcemia. 2- Decreased levels of vitamin D. 3- Increased serum levels of phosphate. 4- Cardiac arrhythmias.

The nurse is caring for a an older adult client recovering from respiratory failure in the intensive care unit. The nurse anticipates the client's will require a diet high in protein due to the risk of which problem related to critical illness? 1- Nitrogen wasting 2- Hypokalemia 3- Renal insufficiency 4- Constipation

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? 1- Ischemic 2- Hemorrhagic 3- Right-sided 4- Left-sided

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? 1- Approximately 60% to 75% of clients recover completely. 2- Only a very small percentage (5% to 8%) of clients recover completely. 3- Usually 100% of clients recover completely. 4- No one with Guillain-Barre syndrome recovers completely.

The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectomy. The nurse overhears the physician instructing the client on the presence of a stoma with temporary pouch. In gathering information for the client, which urinary diversion would the nurse select? 1- Ileal conduit 2- Kock Pouch 3- Ureterosigmoidostomy 4- Indiana Pouch

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? 1- "Let's talk about this. Do you want me to call a support person?" 2- "Do you want to discuss antipregnancy measures?" 3- "Do you want the phone number for the National Sexual Assault Hotline?" 4- "Would you like us to complete HIV testing?"

The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation? 1- In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output. 2- Sinus bradycardia means your heart is not beating fast enough to keep you alive. 3- Sinus bradycardia is nothing to worry about. 4- In many clients a heart rate slower than 70 beats per minute is considered to slow to maintain an adequate cardiac output.

The nurse is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client? 1- Fluttering 2- Nausea 3- Hypotension 4- Fever

The nurse is caring for a client who is intubated and receiving mechanical ventilation. The nurse responds to an alarm on the volume-cycled ventilator and finds the high pressure alarm is ringing. Which problem should the nurse expect to find when assessing the patient and equipment? 1- There is a kink in the ventilator tubing. 2- The tubing has disconnected from the machine. 3- The client airway has been displaced. 4- The tubing has disconnected from the endotracheal tube.

The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment? 1- Assessing the client for signs and symptoms of infection 2- Assessing the client's activity level and functional status 3- Assessing the client for indications of internal or external hemorrhage 4- Assessing the client for signs of venous thromboemboli

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? 1- Insertion of a nasogastric (NG) tube 2- Urine testing for acetone 3- Serum sodium concentration testing 4- Out of bed to the chair three times a day

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? 1- The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. 2- The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. 3- The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. 4- The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.

The nurse is caring for a client with septic shock in the intensive care unit. The nurse assessed a blood pressure of 80/50 mm Hg and heart rate of 48 bpm. Which intravenous medication should the nurse expect will be administered to this client? 1- Dopamine 2- Amiodarone 3- Esmolol 4- Nitroprusside

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition? 1- ERCP 2- MRI 3- CT 4- Ultrasound

The nurse is caring for a patient diagnosed with Hashimoto's thyroiditis. When assessing this patient what symptom would the nurse expect in a patient with hypothyroidism? 1- Bradycardia 2- Bulging eyes 3- Palpitations 4- Flushed skin

The nurse is caring for a patient receiving hemodialysis treatments and who has an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? 1- Using a stethoscope for auscultating the fistula is contraindicated. 2- The patient feels best immediately after the dialysis treatment. 3- Taking a blood pressure reading on the affected arm can cause clotting of the fistula. 4- The patient shouldn't feel pain during initiation of dialysis.

The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence? 1- Anticholinergic 2- Diuretics 3- Anticonvulsant 4- Cholinergic

The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse? 1- The client has converted from HIV infection to AIDS. 2- The client has advanced HIV infection. 3- The client's T4-cell count has decreased due to the pneumocystis pneumonia. 4- The client has another infection present that is causing a decrease in the T4-cell count.

The nurse is providing care for a patient newly diagnosed with systolic heart failure (HF). What medications should the nurse anticipate administering? 1- Beta-blockers 2- Calcium channel blockers 3- Alpha agonists 4- Angiotensin prohibiters

The nurse knows that what PR interval presents a first-degree heart block? 1- 0.24 seconds 2- 0.14 seconds 3- 0.16 seconds 4- 0.18 seconds

The nurse knows to advise the patient with hyperparathyroidism that he or she should be aware of signs of the common complication of: 1- Kidney Stones 2- Heart palpitations 3- Bone fractures 4- Gastric esophageal reflex

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? 1- Petechiae 2- Ecchymoses 3- Cherry angiomas 4- Telangiectasias

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review? 1- Hemoglobin and hematocrit 2- Arterial blood gases 3- BUN and creatinine 4- Glucose level

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? 1- Roll the client in a blanket. 2- Cover the client with a wet cloth. 3- Place the client with the head positioned slightly below the rest of the body. 4- Avoid immediate IV fluid therapy.

The nurse recognizes that Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they: 1- occur at a rate of more than six per minute 2- occur during the QRS complex 3- have the same shape 4- are paired with a normal beat

The nurse recognizes which symptom as a classic sign of cardiogenic shock? 1- Restlessness and confusion 2- Hyperactive bowel sounds 2- High blood pressure 3- Increased urinary output

The nurse should provide further teaching about post bone-marrow biopsy procedures when the client makes which statement? 1- "I'll ask someone to drive me home when I awake from general anesthesia." 2- "I should not take aspirin-containing products for pain relief." 3- "I may feel some aching in my hip for 1-2 days." 4- "I will keep the sterile dressing on until my doctor tells me it's okay to remove it."

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? 1- Atrial fibrillation 2- First-degree heart block 3- Supraventricular tachycardia 4- Sinus tachycardia

The nursing educator is talking with a group of recent nursing graduates about common diagnoses on the unit. What diffuse connective tissue disease would the instructor tell the group is caused by an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema? 1- Rheumatoid arthritis (RA) 2- Systemic lupus erythematosus (SLE) 3- Osteoporosis 4- Polymyositis

The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is: 1- Severe abdominal pain 2- Fever 3- Jaundice 4- Mental agitation

The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial topical medication? 1- Beta-blockers 2- Prostaglandins 3- Carbonic anhydrase inhibitors 4- Alpha-agonists

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? 1- Electrical burns usually follow an internal path. 2- Lightning is higher in voltage than electricity. 3- The skin is a good conductor of electricity. 4- Moisture intensifies the damage inflicted.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? 1- P wave 2- PR interval 3- QRS complex 4- T wave

Trousseau's sign is elicited by which of the following? 1- Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff. 2- A sharp tapping over the facial nerve just in front of the parotid gland and anterior to the ear causes spasm or twitching of the mouth, nose, and eye. 3- After making a clenched fist, the palm remains blanched when pressure is placed over the radial artery. 4- The patient complains of pain in the calf when his foot is dorsiflexed.

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? 1- Pad the side rails on the bed 2- Apply soft wrist restraints 3- Raise all four side rails on the bed 4- Prevent visitors, so as not to agitate the clien

What is the most appropriate nursing diagnosis for the client with acute pancreatitis? 1- Deficient fluid volume 2- Excess fluid volume 3- Decreased cardiac output 4- Ineffective gastrointestinal tissue perfusion

What is used to decrease potassium level seen in acute renal failure? 1- Sodium polystyrene sulfonate 2- Sorbitol 3- IV dextrose 50% 4- Calcium supplements

When caring for patients with respiratory system failure, the critical care nurse understands that a major health disorder caused by hypoxemic respiratory failure is: 1- Acute respiratory distress syndrome. 2- Pulmonary edema. 3- Chronic bronchitis. 4- Emphysema.

When describing the difference between endocrine and exocrine glands, which of the following would the instructor include as characteristic of endocrine glands? 1- The secretions are released directly into the blood stream. 2- The glands contain ducts that produce the hormones. 3- The secreted hormones act like target cells. 4- The glands play a minor role in maintaining homeostasis.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: 1- light flashes and floaters in front of the eye. 2- a recent driving accident while changing lanes. 3- headaches, nausea, and redness of the eyes. 4- frequent episodes of double vision.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? 1- Check the equipment. 2- Contact the physician to review the care plan. 3- Continue the assessment because no actions are indicated at this time. 4- Document the reading because it reflects that the treatment has been effective.

When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias? 1- Premature ventricular contraction (PVC) 2- Ventricular bigeminy 3- Ventricular tachycardia 4- Ventricular fibrillation

Which Glasgow Coma Scale score is indicative of a severe head injury? 1- 7 2- 9 3- 11 4- 13

Which abnormality is not considered a structural abnormality? 1- pelvic inflammatory disease 2- endometriosis 3- vaginal fistulas 4- pelvic organ prolapse

Which category of drugs is contraindicated in clients with glaucoma? 1- mydriatics 2- NSAIDs 3- beta-blockers 4- prostaglandins

Which cells are called white blood cells? 1- Leukocytes 2- Lymphocytes 3- Erythrocytes 4- Platelets

Which cells have the lifespan of approximately 7.5 days and one-third of their population remains in the spleen (unless needed to fight significant bleeding)? 1- Platelets 2- Leukocytes 3- Erythrocytes 4- Lymphocytes

Which cells have the major function of transporting O2 to and removing CO2 from tissues? 1- erythrocytes 2- platelets 3- leukocytes 4- lymphocytes

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? 1- Cushing syndrome 2- Addison disease 3- Graves disease 4- Hashimoto disease

Which drug is the most effective treatment for trichomoniasis? 1- Metronidazole 2- Miconazole 3- Clindamycin 4- Clotrimazole

Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low? 1- U wave 2- T wave 3- P wave 4- QT interval

Which finding indicates that hypertension is progressing to target organ damage? 1- Retinal blood vessel damage 2- Urine output of 60 mL over 2 hours 3- Blood urea nitrogen concentration of 12 mg/dL 4- Chest x-ray showing pneumonia

Which hormone is secreted by the posterior pituitary? 1- Vasopressin 2- Calcitonin 3- Corticosteroids 4- Somatostatin

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? 1- Roll the client in a blanket 2- Cover the client with a wet cloth 3- Place the client with the head positioned slightly below the rest of the body 4- Avoid immediate IV fluid therapy

Which is a classic sign of cardiogenic shock? 1- Tissue hypoperfusion 2- Hyperactive bowel sounds 3- High blood pressure 4- Increased urinary output

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? 1- Intracranial hemorrhage 2- Ischemic stroke 3- Age 18 years or older 4- Systolic blood pressure less than or equal to 185 mm Hg

Which is a symptom of severe thrombocytopenia? 1- Petechiae 2- Inflammation of the mouth 3- Inflammation of the tongue 4- Dyspnea

Which is an age-related change of the hepatobiliary system? 1- Increased drug clearance capability 2- Decreased blood flow 3- Enlarged liver 4- Decreased prevalence of gallstones

Which is not a likely origination point for cardiac dysrhythmias? 1- bundle of His 2- ventricles 3- atria 4- atrioventricular node

Which is the hallmark of heart failure? 1- Low ejection fraction (EF) 2- Pulmonary congestion 3- Limited ADLs 4- Basilar crackles

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? 1- CD4+ counts 2- HIV RNA 3- Western blotting assay 4- ELISA

Which lobe of the brain is responsible for concentration and abstract thought? 1- Frontal 2- Parietal 3- Temporal 4- Occipital

Which medication is used to treat glaucoma by pulling the iris away from the drainage channels so that aqueous fluid can escape? 1- carbachol 2- latanoprost 3- bimatoprost 4- timolol

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? 1- Reduction in blood volume 2- Sodium excess 3- Potassium deficit 4- Increased urinary output

Which of the following topical burn preparations act as wick for sodium and potassium? 1- Silver nitrate solution 2- Silver sulfadiazine (Silvadene) 3- Mafenide acetate (Sulfamylon) 4- Acticoat

Which of the following, if left untreated, can lead to an ischemic stroke? 1- Atrial fibrillation 2- Cerebral aneurysm 3- Arteriovenous malformation (AVM) 4- Ruptured cerebral arteries

Which outcome indicates that treatment of a client with diabetes insipidus has been effective? 1- Fluid intake is less than 2,500 ml/day. 2- Urine output measures more than 200 ml/hour. 3- Blood pressure is 90/50 mm Hg. 4- Heart rate is 126 beats/minute.

Which protein in plasma functions primarily as immunologic agents? 1- Gamma globulins 2- Albumin 3- Fibrinogen 4- Beta globulins

Which term describes an opening between the bladder and the vagina? 1- Vesicovaginal fistula 2- Cystocele 3- Rectocele 4- Rectovaginal fistula

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? 1- Autograft 2- Allograft 3- Homograft 4- Heterograft

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? 1- Superficial partial thickness 2- Deep partial-thickness 3- Full-thickness 4- Fourth degree

Which type of burn injury requires skin grafting? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? 1- Basophils 2- B lymphocyte 3- Plasma cell 4- Neutrophil

Which type of voiding dysfunction is seen in clients diagnosed with Parkinson disease? 1- Incontinence 2- Urinary retention 3- Urgency 4- Incomplete bladder emptying

Which zone consists of the area where the injury is most severe and deepest? 1- Coagulation 2- Stasis 3- Hyperemia 4- Necrosis

While caring for a client who is being treated for severe pelvic inflammatory disease (PID), the nurse insists on keeping the client in a semi-sitting position. The nurse advises this in order to: 1- facilitate pelvic drainage and minimize the upward extension of the infection. 2- prevent nosocomial infections to other clients. 3- prevent movement that may increase pain. 4- facilitate easy distraction of the client.

While performing a morning assessment of an elderly patient on a subacute medical unit, the nurse notes petechiae on a patient's lower extremities. When checking this patient's most recent blood work, the nurse should pay particular attention to the patient's level of: 1- Platelets 2- Neutrophils 3- Iron 4- Albumin

While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following? 1- Liver spots 2- Dark discoloration of the skin 3- Bright red moles 4- Hypertrophied scar tissue

he nursing instructor is going over laboratory results for patients with HIV/AIDS. The instructor tells the students that, upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4 T-lymphocyte cell count drops below what level? 1- 200 cells/mm3 of blood 2- 300 cells/mm3 of blood 3- 400 cells/mm3 of blood 4- 500 cells/mm3 of blood

A client is being discharged to home following a modified radical mastectomy. The nurse is providing discharge instructions and making arrangements for home care. Which interventions will be included in the instructions? Select all that apply. 1- Advise the client that blood pressure measurements, injections, blood donations, and IV infusions are lifelong restrictions on the side of the mastectomy. 2- Recommend wearing gloves while doing yard or housework. 3- Advise the client to use a disposable razor for shaving axillary hair. 4- Encourage the client to wear restrictive clothing on the affected side.

1, 2

Which hormones are secreted by the posterior lobe of the pituitary gland? Select all that apply. 1- Vasopressin 2- Oxytocin 3- Thyroid-stimulating hormone (TSH) 4- Follicle-stimulating hormone (FSH) 5- Luteinizing hormone (LH)

1, 2

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Bradypnea 3- Hypertension 4- Tachycardia

1, 2, 3

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply. 1- Jaundice 2- Petechiae 3- Ecchymoses 4- Cyanosis of the lips 5- Aphthous stomatitis

1, 2, 3

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Hypertension 3- Bradypnea 4- Hypotension 5- Tachycardia

1, 2, 3,

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. 1- Cool, moist skin 2- Decreasing blood pressure 3- Increasing heart rate 4- Delayed capillary refill 5- Increasing urine volume

1, 2, 3, 4

A client has been diagnosed with genital herpes. Knowing that education is an essential part of nursing care of the client with a genital herpes infection, the nurse plans to include which method(s) to minimize HIV transmission? Select all that apply. 1- Avoiding unprotected sexual intercourse 2- Avoiding multiple sexual partners 3- Avoiding physical contact with others in crowded places 4- Avoiding IV drug use 5- Avoiding HPV vaccinations

1, 2, 4

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply. 1- Coronary artery disease 2- Myocardial infarction 3- Pancreatitis 4- Tension pneumothorax 5- Stroke

1, 2, 5

Which condition(s) indicates target organ damage from untreated/undertreated hypertension? Select all that apply. 1- Heart failure 2- Retinal damage 3- Diabetes 4- Hyperlipidemia 5- Stroke

1, 2, 5

A nurse cares for a client with a disorder of the endocrine function of the pancreas. Which hormones or enzymes may be impacted by this disorder? Select all that apply. 1- Insulin 2- Glucagon 3- Somatostatin 4- Lipase 5- Amylase

1,2,3

Normal BUN levels

10-20 mg/dL

Normal platelet count

150,000-400,000

A 58-year-old man has a longstanding diagnosis of poorly controlled type 2 diabetes. As a result of hyperglycemia, the man has developed chronic glomerulonephritis. In light of this new diagnosis, the nurse who is caring for this patient would anticipate that he will exhibit: 1- Hypokalemia 2- Proteinuria 3- Hematuria 4- Arrhythmias

A 69-year-old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for heart failure (HF). During echocardiography, systolic HF could be differentiated from diastolic HF by appraising the patient's: 1- Sinus rhythm 2- Ejection fraction (EF) 3- Stroke volume 4- Left ventricular wall thickness

A 75-year-old woman visited her health care provider for an annual check-up. She told the doctor that she feels exhausted all the time and barely has the energy to go out of her home, run errands, and visit friends. The nurse expects that the health care provider will order which of the following lab studies based on the most common hematologic condition affecting the elderly? 1- White blood count 2- Complete blood count 3- Thrombocyte count 4- Level of B lymphocytes

A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? 1- Occasional U waves 2- Peaked T waves 3- Flattened P waves 4- Prolonged QT interval

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is 1- dipyridamole. 2- aspirin. 3- clopidogrel. 4- ticlodipine.

A client has a dysfunction in one of his glands that is causing a decrease in the level of calcium in the blood. What gland should be evaluated for dysfunction? 1- Thyroid gland 2- Parathyroid gland 3- Thymus gland 4- Adrenal gland

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? 1- The development of chronic obstructive pulmonary disease (COPD) 2- The development of left-sided heart failure 3- The development of right-sided heart failure 4- The development of corpulmonale

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute, despite receiving nasal oxygen at 2 L/minute. To improve the client's shortness of breath, the nurse encourages the client to 1- Take deep breaths 2- Exhale slowly 3- Perform upper chest breaths 4- Increase the flow of oxygen

A client has had a right modified radical mastectomy and axillary lymph node dissection. The nurse is teaching the client about measures to reduce the risk of complications. The client demonstrates understanding of the instructions when she states which of the following? 1- "Anytime I need blood drawn, they should get the sample from my right arm." 2- "I need to use an electric shaver when shaving my right armpit." 3- "I can lift with my right arm objects that weigh as much as 15 pounds." 4- "I should tell my manucurist that it is okay to trim the cuticles on my right hand."

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: 1- severe abdominal pain radiating to the shoulder. 2- anorexia, nausea, and vomiting. 3- eructation and constipation. 4- abdominal ascites.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? 1- Increased serum calcium levels 2- Elevated urine amylase levels 3- Decreased liver enzyme levels 4- Decreased white blood cell count

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? 1- Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. 2- Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. 3- Reassure the client that a headache is expected and will go away without treatment. 4- Notify the physician; a headache is an early sign of worsening neurologic status.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? 1- Measuring and recording fluid intake and output 2- Weighing the client daily at the same time each day 3- Assessing the client's vital signs every 4 hours 4- Checking the client's lungs for crackles during every shift

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? 1- Every 15 minutes 2- Every 30 minutes 3- Every 60 minutes 4- Every 120 minutes

A client is brought to the emergency department after being involved in a house fire. The client has superficial burns on the arms and legs but emergency medical personnel report that the client may have smoke inhalation. The clent is complaining of a headache and some dizziness. The nurse obtains the client's carboxyhemoglobin level which is 15%. Which action by the nurse would be most appropriate? 1- Have the client take slow deep breaths. 2- Administer 100% oxygen. 3- Give the client a fast-acting bronchodilator. 4- Prepare to intubate the client.

A client is prescribed amitriptyline (an antidepressant) for incontinence. The nurse understands that this drug is an effective treatment because it: 1- increases contraction of the detrusor muscle. 2- increases bladder neck resistance. 3- reduces bladder spasticity. 4- decreases involuntary bladder contractions.

A client is prescribed pilocarpine. When preparing the client's teaching plan about this drug, which of the following would the nurse integrate? 1- It acts to decrease aqueous humor production. 2- The client may experience difficulty seeing in the dark. 3- The client's pupils will most likely be dilated. 4- The client may experience a dry mouth and nose.

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will: 1- cease function and shunt blood to the heart and lungs. 2- convert glycogen to glucose for immediate use. 3- produce a toxic byproduct in relation to stress. 4- maintain a basal rate of functioning.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate? 1- "You should discuss that matter with your health care provider." 2- "The diagnosis won't be based on the findings of a single test but by combining all data found." 3- "SLE is a very serious systemic disorder." 4- "Tell me more about your concerns about this potential diagnosis."

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? 1- "Take your temperature every 4 hours." 2- "Increase your fluid intake to 2 to 3 L per day." 3- "Apply an antibacterial dressing to the incision daily." 4- "Be aware that your urine will be cherry-red for 5 to 7 days."

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? 1- Anemia 2- Gastric ulcers 3- Hyperthyroidism 4- Cardiac arrest

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? 1- Fluid restriction 2- Vasopressin therapy 3- Hypertonic saline solution 4- Diet containing extra sodium

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: 1- hematuria. 2- weight loss. 3- increased urine output. 4- increased blood pressure.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? 1- Intubation of the airway 2- BP and pulse measurements every 15 to 30 minutes 3- Insertion of a central venous catheter 4- Hourly administration of a fluid bolus

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? 1- "My legs feel weak." 2- "My finger joints are oddly shaped." 3- "I have pain in my hands." 4- "I have trouble with my balance."

A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate? 1- "Use scented powders to disguise any odor." 2- "Make sure to eat enough fiber to prevent constipation." 3- "Try drinking coffee throughout the day." 4- "Limit the number of times you urinate during the day."

A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment? 1- Purplish tinge to the hands 2- Cherry red color to the nail beds, lips, and oral mucosa 3- Dull or yellow-brown shade to his chest 4- Ashen gray and dull color to his face

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1- Decreased intravascular volume 2- Increased intracranial pressure (ICP) 3- Ischemic cerebrovascular accident (CVA) 4- Brain tissue necrosis

A female patient who has been experiencing progressive syncope, dyspnea, and hypotension has been diagnosed with a third-degree atrioventricular (AV) block. The nurse should understand that the patient is experiencing these symptoms because: 1- Only some of the atrial impulses are being conducted through the AV node into the ventricles. 2- Conduction of the electrical impulse is failing to progress beyond the atria to the ventricles. 3- The patient's sinus node is failing to create an impulse. 4- Impulses starting in a ventricle are being conducted through the ventricles before the next normal sinus impulse.

A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve? 1- V (Trigeminal) 2- VI (Abducens) 3- VII (Facial) 4- IV (Trochlear)

A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication? 1- Potassium level of 6.3 mEq/L 2- Calcium level of 11.6 mg/dl 3- Sodium level of 110 mEq/L 4- Magnesium level of 0.9 mg/dl

After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm? 1- 0.05 and 0.1 seconds. 2- 0.12 and 0.2 seconds. 3- 0.15 and 0.3 seconds. 4- 0.25 and 0.4 seconds.

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis? 1- Perform deep-breathing exercises vigorously. 2- Wear a mask when performing exchanges. 3- Auscultate the lungs frequently. 4- Avoid carrying heavy items.

A male patient in his 20s has presented to a free clinic with signs and symptoms that are highly suggestive of viral conjunctivitis. The nurse is aware of the relationship that can exist between sexually transmitted infections (STIs) and viral conjunctivitis. What assessment question is most likely to be clinically relevant? 1- "Have you ever been tested for HIV?" 2- "Have you ever been diagnosed with herpes simplex virus (HSV)?" 3- "Have you ever had genital warts?" 4- "Have you ever been diagnosed with hepatitis?"

A male patient is being treated for acute respiratory distress syndrome (ARDS) in the intensive care unit. The patient has responded favorably to treatment but remains intubated. What nursing action should the nurse take in order to promote his coping ability? 1- Perform education about the etiology of his disease and about future prevention measures. 2- Encourage the patient's participation in decisions around care and treatment. 3- Emphasize positive assessment findings when discussing the patient's health status with him. 4- Perform passive range of motion exercises frequently throughout each shift.

A middle-aged woman has scheduled an appointment with her nurse practitioner because she has been experiencing intractable muscle weakness in recent weeks. Which of the following characteristics of the patient's weakness should cause the nurse to suspect a neurological etiology? 1- The patient's weakness is most severe in the early morning. 2- The weakness is primarily on the left side of the patient's body. 3- The weakness is not relieved by increasing her food intake. 4- The patient's weakness began around the time of her husband's death.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? 1- Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg 2- Urine output of 20 ml/hour 3- White pulmonary secretions 4- Rectal temperature of 100.6° F (38° C)

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? 1- Abnormal posture 2- Flaccidity 3- Weak muscular tone 4- Decorticate posturing

A nurse is caring for a female client with hypothyroidism. The client is extremely upset about her altered physical appearance. She doesn't want to take her medication because she doesn't believe it's doing any good. What should the nurse do? 1- Tell the client she'll feel better if she consistently takes the thyroid replacement medication. 2- Tell the client she'll soon experience improvement in her looks as the medication corrects her hormone deficiency. 3- Tell the client she needs to learn to accept herself as she is and be compliant during treatment. 4- Tell the client that she looks fine and offer to help her with makeup.

A nurse is caring for a newly admitted patient with a suspected gastrointestinal (GI) bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. The nurse recognizes that the bleeding is likely occurring where? 1- The lower GI tract 2- The upper GI tract 3- The esophagus 4- The anal area

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? 1- Risk for infection 2- Decreased cardiac output 3- Impaired physical mobility 4- Imbalanced nutrition: Less than body requirements

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? 1- Developing no acute complications from the pancreatitis 2- Maintaining normal respiratory function 3- Maintaining satisfactory pain control 4- Achieving adequate fluid and electrolyte balance

A nurse is preparing a review class about hematologic problems for a group of nurses working at the clinic. As part of the class, the nurse is describing the process by which the body continuously replenishes the supply of blood cells. The nurse is describing which process? 1- hemostasis 2- hematopoiesis 3- neutropenia 4- phagocytosis

A nurse is presenting at a community health promotion fair that is focused on disease prevention and screening. A middle-aged participant has brought up an article that she recently read about bladder cancer and has asked the nurse about prevention measures. How should the nurse respond to this woman's inquiry? 1- "The majority of people who develop bladder cancer have a family history of the disease, so genetics play a large part." 2- "If you smoke cigarettes, quitting will greatly reduce your risk of bladder cancer." 3- "People who tend not to drink enough fluids put themselves at an increased risk of bladder cancer." 4- "An unhealthy diet is the most significant risk factor for the development of bladder cancer."

A nurse is providing care to a client who is experiencing low blood glucose levels. The nurse understands that the body attempts to raise the level by secreting which hormone? 1- insulin 2- glucagon 3- somatostatin 4- aldosterone

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? 1- Providing an analgesic for pain 2- Massaging the feet 3- Restricting ambulation 4- Placing sterile cotton between the toes after rewarming

After teaching a group of students about the signs and symptoms of breast cancer, the instructor determines that additional teaching is needed when the group identifies which of the following? 1- Peau d'orange skin 2- Breast symmetry 3- Nipple retraction 4- Painless mass

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? 1- "I won't go to see my sister while she has a cold." 2- "I can eat whatever I want as long as it's low in fat." 3- "I stopped smoking last year; this year I'll quit drinking alcohol." 4- "I won't go to see my nephew right after he gets his vaccines.

A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure? 1- 145/95 or lower 2- 130/80 or lower 3- 150/95 or lower 4- 125/85 or lower

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: 1- touch his or her nose with one finger. 2- close his or her eyes and stand erect. 3- close his or her eyes and discriminate between dull and sharp. 4- close his or her eyes and jump on one foot.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? 1- Positioning the client to prevent airway obstruction 2- Keeping the client in one position to decrease bleeding 3- Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess 4- Maintaining the client in a quiet environment

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? 1- Hyperactive bowel sounds 2- Decreased peristalsis 3- Fecal occult blood 4- Hematemesis

A nurse practitioner who works for Planned Parenthood is responsible for health education seminars. During these presentations, the nurse always discusses the symptoms of the most common STI among young, sexually active people. This is: 1- Candidiasis. 2- Human papillomavirus. 3- Endocervicitis. 4- Salpingitis.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? 1- Positioning to prevent complications 2- Maintenance of a patent airway 3- Assessment of pupillary light reflexes 4- Determination of the cause

A nursing educator is talking with nurses about the effects of the aging process and neurologic changes. What would the educator identify as a normal neurological change that accompanies the aging process? 1- Hyperactive deep tendon reflexes 2- Reduction in cerebral blood flow (CBF) 3- Increased cerebral metabolism 4- Hypersensitivity to painful stimuli

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes? 1- Malnutrition and acute pancreatitis 2- Alcohol consumption and smoking 3- Alcohol consumption and acute pancreatitis 4- Acute pancreatitis and alcohol consumption

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? 1- Naloxone 2- Flumazenil 3- Diazepam 4- N-aceytlcysteine

A patient converts from normal sinus rhythm at 80 beats/min to atrial fibrillation with a ventricular response at 166 beats/min. Blood pressure is 162/74. Respiratory rate is 20/min with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the primary goal of treatment is what? 1- Decrease SA node conduction 2- Control ventricular rate 3- Improve oxygenation 4- Maintain anticoagulation

A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables? 1- Proximity to the CT scanner 2- Variations in tissue density 3- Metabolic activity 4- Oxygen consumption

A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective? 1- Bactrim 2- Cipro 3- Macrodantin 4- Septra

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing? 1- Atrophy 2- Lichenification 3- Keloid 4- Scales

A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be? 1- A GFR of 90 mL/min/1.73 m2 2- A GFR of 30-59 mL/min/1.73 m2 3- A GFR of 120 mL/min/1.73 m2 4- A GFR of 85 mL/min/1.73 m2

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. What medication does the nurse know will be given to prevent further spinal cord damage? 1- Furosemide (Lasix) 2- Methylprednisolone (Solu-Medrol) 3- Cyclobenzaprine (Flexeril) 4- Hydralazine hydrochloride (Apresoline)

A patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern? 1- Isolated systolic hypertension 2- Rebound hypertension 3- Angina 4- Left ventricular hypertrophy

A patient is given atropine to dilate the pupil of her right eye to treat an acute iritis. The nurse is aware that a major consideration is to: 1- Monitor the patient for indicators of hypertension. 2- Check for signs and symptoms of glaucoma. 3- Observe for signs of disorientation or delirium. 4- Assess for cardiac dysrhythmias.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? 1- Epidermis 2- Dermis 3- Papillary layer 4- Stratum corneum

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? 1- Diuretic 2- Anticoagulant 3- Antihypertensive 4- Potassium supplement

A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation? 1- Moral Distress 2- Impaired Verbal Communication 3- Acute Confusion 4- Risk for Imbalanced Body Temperature

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? 1- Large artery thrombosis 2- Cerebral aneurysm 3- Cardiogenic emboli 4- Small artery thrombosis

A patient who is postoperative day 1 following neck dissection surgery has rung his call bell complaining of numb fingers, stiff hands, and a tingling sensation in his lips and around his mouth. The nurse should anticipate that this patient may require the IV administration of: 1- Potassium chloride 2- Calcium gluconate 3- Magnesium sulfate 4- Sodium phosphate

A patient with a diagnosis of HIV exhibits a decreased level of T lymphocytes. What consequence does this state present for this patient? 1- The patient will be incapable of mounting a response to allergens. 2- The patient is particularly susceptible to infection. 3- The patient has diminished oxygen-carrying capacity. 4- The patient will be unable to maintain hemostasis.

A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on a medical unit, and the nurse is writing an individualized care plan. The priority nursing diagnosis for a patient with this condition is what? 1- Deficient fluid volume 2- Excessive fluid volume 3- Hypothermia 4- Hyperthermia

A patient with a neurological disorder is being assessed by the nurse. The nurse assesses the patient's biceps reflex as diminished. The nurse would be correct in documenting this response as what? 1- 0 2- 1+ 3- 2+ 4- 3+

A patient with a primary diagnosis of colorectal cancer has developed bone metastases in recent weeks. When reviewing this patient's daily blood work, the nurse should be aware that secondary bone tumors create a significant risk of what electrolyte imbalance? 1- Hypokalemia 2- Hypercalcemia 3- Hyponatremia 4- Hyperchloremia

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient? 1- The patient requires more pain medication. 2- The patient is developing a paralytic ileus. 3- The patient has developed peritonitis. 4- The patient has developed renal failure.

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? 1- Baclofen 2- Riluzole 3- Dantrolene sodium 4- Diazepam

A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? 1- Placing the patient on a fluid restriction 2- Applying thigh-high elastic stockings 3- Administering an antifibrinolytic agent 4- Assisting the patient with passive range of motion exercises

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? 1- "You must have the second one in 2 weeks and the third in 1 month." 2- "You must have the second one in 1 month and the third in 6 months." 3- "You must have the second one in 6 months and the third in 1 year."

Acticoat has been ordered as a component of a burn patient's wound care and infection control regimen. When applying this wound care product, the nurse should: 1- Allow the Acticoat to dry thoroughly before covering it with a dry dressing. 2- Moisten the Acticoat with sterile water and then apply it to the wound bed. 3- Use a pad of Acticoat to perform mechanical debridement. 4- Change the dressing every 18 to 24 hours.

After a series of visits to her care provider, a 40-year-old woman has been diagnosed with primary hypertension and metabolic syndrome. In addition to her persistently high blood pressure (BP) readings, what criterion would contribute to the woman's diagnosis of metabolic syndrome? 1- Serum sodium levels of ≥135 mmol/L 2- Abnormal lipid levels 3- Increased serum creatinine and/or blood urea nitrogen (BUN) levels 4- Presence of proteinuria

After burning herself by turning off the cold water of her bath, a 3-year-old girl has been brought to the emergency department (ED) with burns that have been assessed as superficial partial-thickness. The ED nurse should recognize which of the following characteristics of this child's burn? 1- The burn is likely to require a skin graft in order to facilitate full healing. 2- The child's burn will heal spontaneously in approximately 1 week and is unlikely to scar. 3- The child will require admission to a burn unit and aggressive treatment to prevent complications. 4- The child's burn involves the epidermis but the dermis is unaffected.

Which of the following would the nurse expect to find in a client with severe hyperthyroidism? 1- Tetany 2- Exophthalmos 3- Buffalo hump 4- Striae

An adult patient has undergone extensive testing that has resulted in a diagnosis of a basophilic pituitary tumor. The pathophysiological effects of the patient's tumor include excessive secretion of adrenocorticotropic hormone (ACTH). As a result, this patient is likely to exhibit signs and symptoms that are characteristic of what endocrine disorder? 1- Addison's disease 2- Cushing's disease 3- Hyperthyroidism 4- Diabetes insipidus

An elderly man has sustained multiple bee stings on his arms, neck, and chest. He went to the ED because of the presence of hives and swelling, which got worse over time. Using the triage system with five levels, his care would be considered: 1- Resuscitative. 2- Emergent. 3- Urgent. 4- Minor.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? 1- The client is in hypovolemic shock. 2- The client has experienced extensive full-thickness burns. 3- The paramedic administered high doses of opioids during transport. 4- The client has experienced partial-thickness burns.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? 1- Blood glucose level of 200 mg/dl 2- White blood cell (WBC) count of 20,000/mm3 3- Potassium level of 3.5 mEq/L 4- Hematocrit (HCT) of 35%

Blood flow to the GI tract is approximately what percentage of the total cardiac output? 1- 10% 2- 20% 3- 30% 4- 40%

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? 1- Place the patient in the supine position. 2- Administer diphenhydramine (Benadryl) for the allergic reaction. 3- Administer atropine to control the side effects of edrophonium. 4- Call the rapid response team because the patient is preparing to arrest.

During a follow-up visit, a female client who underwent a mastectomy asks the nurse if she can work in her backyard or at least do some household work. Which suggestion would be most appropriate? 1- Avoid working in the garden or yard altogether. 2- Wear gloves and protective clothing to avoid any injuries. 3- Increase the frequency of follow-up visits if she does works. 4- Avoid household chores for at least 6 to 9 months.

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion. 1- Macule 2- Vesicle 3- Pustule 4- Cyst

Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet? 1- Low oxalate 2- Low purine 3- High protein 4- High sodium

Lower motor neuron lesions cause 1- increased muscle tone. 2- flaccid muscles. 3- no muscle atrophy. 4- hyperactive and abnormal reflexes.

Mr. Faulkner is a 69-year-old man who has enjoyed generally good health for his entire adult life. As a result, he has been surprised to receive a new diagnosis of hypertension after a series of visits to his primary care provider. The nurse who is working with Mr. Faulkner should recognize which of the following aspects of aging and hypertension? 1- The diagnostic criteria for hypertension in adults over 65 differ from those for younger adults. 2- The incidence and prevalence of hypertension increase with age. 3- Blood pressure remains stable throughout adulthood but tends to be assessed more often by health care providers of older adults. 4- Older adults are less vulnerable to the pathophysiological effects of hypertension than are younger adults

Production of melanin is controlled by a hormone secreted by which gland? 1- Thyroid 2- Hypothalamus 3- Adrenal 4- Parathyroid

The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: 1- 20 2- 15 3- 10 4- 5

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? 1- Basophils 2- Neutrophils 3- Eosinophils 4- Monocytes

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately? 1- Increased appetite 2- Persistent cough 3- Weight loss 4- Ability to sleep through the night

The following catheterization procedures are used to treat clients with urinary retention. Which procedure would the nurse identify as carrying the greatest risk to the client? 1- Suprapubic cystostomy tube 2- Permanent drainage with a urethral catheter 3- Clean intermittent catheterization 4- Credé voiding procedure

The nurse is caring for a client who is prescribed medication for the treatment of hypertension. The nurse recognizes that which medication conserves potassium? 1- Furosemide 2- Spironolactone 3- Chlorothiazide 4- Chlorthalidone

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated? 1- The registered nurse stating to administer digoxin 2- The registered nurse administering atropine sulfate intravenously 3- The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute 4- The registered nurse stating to administer all medications except those which are cardiotonics

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately? 1- Chalazion 2- Acute angle-closure glaucoma 3- Hordeolum 4- Blepharitis

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances? 1- Calcium 2- Uric acid 3- Struvite 4- Cystine

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? 1- Vitiligo 2- Psoriasis 3- Melanoma 4- Petechia

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? 1- Anaphylactic 2- Hypovolemic 3- Neurogenic 4- Cardiogenic

The nurse expects to see which of the following characteristics on an ECG strip for a patient who has third-degree AV block? 1- Extended PR interval 2- More P waves than QRS complexes 3- Atrial rate of 60 bpm or below 4- Shortened QRS duration.

The nurse has implemented a bladder retraining program with a 65-year-old woman after the removal of her indwelling urinary catheter. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient has 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding? 1- Perform a straight catheterization on this patient. 2- Avoid further interventions at this time, as this is an acceptable finding. 3- Place an indwelling urinary catheter. 4- Press on the patient's bladder in an attempt to encourage complete emptying.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? 1- Position the client in the supine position 2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg 3- Restrain the client, as indicated 4- Administer enemas, as needed

The nurse is analyzing a rhythm strip. What does the nurse look at to identify ventricular repolarization? 1- P wave 2- T wave 3- U wave 4- QRS complex

The nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? 1- Oral temperature of 100°F 2- Tachypnea and restlessness 3- Frequent loose stools 4- Weight loss of 1 pound since yesterday

The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with? 1- Hypothyroidism 2- Hyperthyroidism 3- Syndrome of inappropriate antidiuretic hormone secretion (SIADH) 4- Diabetes insipidus (DI)

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? 1- Dilated pupils 2- Constricted pupils 3- One pupil is dilated and the opposite pupil is normal 4- Roth's spots

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? 1- Fungal infection 2- Herpes zoster 3- Psoriasis 4- Seborrheic dermatosis

The nurse is aware that a patient has been diagnosed with thrombocytopenia. Which of the following is the most typical first indicator of the diagnosis that a patient will exhibit? 1- Fatigue 2- Petechiae 3- Hypotension 4- Tachycardia

The nurse is caring for a client who has been prescribed total parental nutrition (TPN). After several days of receiving TPN, the nurse notes the client is producing increased amount of urinea nd reporting increased thirst and blurred vision. What should be the nurse's initial action? 1- Check the client's blood pressure 2- Assess the client's blood glucose level 3- Ascultate the client's chest 4- Dip the client's urine for urinalysis

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? 1- The client will require intravenous access for three days 2- The client requires total parenteral nutrition 3- The client requires infusion of intravenous antibiotics 4- The client requires infusion of a dextrose 5% water (D5W)

The nurse is caring for a client with a lymphatic system disorder. What physical assessment is a priority for the nurse to perform? 1- Examine the color and quantity of urine. 2- Inspect the tonsils for size and appearance. 3- Frequently examine and record blood pressure. 4- Examine for any signs of physical injury

The nurse is caring for a client with essential hypertension. The nurse reviews labwork and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure? 1- The kidney retains sodium and water. 2- The kidney excretes sodium and water. 3- The kidney retains sodium and excretes water. 4- The kidney retains water and excretes sodium.

The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When doing patient education, what should be included regarding hand and arm care of the affected side? 1- Avoid exercise of the arm. 2- Keep cuticles clipped. 3- Avoid lifting objects greater than 10 pounds. 4- Use a sunscreen with an SPF of 4 to 8.

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 1- 0 2- 1+ 3- 2+ 4- 3+

The nurse is doing an initial assessment on a patient recently admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn. The nurse uses this technique to assess for what type of aphasia? 1- Auditory-receptive 2- Visual-receptive 3- Expressive speaking 4- Expressive writing

The nurse is educating a patient about the best time to perform breast self-examination (BSE). When does the nurse inform her is the best time after menses to perform BSE? 1- 3 to 4 days 2- 5 to 7 days 3- 8 to 9 days 4- After the 10th day

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? 1- A complete blood count including differential 2- Serum antibodies for H. pylori 3- A sigmoidoscopy 4- Gastric analysis

The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm? 1- Atrial fibrillation 2- Atrial flutter 3- Ventricular tachycardia 4- Ventricular fibrillation

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? 1- VIII 2- X 3- III 4- VII

The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis? 1- Imbalanced nutrition: more than body requirements 2- Diarrhea 3- Bowel incontinence 4- Constipation

The nurse is performing patient teaching with a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. How often should the patient's family members undergo examination for the detection of glaucoma? 1- At least monthly 2- At least once every 2 years 3- At least once every 5 years 4- At least once every 10 years

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? 1- A urinary output of 10 mL/hr 2- A urinary output of 30 mL/hr 3- A urinary output of 80 mL/hr 4- A urinary output of 100 mL/hr

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete piror to this assessment? 1- Prepare for a prostate examination. 2- Ask the client to empty the bladder. 3- Assist the client to a Fowler's position. 4- Dim the lights for privacy.

The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure? 1- In the right upper quadrant 2- At the umbilicus 3- At the lower border of the liver 4- Just below the last rib

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? 1 "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." 2 "I can't use a spacer or holding chamber with the MDI." 3 "I will take a slow, deep breath in after pushing down on the MDI." 4 "I will shake the MDI container before I use it."

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity? 1- "You have inherited your parent's immunity to the disease." 2- "Your symptoms are a result of your body attacking itself." 3- "You have antigens to the disease, but they do not prevent the disease." 4- "You are not immune to the disease causing the symptoms."

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? 1- Gallbladder 2- Pancreas 3- Stomach 4- Liver

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? 1- CN I 2- CN II 3- CN III 4- CN IV

The nurse on the medical-surgical floor is reviewing discharge instructions with a patient who has a history of glaucoma. Which classification of drugs on the patient's discharge instructions is used to treat the patient's glaucoma? 1- Antiemetics 2- Cholinergics 3- Antibiotics 4- Angiotensin-converting enzyme (ACE) inhibitors

The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take? 1- Administer the medications as ordered. 2- Hold the medications until after dialysis. 3- Check with the dialysis nurse about the medications. 4- Ask if the client wants to take the medications.

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? 1- "The client probably has a case of the flu and you should give acetaminophen." 2- "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." 3- "This is one of the side effects from antiretroviral therapy and will require changing the medication." 4- "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider."

The nurse recognizes that urinalysis results that most likely indicate a urinary tract infection include: 1- proteinuria 2- WBC 50 3- RBC 3 4- glucose trace

The nurse teaches the client that reducing the viral load will have what effect? 1- Shorter time to AIDS diagnosis 2- Longer survival 3- Shorter survival 4- Longer immunity

The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis? 1- Increased cardiac biomarkers 2- Hypotension 3- Tachycardia 4- Excessive sweating

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for: 1- Tonometry. 2- Ophthalmoscopy. 3- Gonioscopy. 4- Perimetry.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: 1- naloxone (Narcan). 2- famotidine (Pepcid). 3- nitroglycerin (Nitro-Bid). 4- atracurium (Tracrium).

Vasopressin (antidiuretic hormone, ADH) has just been released into an individual's circulation. Which of the following changes in homeostasis most likely prompted the individual's posterior pituitary gland to release this hormone? 1- Psychological or physiological stress 2- Increased blood osmolality 3- Increased oxygen demand 4- Increased sodium intake

What is a hallmark of the diagnosis of nephrotic syndrome? 1- Hyponatremia 2- Proteinuria 3- Hypoalbuminemia 4- Hypokalemia

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? 1- Administering an analgesic once per shift, as ordered, to prevent drug addiction 2- Positioning the client on the side with the knees flexed 3- Encouraging frequent visits from family and friends 4- Administering frequent oral feedings

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? 1- Weight loss of 2 pounds in 3 days 2- Change in the client's handwriting and/or cognitive performance 3- Anorexia for more than 3 days 4- Constipation for more than 2 days

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? 1- P wave 2- QRS complex 3- PR interval 4- QT interval

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy? 1- Depression, memory impairment, and coma 2- Respiratory or urinary system infections 3- Rheumatoid arthritis 4- Cardiac dysrhythmias and heart failure

Which clinical finding should a nurse look for in a client with chronic renal failure? 1- Hypotension 2- Uremia 3- Metabolic alkalosis 4- Polycythemia

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism? 1- Hypocalcemia 2- Hypercalcemia 3- Hyperphosphatemia 4- Hypophosphaturia

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? 1- Electrocardiogram (ECG) 2- Echocardiogram 3- Serum electrolytes 4- Blood urea nitrogen (BUN)

Which factor contributes to UTI in older adults? 1- Low incidence of chronic illness 2- Immunocompromise 3- Sporadic use of antimicrobial agents 4- Active lifestyle

Which finding should a nurse identify as requiring further investigation? 1- Red blood cell (RBC) count of 4.9 million/mm3 2- Platelet count of 115,000/mm3 3- White blood cell (WBC) count of 7,000/mm3 4- Hematocrit of 45%

Which medication classification is prescribed when allergy is a factor causing the skin disorder? 1- Corticosteroids 2- Antihistamines 3- Antibiotics 4- Local anesthetics

Which medication may be ordered to relieve discomfort associated with a UTI? 1- Nitrofurantoin 2- Phenazopyridine 3- Ciprofloxacin 4- Levofloxacin

Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys? 1- Initiation 2- Oliguria 3- Diuresis 4- Recovery

Which secondary skin lesions are associated with eczema? 1- Scales 2- Crusts 3- Ulcers 4- Erosion

Which term refers to a form of white blood cell involved in immune response? 1- Granulocyte 2- Lymphocyte 3- Spherocyte 4- Thrombocyte

Which type of cell is believed to play a significant role in cutaneous immune system reactions? 1- Merkel cells 2- Langerhans cells 3- Melanocytes 4- Phagocytes

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? 1- Varicella 2- Influenza 3- Hepatitis B 4- Human papilloma virus (HPV)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: 1- Weakness on one side of the body and difficulty with speech 2- Severe headache and early change in level of consciousness 3- Footdrop and external hip rotation 4- Confusion or change in mental status

nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: 1- Epidermal layer only. 2- Epidermis and a portion of deeper dermis. 3- Entire dermis and subcutaneous tissue. 4- Dermis and connective tissue.

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. 1- Epistaxis (nosebleed) 2- Confusion 3- Sudden numbness 4- Sudden ear pain 5- Visual disturbances

2, 3, 4

The nurse is reviewing a client's laboratory test results and notes that the client's hematocrit is increased. The nurse suspects hemoconcentration related to dehydration. Which assessment finding would support the nurse's suspicion? Select all that apply. 1- increased pulse pressure 2- elevated urine specific gravity 3- tachycardia 4- weight gain 5- slow skin turgor

2, 3, 5

Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply. 1- Hyper-reactive deep tendon reflexes 2- Decreased muscle mass 3- Increased sensitivity to heat and cold 4- Stage IV sleep is prolonged 5- Increased sensitivity of taste buds 6- Reduced papillary responses

2, 3, 6

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: 1- Increasing intracranial pressure (ICP) 2- An epidural hematoma 3- Leakage of cerebrospinal fluid (CSF) 4- Meningitis

A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? 1- Hepatitis A 2- Hepatitis B 3- Hepatitis C 4- Hepatitis D

A 58-year-old smoker is undergoing lung function testing because of his recent history of progressive dyspnea and a productive cough. Which of the following assessment findings during spirometry would be consistent with a diagnosis of chronic obstructive pulmonary disease (COPD)? 1- The patient's vital capacity is ≤75% of expected norms for his age and gender. 2- The patient's SaO2 does not increase with the application of supplementary oxygen. 3- The patient's ability to forcibly exhale is significantly diminished. 4- The patient exhibits adventitious lung sounds during inhalation

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: 1- nausea and vomiting. 2- dyspnea and cyanosis. 3- fatigue and weakness. 4- thrush and circumoral pallor.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? 1- Acute glomerulonephritis 2- Ureteral stricture 3- Urinary calculi 4- Renal cell carcinoma

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? 1- Macule 2- Vesicle 3- Pustule 4- Cyst

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment? 1- "The tube helps control fluid and electrolyte imbalance." 2- "The tube provides relief from nausea and vomiting." 3- "The tube allows the gastrointestinal tract to rest." 4- "The tube allows toxins to be removed."

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? 1- Paracentesis 2- Liver transplantation 3- High-dose corticosteroids 4- Azathioprine

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia? 1- Increase fat intake and limit carbohydrates. 2- Eliminate fat intake and increase protein intake. 3- Increase carbohydrates and limit protein intake. 4- Increase protein, carbohydrates, and fat intake.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? 1- Albumin 2- Dextrose 5% in water (D5W) 3- Lactated Ringer's solution 4- Normal saline solution with 20 mEq of potassium per 1,000 ml

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? 1- On the left side 2- Trendelenburg 3- On the right side 4- High Fowler

A client is admitted to the hospital and will be undergoing tests to determine if he has an abdominal mass. What should the nurse be sure to document when asking about allergies? 1- If the client is allergic to beef 2- If the client is allergic to pork 3- If the client is allergic to seafood 4- If the client is allergic to grapefruit

A client is diagnosed with an exudative retinal detachment. When reviewing the client's history, the nurse would identify which of the following as a possible underlying cause? 1- Trauma 2- Diabetes 3- Macular degeneration 4- Hypertension

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? 1- Decreased level of consciousness (LOC) 2- Elevated blood pressure 3- Increased urine output 4- Decreased heart rate

A client is scheduled for a diagnostic test to measure blood hormone levels. The nurse expects that this test will determine which of the following? 1- The concentration of a substance in plasma 2- Details about the size of the organ and its location 3- The functioning of endocrine glands 4- The client's blood sugar level

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? 1- Small bowel series 2- Computer tomography 3- Colonoscopy 4- Upper GI series

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? 1- Sciatic nerve pain 2- Herniation 3- Paresthesia 4- Paralysis

A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder? 1- Asystole 2- Premature ventricular contraction 3- Atrial flutter 4- Ventricular fibrillation

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication? 1- Exophthalmos 2- Thyroid storm 3- Myxedema coma 4- Tibial myxedema

A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which action? 1- Determine the client's ability to manage stoma care. 2- Show pictures and drawings of placement of the stoma. 3- Maintain skin and stomal integrity. 4- Suggest a visit to a local ostomy group.

A client visits the clinic to seek treatment for disturbed sleep cycles and depressed mood. Which glands and hormones help to regulate sleep cycles and mood? 1- Thymus gland, thymosin 2- Parathyroid glands, parathormone 3- Pineal gland, melatonin 4- Adrenal cortex, corticosteroids

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? 1- Have the client avoid physical exertion 2- Emphasize complete bed rest 3- Look for signs of increased intracranial pressure 4- Look for a halo sign

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? 1- Placing the client in a semi-Fowler's position 2- Maintaining nothing-by-mouth (NPO) status 3- Administering morphine I.V. as ordered 4- Providing mouth care

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? 1- Increased pH with decreased hydrogen ions 2- Increased serum levels of potassium, magnesium, and calcium 3- Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL 4- Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75%

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? 1- Cure the cirrhosis. 2- Treat the esophageal varices. 3- Reduce fluid accumulation and venous pressure. 4- Promote optimal neurologic function.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? 1- Chenodiol 2- Ursodiol 3- Tacrolimus 4- Interferon alfa-2b, recombinant

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? 1- Maintaining adequate hydration 2- Administering prescribed antipyretics 3- Restricting fluid intake and hydration 4- Hyperoxygenation before and after tracheal suctioning

A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? 1- "Squamous cell carcinomas do not present with detectable symptoms." 2- "You should have sought treatment earlier." 3- "Very few symptoms are associated with renal cancer." 4- "Painless gross hematuria is the first symptom in renal cancer."

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? 1- Impaired urinary elimination 2- Toileting self-care deficit 3- Risk for infection 4- Activity intolerance

A critical care nurse knows to assess the cardiac system for the probable cause of heart disease subsequent to trauma. Which of the following is a major concern? 1- Heart block 2- Pericarditis 3- Cardiac tamponade 4- Mitral regurgitation

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? 1- Risk for Fluid Volume Deficit 2- Risk forElectrolyte Imbalance 3- Impaired Swallowing 4- Altered Nutrition:Less Than Body Requirements

A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver? 1- Breakdown amino acids 2- Convert urea into ammonia 3- Excrete bile 4- Break down coagulation factors

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? 1- Temperature of 101 degrees F (38 degrees C) 2- Diaphoresis 3- Delirium 4- Bradycardia

A male patient has just been diagnosed with end-stage renal disease (ESRD) and has presented numerous questions to the nurse in anticipation of his upcoming appointment with his primary care provider. Specifically, the patient has many questions surrounding hemodialysis. What should the nurse teach this patient about his diagnosis and hemodialysis? 1- "Hemodialysis is becoming much less common because of improved medications for the management of ESRD." 2- "Your doctor will probably recommend hemodialysis only as a last resort if conservative treatments are unsuccessful." 3- "These days, many patients are encouraged to start hemodialysis well before their ESRD becomes severe." 4- "Your doctor will probably start you on hemodialysis a few times a month and then increase the frequency."

A nurse caring for a patient with diabetes insipidus is reviewing the patient's laboratory results. What is an expected urinalysis finding? 1- Glucose in the urine 2- Albumin in the urine 3- Urine specific gravity of 1.001 to 1.005 4- Leukocytes in the urine

A nurse has asked the unit educator what happens when the amount of fluid in the pericardial sac increases. What should the educator tell the nurse? 1- It raises the pressure inside the pericardial sac, causing fluid to leak through. 2- It raises the pressure inside the pericardial sac, compressing the lungs. 3- It raises the pressure inside the pericardial sac, compressing the heart. 4- It raises the pressure inside the pericardial sac, causing it to rupture.

A nurse has assessed a patient's orientation during the initial head-to-toe assessment near the beginning of a shift. The patient is able to state his own full name and knows the name of the hospital but is unable to identify the month and the year. How should the nurse best document this assessment finding? 1- "Patient is demonstrating signs of decreased neurological function." 2- "Patient is disoriented." 3- "Patient is oriented to person and place, but unable to state month and year." 4- "Patient is oriented to person, oriented to place, but not oriented to time."

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: 1- Reddened; blanches with pressure. 2- Blistered with a mottled red base. 3- Dry and pale white. 4- Broken epidermis that is weeping.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: 1- hypotension. 2- thick, coarse skin. 3- deposits of adipose tissue in the trunk and dorsocervical area. 4- weight gain in arms and legs.

A nurse is assigned to care for a patient with increased parathormone secretion. Which of the following serum levels should the nurse monitor for this patient? 1- Glucose 2- Sodium 3- Calcium 4- Potassium

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? 1- Anaphylaxis 2- Sepsis 3- Hypovolemia 4- Cardiac dysfunction

A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal? 1- Determine the stone type. 2- Relieve any obstruction. 3- Relieve the pain. 4- Prevent nephron destruction.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? 1- "Exposure to sunlight will help control skin rashes." 2- "There are no activity limitations between flare-ups." 3- "Monitor your body temperature." 4- "Corticosteroids may be stopped when symptoms are relieved."

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? 1- Hepatitis B is transmitted primarily by the oral-fecal route. 2- Hepatitis A is frequently spread by sexual contact. 3- Hepatitis C increases a person's risk for liver cancer. 4- Infection with hepatitis G is similar to hepatitis A.

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? 1- large-artery thrombotic 2- small, penetrating artery thrombotic 3- cardio embolic 4- cryptogenic

A nurse is reviewing the complete blood count with differential for a client with severe allergies. Which white blood cell would the nurse expect to be elevated? 1- neutrophil 2- monocyte 3- eosinophil 4- lymphocyte

A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? 1- "I will avoid friends and family members who are sick." 2- "I will eat lots of chicken and dairy products." 3- "I may stop taking this medication when I feel better." 4- "I will see my ophthalmologist regularly for a check-up."

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? 1- Calcium and magnesium 2- Potassium and calcium 3- Magnesium and potassium 4- Potassium and sodium

A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following? 1- Hyperuricemia 2- Pancreatitis 3- Diabetes mellitus 4- Hyperparathyroidism

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? 1- Insertion of an ICD 2- Insertion of a permanent pacemaker 3- Catheter ablation therapy 4- Maze procedure

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings? 1- Hand that appears pink with some white spotting 2- Hand that is firm to palpation 3- Hand that is insensitive to touch 4- Hand that is cool with pale nailbeds

A patient is diagnosed with a complicated UTI. Which of the following drugs will the patient most likely begin initial pharmacologic therapy? 1- Phenazopyridine 2- Fluoroquinolone 3- Cephalosporin 4- Nitrofurantoin

A patient presented to the emergency room with gunshot wounds to the abdomen and right thigh. The trauma nurse documented a positive Kehr's sign. Based on the diagnosis, the nurse knows to report the possibility of: 1- Acute pancreatitis. 2- Damage to the small bowel. 3- A ruptured spleen. 4- Liver laceration.

A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize most related to discharge teaching? 1- The patient will obtain measurement of drainage from the T-tube. 2- The patient will exercise three times a week. 3- The patient will take immunosuppressive agents as required. 4- The patient will monitor for signs of liver dysfunction.

A patient with a brain tumor has been admitted to the critical care unit after developing syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). In light of this patient's endocrine disorder, what assessments should the nurse prioritize? 1- Potassium levels, blood urea nitrogen (BUN), creatinine 2- Abdominal girth, lung auscultation 3- Sodium levels, urine output 4- Arterial blood gases, level of consciousness

A patient with a diagnosis of open-angle glaucoma is being prepared for discharge, and the nurse is performing relevant health education. Which of the following teaching points should the nurse emphasize? 1- The need to wear sunglasses or other forms of eye protection in all high-light situations 2- The need to maintain vigilant hygiene of the eyes and perform saline flushes regularly 3- The importance of adhering to life-long treatment because the disease cannot be cured 4- The importance of not rubbing or pressing the eyes while washing the periorbital region

A patient with portal hypertension has been admitted to the medical floor. What will the nurse assess for related to portal hypertension? 1- Bowel obstruction 2- Vitamin A deficiency 3- Ascites 4- Hepatic encephalopathy

A primary nursing assessment for a patient who has sustained a fracture involving the basilar skull is inspection for: 1- Leakage of CSF from the nose. 2- Ecchymosis of the mastoid process of the temporal bone. 3- Leakage of CSF from the ear. 4- Vomiting and headaches due to increased intracranial pressure.

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? 1- Liver 2- Ileum 3- Stomach 4- Large Intestine

Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment? 1- Helps push oxygen into the tissues of the body 2- Retains leukocytes in the vascular compartment 3- Helps retain fluid in the vascular compartment 4- Absorbs carbon dioxide from the tissues for transport to the lungs

An elderly patient has developed Clostridium difficile-related diarrhea, a problem that has led to dehydration and hypokalemia. The increased peristalsis that characterizes diarrhea has the potential to cause fluid volume deficit and electrolyte deficits because: 1- Increased peristalsis diverts energy away from the absorptive activities of the small intestine. 2- Increased peristalsis creates increased metabolic demand, which in turn depletes fluid and electrolyte reserves. 3- An increase in peristalsis means that the colon cannot absorb the substances that it normally absorbs. 4- An increase in peristalsis reduces the normal surface area of the villi and microvilli in the colon.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to 1- control fever. 2- control shivering. 3- dehydrate the brain and reduce cerebral edema. 4- reduce cellular metabolic demand.

Continuous positive airway pressure (CPAP) has been ordered for a patient in the intensive care unit in an effort to defer intubation. The respiratory therapist has set up the patient's CPAP system and the nurse is now responsible for maintaining the system. When assessing the function of the patient's CPAP, the nurse should ensure that: 1- Suction is set between 30 and 45 mm Hg. 2- The patient receives nebulized bronchodilators every 2 to 3 hours. 3- A tight seal exists between the mask and the patient's mouth. 4- The patient is breathing between 30 and 40 breaths per minute.

Culture of client's vaginal discharge reveals Gardnerella vaginalis. Which of the following would the nurse expect to assess? 1- Foul, foamy discharge 2- Thick, curdy, white discharge 3- Fishy-smelling watery discharge 4- Yellowish-white discharge

Evaluation of an adult client reveals oversecretion of growth hormone. Which of the following would the nurse expect to find? 1- Excessive urine output 2- Weight loss 3- Bulging forehead 4- Constant thirst

Hypertension that can be attributed to an underlying cause is termed 1- primary hypertension. 2- essential hypertension. 3- secondary hypertension. 4- isolated systolic hypertension.

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? 1- Removal of clothing 2- Irrigation of the wound 3- Application of ice 4- Removal of hair

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? 1- Cerium nitrate solution 2- Gentamicin sulfate 3- Sulfadiazine, silver (Silvadene) 4- Mafenide (Sulfamylon)

Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication? 1- Constricts intraocular vessels 2- Paralyzes ciliary muscles 3- Constricts pupil 4- Dilates the pupil

Serologic testing of a middle-aged woman with a recent history of severe flu-like symptoms has just resulted in a diagnosis of hepatitis A. Which of the following assessment questions should the nurse prioritize when discussing this diagnosis with the patient? 1- "Are you currently in a monogamous sexual relationship?" 2- "How would describe your typical diet? 3- "Which restaurants have you eaten in over the past few weeks?" 4- "Have you ever used recreational drugs?"

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? 1- The wound will take up to 3 weeks to heal. 2- Pain management will be a challenge. 3- Skin grafting will be necessary. 4- Ligaments, tendons, muscles, and bone are not involved.

The clinic nurse is teaching a young woman about preventing recurrent urinary tract infections. What information should the nurse include? 1- Bathe daily. 2- Avoid voiding immediately after sexual intercourse. 3- Drink liberal amounts of fluids. 4- Void every 6 to 8 hours.

The most important nursing priority of treatment for a patient with an altered LOC is to: 1- Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. 2- Prevent dehydration and renal failure by inserting an IV line for fluids and medications. 3- Maintain a clear airway to ensure adequate ventilation. 4- Position the patient to prevent injury and ensure dignity.

The nurse auscultates a bruit over the thyroid glands. What does the nurse understand is the significance of this finding? 1- The patient may have hypothyroidism. 2- The patient may have thyroiditis. 3- The patient may have hyperthyroidism. 4- The patient may have Cushing disease.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? 1- Normal 2- Hypoactive 3- Hyperactive 4- Borborygmi

The nurse instructs a client to perform continuous ambulatory peritoneal dialysis correctly at home. Which educational information should the nurse provide to the client? 1- Wear a mask while handling any dialysate solutions. 2- Keep the catheter stabilized to the abdomen, below the belt line. 3- Use an aseptic technique during the procedure. 4- Clean the catheter insertion site daily with soap.

The nurse is admitting a client into the intensive care unit after cardiac surgery. The nurse notes the client has temporary pacemaker wires surgically placed of into the middle lining of the heart. The nurse knows the client has which type of pacemaker? 1- External pacemaker 2- Transvenous pacemaker 3- Epicardial pacemaker 4- Transthoracic cardiac pacemaker

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location? 1- Ileum 2- Cecum 3- Sigmoid colon 4- Duodenum

The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' would the nurse expect to find? 1- Hair loss 2- Moon face 3- Bulging eyes 4- Fatigue

The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion? 1- Hives 2- Impetigo 3- Port-wine stains 4- Psoriasis

The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation? 1- Severe hypertension 2- Hyperactivity 3- Intoxication 4- Cherry red skin coloring

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? 1- Forearm 2- Hand 3- Foot 4- Upper arm

The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? 1- Hypernatremia 2- Hypokalemia 3- Hyperkalemia 4- Hypercalcemia

The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. What instruction should the nurse give the patient? 1- Limit oral fluid intake for 1 to 2 weeks. 2- Report the presence of fine, sandlike particles through the nephrostomy tube. 3- Notify the health care provider about cloudy or foul-smelling urine. 4- Report pink urine within 24 hours after the procedure.

The nurse is caring for a patient with a bone tumor. The nurse provides education that teaches the patient to implement measures to reduce the risk of pathologic fractures. What intervention will assist the patient in fracture prevention? 1- Teaching the patient to achieve maximum weight-bearing capabilities 2- Maintaining strict bed rest 3- Supporting the affected extremity with external supports (splints) 4- Limiting the patient's reliance on ass

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? 1- To decrease metabolism 2- To depress the central nervous system and increase the pain threshold 3- To reduce gastric and pancreatic secretions 4- To relieve nausea and vomiting

The nurse is caring for a patient with end-stage kidney disease in the hospital and smells a fetid odor from the patient's breath. What major manifestation of uremia will be present? 1- A decreased serum phosphorus level 2- Hyperparathyroidism 3- Hypocalcemia with bone changes 4- Increased secretion of parathormone

The nurse is closely monitoring the blood work of a patient who has a diagnosis of primary hyperparathyroidism. The nurse should be aware that the fluid and electrolyte disturbances associated with this disease create a significant risk of what problems? 1- Fluid volume overload and pruritus 2- Metabolic acidosis and cardiac ischemia 3- Renal calculi and urinary obstruction 4- Deep vein thrombosis and pulmonary embolism

The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? 1- ability to perform activities of daily living (ADL) 2- decreased joint pain 3- increased fatigue 4- a weight gain of 2 pounds

The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block? 1- A variable heart rate, usually fewer than 60 bpm 2- An irregular rhythm 3- Delayed conduction, producing a prolonged PR interval 4- P waves hidden with the QRS complex

The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black, tarry stool. What does the nurse understand may be a side effect of this medication that the client displays? 1- Leukocytosis 2- Leukopenia 3- Thrombocytopenia 4- Neutropenia

The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test? 1- Head of the bed in a 90° semi-Fowler's position 2- Prone position 3- On the side opposite the aspiration site 4- Lithotomy position

The nurse is providing patient education in anticipation of the patient's scheduled bone marrow aspiration and biopsy. When teaching the patient about care after the procedure, the nurse should encourage the patient to do which of the following? 1- Take aspirin to alleviate pain. 2- Remain on bed rest for 24 to 36 hours after the procedure. 3- Avoid bathing until the site heals. 4- Avoid the use of oral analgesics.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? 1- Cerium nitrate solution 2- Gentamicin sulfate 3- Sulfadiazine, silver (Silvadene) 4- Mafenide (Sulfamylon)

The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for? 1- Administer an intravenous antibiotic to the mom while in labor. 2- Complete a full assessment of the newborn on delivery. 3- Prepare for a cesarean section. 4- Place an antibacterial ointment on the mother's lesions.

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of 1- albinism. 2- vitiligo. 3- anemia. 4- local arterial insufficiency.

The nursing assessment findings reveal joint swelling and tenderness in the great toe of a client. What does the nurse suspect? 1- ankylosing spondylitis 2- osteoarthritis 3- gout 4- rheumatoid arthritis

The nursing educator is teaching a group of new graduates about Addison's disease. What symptom would the educator identify as being characteristic of Addison's disease? 1- Truncal obesity 2- Hypertension 3- Muscle weakness 4- "Moon" face

The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation? 1- It is a scheduled procedure 1 to 10 days in advance. 2- The client is sedated before the procedure. 3- It is used to eliminate ventricular dysrhythmias. 4- It uses less electrical energy than cardioversion.

What is a common source of airway obstruction in an unconscious client? 1- A foreign object 2- Saliva or mucus 3- The tongue 4- Edema

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil? 1- Anti-infectives 2- Corticosteroids 3- Cycloplegics 4- NSAIDs

When do most perinatal HIV infections occur? 1- Through breastfeeding 2- In utero 3- After exposure during delivery 4- Through casual contact

When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating 1- normal sinus rhythm. 2- sinus bradycardia. 3- sinus dysrhythmia. 4- sinus tachycardia.

Which client is most likely to develop systemic lupus erythematosus (SLE)? 1- A 25-year-old white male 2- A 25-year-old Jewish female 3- A 27-year-old black female 4- A 35-year-old Hispanic male

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease? 1- Keep an accurate record of intake and output. 2- Use nasal desmopressin acetate (DDAVP). 3- Have regular follow-up care. 4- Exercise to improve cardiovascular fitness.

Which nursing intervention should the nurse caring for the client with pyelonephritis implement? 1- Straight catheterize the client every 4 to 6 hours. 2- Administer acetaminophen (Tylenol). 3- Teach client to increase fluid intake up to 3 liters per day. 4- Restrict fluid intake to 1 liter per day.

Which of the following is a true statement regarding the purposes of skin grafts? 1- Increases evaporative fluid loss. 2- Increases potential for infection. 3- Reduces scarring and contractures. 4- Prolongs recovery

Which of the following nursing actions is most important in caring for the client following lithotripsy? 1- Monitor the continuous bladder irrigation. 2- Administer allopurinol (Zyloprim). 3- Strain the urine carefully for stone fragments. 4- Notify the physician of hematuria.

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning? 1- "I've been feeling sick to my stomach for about 3 or 4 days now." 2- "The food I ate seemed to look and taste like it should." 3- "My brother got sick like me after eating the same food." 4- "I have a pain in my left side, down low near my groin."

Which type of incontinence is the involuntary loss of urine through an intact urethra as a result of coughing? 1- Reflex 2- Urge 3- Stress 4- Overflow

While taking a health history on a 20-year-old woman, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse knows that this medication is used to treat what medical condition? 1- Bacterial vaginosis 2- Human papillomavirus (HPV) 3- Candidiasis 4- Toxic shock syndrome (TSS)

he nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? 1- Remove the peripheral IV line 2- Start a dextrose 5% water infusion 3- Run a normal saline line to keep the vein open 4- Obtain a blood culture from the IV insertion site

he nurse practitioner who assesses a patient with hyperthyroidism would expect the patient to report which of the following conditions? 1- Fatigue 2- Dyspnea 3- Weight loss 4- Hair loss

he triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? 1- Cover the burn with ice and secure with a towel. 2- Apply skin lotion to the area that is burned. 3- Immerse the child in a cool bath. 4- Avoid touching the burned area in any way.

A nurse is reading a journal article about white blood cells and how they function. The nurse demonstrates understanding of the article by identifying which white blood cell as a granulocyte? Select all that apply. 1- monocytes 2- lymphocytes 3- eosinophils 4- basophils 5- neutrophils

3, 4, 5

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) 1- Jugular vein distention 2- Ascites 3- Pulmonary crackles 4- Dyspnea 5- Cough

3, 4, 5

A 49-year-old man with a history of poorly controlled type 1 diabetes has developed osteomyelitis adjacent to a chronic diabetic ulcer on his great toe. The patient has been informed that medical treatment for osteomyelitis requires a longer course of antibiotics than most other infections because: 1- Osteomyelitis is usually caused by simultaneous infection with several microorganisms, which must be treated sequentially. 2- Osteomyelitis requires treatment with topical antibiotics rather than IV antibiotics, necessitating a longer course of treatment. 3- Osteomyelitis is usually the result of fungal infection rather than bacterial infection. 4- Osteomyelitis involves the active infection of bone tissue, which is largely avascular.

A 71-year-old man has made an appointment with his primary care provider at the urging of his wife, who states that he has occasionally had episodes of weakness and slurring of words over the past several weeks. The care provider recognizes the possibility that the man has been experiencing transient ischemic attacks (TIAs). TIAs have which of the following characteristics? 1- TIAs result in motor symptoms rather than sensory symptoms. 2- TIAs are a result of minor cerebral hemorrhages that spontaneously resolve. 3- TIAs cause irreversible, but minor, neurological damage. 4- TIAs cause symptoms that last less than 1 hour.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? 1- Monitor pulse oximetry every hour. 2- Withhold oral feedings for the client. 3- Instruct the client to avoid coughing. 4- Reposition the client every 2 hours.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate? 1- Furosemide 2- Nitroglycerin 3- Dopamine 4- Morphine sulfate

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared charred. What depth of burn injury does the client have? 1- full thickness (third degree) 2- superficial (first degree) 3- superficial partial-thickness or deep partial-thickness (second degree) 4- fourth degree

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? 1- Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction 2- Ineffective cerebral tissue perfusion related to increased intracranial pressure 3- Disturbed thought processes related to brain injury 4- Ineffective airway clearance related to brain injury

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? 1- Blood urea nitrogen (BUN) level of 12 mg/dl 2- Blood glucose level of 90 mg/dl 3- Serum sodium level of 134 mEq/L 4- Serum potassium level of 5.8 mEq/L

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? 1- Encourage oral fluids. 2- Administer furosemide (Lasix) 20 mg IV 3- Start hemodialysis after a temporary access is obtained. 4- Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for: 1- exophthalmos and conjunctival redness. 2- flushed, warm, moist skin. 3- systolic murmur at the left sternal border. 4- decreased body temperature and cold intolerance.

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have? 1- Secondary 2- Pathologic 3- Malignant 4- Essential (primary)

A client is being seen in the clinic to receive the results of the lab work to determine thyroid levels. The nurse observes the client's eyes appear to be bulging, and there is swelling around the eyes. What does the nurse know that the correct documentation of this finding is? 1- Retinal detachment 2- Periorbital swelling 3- Bulging eyes 4- Exophthalmos

A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? 1- If the client experiences nausea, omit the dose. 2- The client should be alert for joint aches. 3- This medication is commonly used for many inflammatory reactions and is relatively safe. 4- Be alert for signs and symptoms of infection and report them immediately to the physician.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered

A client presents at the clinic with reports of urinary retention. What question should the nurse ask to obtain additional information about the client's report? 1- "Have you had a fever and chills?" 2- "How much fluid are you drinking?" 3- "Do you get up at night to urinate?" 4- "When did you last urinate?"

A client requires hemodialysis. Which type of drug should be withheld before this procedure? 1- Phosphate binders 2- Insulin 3- Antibiotics 4- Cardiac glycosides

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? 1- Keep the AV fistula site dry. 2- Keep the AV fistula wrapped in gauze. 3- Take the client's blood pressure in the left arm. 4- Assess the AV fistula for a bruit and thrill.

A client with a spinal cord injury has full head and neck control when the injury is at which level? 1- C1 2- C2 to C3 3- C4 4- C5

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: 1- fluid resuscitation. 2- infection. 3- body image. 4- pain management.

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? 1- Ipratropium bromide 2- Fluticasone propionate 3- Ipratropium bromide and albuterol sulfate 4- Albuterol

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? 1- fluid intake and output. 2- urine specific gravity. 3- vital signs. 4- weight.

A female patient with a recent diagnosis of end-stage renal disease (ESRD) is scheduled to soon begin hemodialysis. A nephrology nurse has been conducting extensive patient teaching in anticipation of this treatment. What diet should the nurse recommend to minimize her patient's risk of complications and interdialytic weight gain? 1- Low-fat diet with an emphasis on simple carbohydrates 2- Small, frequent meals with an emphasis on leafy green vegetables 3- Low-potassium, high-calorie diet 4- Low-protein, low-sodium diet

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum? 1- Cardiac sphincter 2- Hypoharyngeal sphincter 3- Ileocecal valve 4- Pyloric sphincter

A hospital patient's most recent blood work reveals a Ca2+ level of 14.2 mg/dL (normal 8.5 to 10.5 mg/dL) and a phosphorus level of 1.4 mg/dL (normal 3.0 to 4.5 mg/dL). What hormone has the potential to cause this alteration in the patient's electrolyte levels? 1- Calcitonin 2- Corticotropin-releasing hormone (CRH) 3- Thyroid hormone 4- Parathyroid hormone

A male patient is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When the nurse assesses the patient, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm? 1- Superficial partial-thickness 2- Deep partial-thickness 3- Full partial-thickness 4- Full-thickness

A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? 1- Pulmonary congestion 2- Cough 3- Dyspnea 4- Jugular venous distention

A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? 1- Positive Romberg test, indicating a problem with level of consciousness 2- Negative Romberg test, indicating a problem with body mass 3- Negative Romberg test, indicating a problem with vision 4- Positive Romberg test, indicating a problem with equilibrium

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? 1- No JVD is present. 2- JVD is noted at the level of the sternal angle. 3- JVD is noted 2 cm above the sternal angle. 4- JVD is noted 4 cm above the sternal angle.

A nurse is assessing a patient with impetigo. The nurse would most likely observe which of the following? 1- Wheal 2- Pustule 3- Vesicle 4- Papule

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: 1- Coma 2- Absence of brain stem reflexes 3- Apnea 4- Glasgow Coma Scale of 6

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do? 1- Monitor laboratory values daily for elevated thyroid-stimulating hormone. 2- Observe for swelling of the neck, tracheal deviation, and severe pain. 3- Evaluate the quality of the client's voice postoperatively, noting any drastic changes. 4- Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients? 1- Clients with recurrent life-threatening bradycardias 2- Clients with sinus tachycardia 3- Clients with ventricular bradycardia 4- Clients with recurrent life-threatening tachydysrhythmias

A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this morning was 150/92 mm Hg. When the client asks the nurse what his or her blood pressure should be, what is the nurse's most appropriate response? 1- "Your blood pressure is fine. Just keep doing what you're doing." 2- "The current recommendation is for everyone to have blood pressure of 140/90 mm Hg or lower." 3- "The lower the better. Blood pressure of 120/80 mm Hg is best for everyone." 4- "Clients with diabetes should have a lower blood pressure goal. You should strive for 130/80 mm Hg."

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: 1- identification of information due to slowed passages of information to brain. 2- cognitive ability to understand relayed information. 3- processing information transferred from the environment. 4- response due to interrupted impulses from the central nervous system

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? 1- frontal 2- parietal 3- temporal 4- occipital

A nurse is establishing a patient's airway. Which action would the nurse perform first? 1- Giving abdominal thrusts 2- Using the jaw-thrust maneuver 3- Inserting an artificial airway 4- Repositioning the patient's head

A nurse is providing care to a client in the ICU and monitors the client's blood glucose levels four times a day. The nurse anticipates administering insulin therapy based on which blood glucose range for the client? 1- 80 to 100 mg/dL (4.44 to 5.55 mmol/L) 2- 100 to 110 mg/dL (5.55 to 6.11 mmol/L) 3- 120 to 140 mg/dL (6.66 to 7.77 mmol/L) 4- 140 to 180 mg/dL (7.77 to 9.99 mmol/L)

A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom? 1- Urinary retention 2- Fever 3- Frequency 4- Painless hematuria

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: 1- 170 mm Hg/105 mm Hg 2- 175 mm Hg/100 mm Hg 3- 185 mm Hg/110 mm Hg 4- 190 mm Hg/120 mm Hg

A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis? 1- Anastrozole 2- Exemestane 3- Letrozole 4- Tamoxifen

A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of? 1- Monocytes 2- B lymphocytes 3- Leukocytes 4- T lymphocytes

A patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing? 1- Sinus bradycardia 2- Ventricular tachycardia 3- Normal sinus rhythm 4- Sinus tachycardia

A patient has been diagnosed with postrenal failure. The nurse reviews the patient's electronic health record and notes a possible cause. Which of the following is the possible cause? 1- Acute pyelonephritis 2- Osmotic dieresis. 3- Dysrhythmias 4- Renal calculi

A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The patient shares with the nurse that she's worried about her future, but she seems to be adjusting well to her diagnosis and surgery. What nursing intervention is appropriate to support this patient's coping? 1- Tell the patient's spouse or partner to be supportive while she recovers. 2- Encourage the patient to proceed with the next phase of treatment. 3- Recommend that the patient remain cheerful for the sake of her children. 4- Refer the patient to the American Cancer Society's Reach to Recovery program or another support program.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? 1- Simple 2- Comminuted 3- Depressed 4- Basilar

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? 1- Dysfunction of the spinal accessory nerve 2- Dysfunction of the acoustic nerve 3- Dysfunction of the facial nerve 4- Dysfunction of the vagus nerve

A patient is being treated in the critical care unit for urosepsis. The patient's level of consciousness has decreased over the past 12 hours, but the nurse is continuing to conduct regularly scheduled pain assessments in the knowledge that: 1- Pain is associated with a consequent decrease in renal function. 2- Pain blunts the patient's awareness of other important signs and symptoms. 3- Pain contributes to hyperglycemia and hypoglycemia. 4- Pain increases the patient's cardiac workload.

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? 1- Numbness of an arm or leg 2- Double vision 3- Severe headache 4- Dizziness and tinnitus

A patient suffered a brain stem injury in an assault and is currently receiving controlled mandatory ventilation (CMV) in the intensive care unit. When conducting the scheduled assessments of this patient, the nurse should be aware of which of the following characteristics of CMV? 1- The patient breathes spontaneously, but a set tidal volume is delivered. 2- Oxygen supplementation is constantly adjusted by the ventilator in response to the patient's respiratory rate. 3- The patient's tidal volume is determined spontaneously, but the respiratory rate is controlled by CMV. 4- The rate and tidal volume are set, and the patient does not breathe spontaneously.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? 1- Ventricular tachycardia 2- Atrial fibrillation 3- Third-degree heart block 4- Ventricular fibrillation

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? 1- Frontal lobe 2- Occipital lobe 3- Parietal lobe 4- Brain stem

A patient with a history of acute coronary syndrome is having an electrocardiogram (ECG). When interpreting the ECG for potential signs of cardiac ischemia, the nurse should focus on which of the following waveforms and intervals? 1- P wave 2- U wave 3- QT interval 4- ST segment

A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection? 1- Clotrimazole (Gyne-Lotrimin) 2- Metronidazole (Flagyl) 3- Podophyllin (Podofin) 4- Acyclovir (Zovirax)

A patient's electrocardiogram (ECG), which has been ordered stat, indicates that the patient is experiencing ventricular tachycardia (VT). Which of the following nursing diagnoses should the nurse prioritize in the immediate care of this patient? 1- Anxiety related to fear of the unknown 2- Deficient knowledge, deficient regarding the arrhythmia and its treatment 3- Dysreflexia 4- Cardiac output (CO), decreased

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? 1- Checking stools for occult blood 2- Performing range-of-motion (ROM) exercises on the left side 3- Keeping skin clean and dry 4- Elevating the head of the bed to 30 degrees

An adult patient's blood pressure readings have ranged from 138/92 to 154/100 during the past several weeks. As a result, the patient's nurse practitioner has ordered diagnostic follow-up. Which of the following diagnostic tests should the nurse prioritize when assessing the patient for target organ damage? 1- C-reactive protein (CRP) levels 2- Sodium, chloride, and potassium levels 3- Arterial blood gas (ABG) results 4- Blood urea nitrogen (BUN) and creatinine levels

Antiretroviral medications should be offered to clients with T-cell counts less than 1- 50 cells/mm3. 2- 150 cells/mm3. 3- 250 cells/mm3. 4- 350 cells/mm3.

Assessment of a client reveals evidence of a cystocele. The nurse interprets this as which of the following? 1- Herniation of the rectum into the vagina 2- Protrusion of intestinal wall into the vagina 3- Downward displacement of the cervix 4- Bulging of the bladder into the vagina

Behavioral interventions for urinary incontinence can be coordinated by a nurse. A comprehensive program that incorporates timed voiding and urinary urge inhibition is referred to as what? 1- Voiding at given intervals 2- Prompted voiding 3- Interval voiding 4- Bladder retraining

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: 1- high Fowler's position. 2- lithotomy position. 3- dorsal recumbent position. 4- supine position.

Both the liver and the spleen have a role in erythrocyte metabolism. How would this role best be described? 1- The spleen helps in creating mature erythrocytes. 2- The liver generates erythropoietin which regulates the rate of erythrocyte production. 3- The spleen stores the iron component of hemoglobin from erythrocytes and returns it to the red marrow. 4- The spleen removes erythrocytes after 120 days, and the liver removes severely damaged erythrocytes.

Cardiac effects of hyperthyroidism include 1- decreased pulse pressure. 2- decreased systolic blood pressure. 3- bradycardia. 4- palpitations.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: 1- sodium. 2- potassium. 3- magnesium. 4- phosphorus.

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection? 1- Use clean technique during insertion 2- Use sterile technique to disconnect the catheter from the tubing to obtain urine specimens 3- Place the catheter bag on the client's abdomen when moving the client 4- Perform meticulous perineal care daily with soap and water

In response to a patient's elevated blood glucose level, the nurse has administered a dose of insulin as ordered. The nurse understands that insulin results in a lowered level of blood glucose by: 1- Breaking the molecular bonds in glucose molecules 2- Stimulating thyroid hormone release and increasing metabolic needs 3- Inhibiting the action of glucagon 4- Facilitating glucose transport into body cells

It is important for the nurse to encourage the client to rise slowly from a sitting or lying position because gradual changes in position 1- help reduce the blood pressure to resupply oxygen to the brain. 2- help reduce the work required by the heart to resupply oxygen to the brain. 3- provide time for the heart to increase the rate of contraction to resupply oxygen to the brain. 4- provide time for the heart to reduce the rate of contraction to resupply oxygen to the brain.

Plasma proteins play an essential role in maintaining water balance and blood pressure. Select the laboratory analysis that a nurse should review to check the levels of the most abundant plasma protein. 1- Fibrinogen 2- Prothrombin 3- Gamma globulin 4- Albumin

The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education? 1- Pats skin dry after bathing 2- Uses moisturizing creams 3- Keeps nails trimmed short 4- Brief, hot daily showers

The following outcome appears on the plan of care for a client with genital herpes: "Client demonstrates knowledge about measures to reduce the risk of transmission and recurrences." Which of the following, if reported by the client, would support achievement of this outcome? 1- Avoids sexual activity when lesions are present 2- Cleans lesions with strong anti-bacaterial soap 3- Applies occlusive dressings to lesions 4- Consistently uses condoms with sexual activity

The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? 1- "If the health care provider massages over the exact painful area, the pain will disappear." 2- "The area may determine the severity of the pain." 3- "This determines the pain medication to be ordered." 4- "Often the area of pain is referred from another area."

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? 1- Tachycardia 2- Ascites 3- Nocturia 4- Dizziness

The nurse cares for a client in the burn unit. What is an early sign of sepsis in the client with burn injury? 1- Hyperthermia 2- Decreased pulse rate 3- Clammy skin 4- Narrowing pulse pressure

The nurse documents that a client is having a normal sinus rhythm. What characteristics of this rhythm has the nurse assessed? 1- Heart rate between 60 and 150 beats per minute. 2- Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 seconds. 3- The ventricles depolarize in 0.5 seconds or less. 4- The sinoatrial (SA) node initiates the impulse.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? 1- Occipital skull fracture 2- Temporal skull fracture 3- Frontal skull fracture 4- Basilar skull fracture

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? 1- Cranial nerve I 2- Cranial nerve V 3- Cranial nerve XI 4- Cranial nerve XII

The nurse is caring for a client who has been in the intensive care unit for 5 days. The nurse is preparing the client to ambulate by having the client sit at the edge of the bed. The nurse notes the client is unable lift the front of the foot and toes upward. What nursing intervention is appropriate based on this assessment? 1- Encourage to the client to stand up and stretch out the foot 2- Massage the anterior surface and toes of the foot 3- Provide the client with an assistive device and encourage ambulation within the room 4- Promote dorsiflexion with a footboard and request a physiotherapy consult

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? 1- Concave 2- Brittle 3- Discolored 4- Clubbing

The nurse is caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What nursing intervention should the nurse provide to the client during the test? 1- Administer oral radioactive vitamin B12 to the client. 2- Administer a nonradioactive B12 injection. 3- Collect urine for 24 to 48 hours after the client receives the nonradioactive B12. 4- Support the client and monitor the status.

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? 1- Skin scraping 2- Tzanck smear 3- Patch test 4- Biopsy

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority? 1- Knowledge Deficit 2- Powerlessness 3- Anxiety 4- Impaired Skin Integrity

The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase? 1- Jaundice 2- Clay-colored stools 3- Liver function tests approaching normal 4- Rash

The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency? 1- Heart rate of 62 2- Blood pressure 90/58 mm Hg 3- Oxygen saturation of 96% 4- Temperature of 102ºF

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? 1- The woman is demonstrating the early signs of cardiogenic shock. 2- The woman has left-sided heart failure. 3- The woman is also likely to experience shortness of breath. 4- The woman may be experiencing an exacerbation of right-sided HF.

The nurse is conducting an abdominal assessment of a patient who is postoperative day 1 following an open cholecystectomy. During auscultation of the patient's abdomen, the nurse has noted that clicks and gurgles are audible approximately every 10 seconds. How should the nurse follow up this assessment finding? 1- The nurse should administer a p.r.n. stool softener. 2- The nurse should contact the patient's care provider. 3- The nurse should assess the patient for paralytic ileus. 4- The nurse should document normoactive bowel sounds.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status? 1- Pulse oximetry 2- Listening to breath sounds 3- End-tidal CO2 4- Arterial blood gases

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? 1- BNP of 100 2- Sodium level of 135 3- Hemoglobin of 12 4- Potassium level of 3.1

The nurse is reviewing a client's laboratory studies and determines that the client has an elevated calcium level. What does the nurse know will occur as a result of the rise in the serum calcium level? 1- A rise in serum calcium stimulates the release of T lymphocytes. 2- A rise in serum calcium stimulates the release of erythropoietin. 3- A rise in serum calcium inhibits the release of calcitonin. 4- A rise in serum calcium stimulates the release of calcitonin from the thyroid gland.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? 1- Age younger than 40 years 2- Hyperopia since age 20 years 3- History of respiratory disease 4- Prolonged use of corticosteroids

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective? 1- "My energy level will gradually increase over time." 2- "I do not need to make any changes in my diet." 3- "My medications will ultimately correct my problem." 4- "I should avoid prolonged sun exposure."

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? 1- "I will wash my hands whenever I get home from work." 2- "I will make sure to have my own toothbrush and tube of toothpaste at home." 3- "I will avoid contact with people who are sick or who have recently been vaccinated." 4- "I will be sure to eat lots of fresh fruits and vegetables every day."

The nurse knows to assess a patient with hyperthyroidism for the primary indicator of: 1- Fatigue 2- Weight gain 3- Constipation 4- Intolerance to heat

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: 1- Obesity 2- Dyslipidemia 3- Smoking 4- Hypertension

The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? 1- Apply ice to the site of the burn for 5 to 10 minutes. 2- Wrap the patients affected extremity in ice until help arrives. 3- Apply an oil-based substance or butter to the burned area until help arrives. 4- Wrap cool towels around the affected extremity intermittently

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? 1- To drain the pancreatic bed 2- To aid opening up of pancreatic duct 3- To prevent the occurrence of fibrosis 4- To avoid inflammation of the pancreas

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? 1- Myelogram 2- Electroencephalogram 3- Echoencephalography 4- Cerebral angiography

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? 1- Central 2- Sympathetic 3- Peripheral 4- Parasympathetic

The staff educator is talking to a group of new emergency department nurses about hypertensive crises. The nurse educator is aware that hypertensive urgency differs from hypertensive emergency in what way? 1- The patient's blood pressure (BP) is always higher in a hypertensive emergency. 2- Close hemodynamic monitoring is required during treatment of hypertensive emergencies. 3- Hypertensive urgency is treated with rest and tranquilizers to lower BP. 4- Hypertensive emergencies are associated with evidence of target organ damage.

The trochlear nerve controls which function? 1- Movement of the tongue 2- Hearing and equilibrium 3- Visual acuity 4- Eye muscle movement

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? 1- A bounding pulse 2- Bradycardia 3- Hypertension 4- Lethargy and stupor

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? 1- Complaints of intense thirst 2- Moderate to severe pain 3- Urine output of 70 ml the first hour 4- Hoarseness of the voice

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease? 1- Telangiectasia 2- Ecchymosis 3- Fluid-filled vesicles 4- Purplish cutaneous lesions

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? 1- Extreme thirst 2- Intake and output 3- Nutritional status 4- Body temperature

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? 1- Jaundice 2- Pruritus of the arms and legs 3- Fatigue during ambulation 4- Irritability and drowsiness

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? 1- Parasympathetic 2- Central 3- Peripheral 4- Sympathetic

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement? 1- Chest pain 2- Decreased cognitive ability 3- Behavioral changes 4- Hypertension

Which blood test confirms the presence of antibodies to HIV? 1- Erythrocyte sedimentation rate (ESR) 2- p24 antigen 3- Reverse transcriptase 4- Enzyme immunoassay (EIA)

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues? 1- Rheumatoid arthritis 2- Systemic lupus erythematosus 3- Polymyalgia rheumatic 4- Scleroderma 4 The nurse is constructing a teaching plan for the client newly diagnosed with scleroderma. What should the nurse include in the teaching plan? 1- Take all antibiotics until they are gone. 2- Perform weight-bearing exercises daily. 3- Avoid sunlight and ultraviolet light. 4- Protect the hands and feet from cold.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism? 1- Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess 2- Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing 3- Disturbed body image related to weight gain and edema 4- Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? 1- Keep the client flat for one hour after administration 2- Administer every five minutes during cardiac resuscitation 3- Document heart rate before and after administration 4- Monitor vital signs and cardiac rhythm

Which of the following could be a possible cause of cyanosis? 1- Carbon monoxide poisoning 2- Fever 3- Anemia 4- Low tissue oxygenation

Which of the following types of shock will a nurse observe in a client with extensive burns? 1- Anaphylactic shock 2- Neurogenic shock 3- Septic shock 4- Hypovolemic shock

Which statement is true about both lung transplant and bullectomy? Both procedures cure COPD. Both procedures treat end-stage emphysema. Both procedures treat patients with bullous emphysema. Both procedures improve the overall quality of life of a client with COPD.

Which term refers to the period of time during which mourning of a loss takes place? 1- Grief 2- Mourning 3- Hospice 4- Bereavement

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is: 1- Cyanosis 2- Addison's disease 3- Polycythemia 4- Vitiligo

the nurse is caring for a client who is receiving nutrition through a nasogastric tube. How should the nurse position the client after a bolus feeding has been completed? 1- In a supine position with bedrails raised 2- In a prone position with knees to chest 3- With legs elevated on a 45-degree angle 4- With head of the bed elevated to 30 degrees

A nurse is administering supplemental oxygen to a client with COPD. The nurse assesses the oxygen saturation level to evaluate the client's status. Which reading would the nurse identify as being appropriate to reduce the risk of vital organ damage in this client? 82% 86% 89% 92%

4- 92%

Normal RBC count is ?

4-6 million

The nurse is assessing the skin of an older adult patient. Which of the following would the nurse identify as abnormal? 1- Cherry angioma 2- Telangiectasias 3- Xerosis 4- Bulla

Intracranial pressure normal range?

5-20 mmHg. more than that is gets treated

The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? 1- Comatose 2- Somnolence 3- Stupor 4- Normal

A weight-loss and exercise program is recommended for a client with type 2 diabetes. When teaching the client about lifestyle changes, what type of assessment would the nurse prioritize? A Individual cultural assessment B Braden scale assessment C Body mass index (BMI) assessment D Head-to-toe physical assessment

The hospital is having a problem with healthcare-associated infections. A committee has been established to study the problem and make recommendations. The nurse working on the committee knows that this work addresses what? A National Patient Safety Goals B Patient safety indicators C Prevention quality indicators D Inpatient quality indicators

Which is an example of a behavior that facilitates health? A Self-monitoring for signs and symptoms of illness B A sedentary lifestyle C Noncompliance with a medication regimen D Recreational drug use

Guillian-Barre Syndrome (GBS)

Acute inflammatory condition involving the spinal nerve roots, peripheral nerves and possibly cranial nerve.

decrease in cortisol is what disease

Addison's disease

low cortisol means what disease?

Addison's disease

Hepatic Cellular Carcinoma is associated with ?

Cirrhotic liver (associated with hepatitis B and C and with alcoholism)

increase in cortisol is what disease

Cushing's syndrome

Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following? a Provision of primary care services, often with care being provided to underserved populations b Nursing care of clients with complex needs who are discharged from acute care institutions early in the recovery process c Nursing care directed to specific client groups with identified needs, usually related to illness d Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups

A nurse is employed by a community organization engaged in health promotion. In this role, the nurse teaches clients steps they can take toward achieving wellness. The nurse would explain "wellness" to a client as: A viewing one's health in terms of a balance of body, mind, and spirit, which means being open to alternative treatment options. B a state of complete physical, mental, and social well-being. C the absence of disease. D an ongoing and intentional effort to achieve the highest potential for total well-being.

D definition of health is the sate of complete physical, mental, and social well being.

What bacteria causes peptic ulcers?

Helicobacter pylori

_____________ is the gold standard for diagnosing liver disease

Liver Biopsy

Is there a vaccine for Hep C?

NO. Therefore screening and counseling is important

Silvery-white scales are a symptom of which of skin disorder?

Psoriasis

Kehr's sign?

Referred pain down the left shoulder; indicative of a ruptured spleen.

Medication for Glaucoma

Tafluprost, Pilocarpine Hydrochloride.

Treatment for peptic ulcers

Triple therapy: for a full list of meds look on pg 694 1. Acid suppression (proton pump inhibitor-PPI) 2. Metronidazole (Flagyl) 3. Amoxicillin/Biaxin 4 other Antibiotics- for H pylori 5. H2 Receptors- Famotidine (Pepcid) avoid smoking, stress, or other aggitations

Hypertensive urgency vs emergency

Urgency: over 180 or 120 without end organ damage Emergency: with end organ damage

Protinuria

When blood cells or proteins are present in the urine

A pheochromocytoma is a rare adrenal tumor that causes increased heart rate, blood pressure, and metabolism because of increased levels of circulating: 1- Catecholamines. 2- Cortisol. 3- Aldosterone. 4- Glucocorticoids.

Thyroid storm

a relatively rare, life-threatening condition caused by exaggerated hyperthyroidism. INCREASE TEMP, PULSE, and HTN

ischemic stroke

a type of stroke that occurs when the flow of blood to the brain is blocked

Hashimoto's disease is what?

an autoimmune disease in which the body's own antibodies attack and destroy the cells of the thyroid gland

Graves disease is caused by what?

an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or exophthalmos

diabetes insipidus is caused by what hormone?

antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect

Guillain-Barre syndrome

autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden muscle weakness

Hepatitis C (HCV)

bloodborne viral disease that affects the liver; transmitted by blood exposure, sharing needles, or from infected mother to infant; rarely transmitted by sexual contact

Hypothyroidism

condition of hyposecretion of the thyroid gland causing low thyroid levels in the blood that result in

exopthalmosis

condition produced by hyperthyroidism in which the eyeballs protrude beyond their normal protective orbit because of swelling in the tissues behind them

adrenal cortex secretes

cortisol, aldosterone, androgens

xerosis means

dry skin

Atopic Dermatitis is also known as

eczema

Hepatitis A is spread by

fecal-oral route

protein in urine indicates

glomerulus problem/ kidney disease (not UTI)

Tzanck smear test for ___________

herpes

parathyroid hormone

increases blood calcium levels

Hepatitis means

inflammation of the liver

steps of abdominal assessment

inspection, auscultation, percussion, palpation

Hepatic encephalopathy

liver coma, crazy movements, high amonia level, don't give protien

Thrombocytopenia means?

low platelet count

Management of ARDS

mechanical ventilation w/ low tidal volumes, address underlying cause

myathenia gravis

neuromuscular disorder that causes fluctuating weakness of certain skeletal muscle groups; (of the eyes, face and sometimes limbs

Peptic Ulcer Disease

open sore in the lining of the stomach or duodenum

Meckel's diverticulum

outpouching of distal ileum

cystocele

protrusion of the bladder

Management of pancreatitis

resting pancreas, pain mgmnt, volume resuscitation.

the layer of skin that absorbs water

stratum Corneum

Signs of Hemmorhage

tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.

portal hypertension

the elevation of blood pressure within the portal venous system

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation (related to incraesed ICP)

A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to: 1- Apply ice and tell the patient to keep his head elevated 2- Administer saline lavage and tell the patient not to swallow the solution 3- Apply warm compresses to the bridge of the patient's nose 4- Administer analgesia and a nebulized bronchodilator

A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?1- Notify the surgical team. 2- Document the assessment findings. 3- Administer dantrolene sodium. 4- Obtain cooling blankets.

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? 1- Respect the client's and family members' choices. 2- Share emotional pain. 3- Abide by the dying client's wishes. 4- Ask the family members about spiritual care.

Specifying the immediate, intermediate, and long-term goals of learning is an integral component of the teaching-learning process. Which of the following individuals should be included in this goal-setting process? Select all that apply. A The patient's family members B An advanced practice nurse C The nurse who will conduct the teaching D The patient's primary care provider D The patient himself or herself

A, C, D

___________ is a behavioral pattern of substance use characterized by a compulsion to take the substance (drug or alcohol) primarily to experience its psychic effects.

Addiction

_______ respiration= repeated breathing pattern characterized by fluctuation in the depth of respiration: first deeply, then shallow, then not at all. Usually accompanies death.

Cheyne Stokes

Elderly are at greater risk for drug ___________ due to increased sensitivity do medications

Drug Toxicity

Patients who are controlling their own opioid administration usually become sedated and stop pushing the button before any significant ___________ depression occurs. Nevertheless, assessment of __________ status remains a major nursing role.

Respiratory

What system is still important to access when the patient has a PCA pump

Respiratory. Patients who are controlling their own opioid administration usually become sedated and stop pushing the button before any significant respiratory depression occurs. Nevertheless, assessment of respiratory status remains a major nursing role.

____________= (the need for increasing doses of opioids to achieve the same therapeutic effect) develops in almost all patients taking opioids for extended periods

Tolerance

Elderly have a Changes in medication ____________ and metabolism due to decreased function of the liver, kidney, and GI system

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