Med Surge (Questions)

B

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a) Bell's palsy b) trigeminal neuralgia c) migraine headache d) angina pectoris

C (current guidelines are to have a mammogram q 2 years until 74 yo)

A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's best response? a) "Having a mammogram when you are older is less painful." b) "We need to consider your family history of breast cancer first." c) "The incidence of breast cancer increases with age." d) "It will be sufficient if you perform breast examinations monthly."

C

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client? a) client who had an ileal conduit 3 days ago b) middle-aged client who had a kidney transplant 3 days ago c) middle-aged stable client with bladder cancer awaiting surgery d) elderly client just admitted for an acute stroke

B

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? a) evaluating vital signs frequently b) maintaining fluid and electrolyte balance c) preventing wound infections d) managing the child's pain

B (delivers highest FiO2)

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? a) face tent b) nonrebreather mask c) nasal cannula d) simple mask

B (Acute wrist flexion places pressure on inflamed median nerve w/ carpal tunnel = pain and numbness)

A client complains that they experience pain and numbness in the fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen's sign? a) Having the client hold both hands above their head with their arms straight for 30 seconds b) Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds c) Tapping gently over the median nerve in the wrist d) Having the client extend their wrists while the nurse provides resistance

A (tracheal dev AWAY from affected side = tension pneumo = emergency)

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax? a) Sudden, sharp pain on the affected side. b) Tracheal deviation toward the affected side. c) Bradypnea and elevated blood pressure. d) Presence of crackles and wheezes.

C

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to a) palpate the abdomen. b) insert a rectal tube. c) auscultate bowel sounds. d) change the client's position.

D

A client has a testicular nodule that is highly suspicious for testicular cancer. A laboratory test that supports this diagnosis is: a) decreased beta-human chorionic gonadotropin (hCG). b) decreased alpha fetoprotein (AFP). c) increased testosterone. d) increased AFP.

A

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do? a) Take acetaminophen or ibuprofen. b) Limit the frequency of using nitroglycerin. c) Take the nitroglycerin with a few glasses of water. d) Rest in a supine position to minimize the headache.

B (a is hyperplasia, c is anaplasia and d is metaplasia)

A client has an abnormal result on a Papanicolaou test. The client asks the nurse what dysplasia means. Which definition should the nurse provide? a) increase in the number of normal cells in a normal arrangement in a tissue or an organ b) alteration in the size, shape, and organization of differentiated cells c) presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin d) replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found

C

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) respiratory acidosis b) metabolic acidosis c) metabolic alkalosis d) respiratory alkalosis

A (indicates CSF leak) (normal for mild h/a to occur)

A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the health care provider (HCP)? a) A moderate amount of serous fluid was noted on the lumbar dressing. b) The client is concerned about the test results. c) The client required analgesia for headache. d) The client's oral intake was 1,200 mL in the past 8 hours.

B (note the cause was high voltage - mess with the heart's electrical system)

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? a) Monitor urine output once a shift. b) A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. c) Initiate an antibiotic within 3 hours of the injury. d) Infuse dextrose and water at 50 mL per hour to avoid overload of the circulatory system

B

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) abdominal pain or diarrhea b) light-headedness or paresthesia c) hallucinations or tinnitus d) nausea or vomiting

C (Mumps = droplet)

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? a) mumps b) impetigo c) measles d) cholera

C

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C). Which outcome would be a priority for this client? a) prevention of urinary tract complications b) alleviation of nausea c) alleviation of pain d) maintenance of fluid and electrolyte balance

D

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values? a) decreased urine amylase level b) increased calcium level c) decreased glucose level d) increased serum amylase and lipase levels

A (is a bac infection of lower urinary tract via ascending urethral route)

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? a) Wash the perineum with warm water and soap, cleaning from front to back. b) Treat fungal infections such as athlete's foot immediately. c) Have a pneumonia immunization to prevent streptococcal infection. d) Treat skin lesions with antibiotics, and cover any open lesions.

C (s/s of fat embolism) (next would do contact MD)

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? a) Elevate the affected extremity. b) Contact the nursing supervisor. c) Administer oxygen. d) Contact the physician.

D

A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? a) crackles auscultated halfway up lungs, previously in bases b) PaO2 80 mm Hg c) blood pressure 140/80 mm Hg d) trace peripheral edema, previously +2

A

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and their family to expect which common symptom that typically resolves spontaneously? a) depression b) ankle edema c) memory lapses d) dizziness

C (swelling of surgical site may obstruct airway)

A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? a) automated vital signs machine b) humidifier c) tracheostomy set d) cardiac monitor

D

A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) jugular vein distention b) right upper quadrant pain c) dependent edema d) bibasilar crackles

D (r/t ATH)

A client presents to the clinic for a follow-up visit for hospitalization due to uncontrolled diabetes. Which of the following assessment findings indicates a complication of diabetes mellitus? a) Hemoglobin of 9 g/dL (90 g/L) b) Inflamed, painful joints c) Pale yellow urine d) Blood pressure of 160/100 mm Hg

B (b/c it compresses spinal nerves)

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? a) Homans' sign b) back pain when the knees are flexed c) pain radiating down the posterior thigh d) atrophy of the lower leg muscles

A (Sciatic nerve dmg) (Knee flexion would relieve) (Homans is for DVT)

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? a) pain radiating down the posterior thigh b) back pain when the knees are flexed c) atrophy of the lower leg muscles d) Homans' sign

B

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

B (want to keep legs abducted to pv dislocation)

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) performing passive range-of-motion (ROM) exercises on the client's legs once each shift b) keeping a pillow between the client's legs at all times c) turning the client from side to side every 2 hours d) maintaining the client in semi-Fowler's position

D (adduction = internal rotation)

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. How should the nurse respond to the client's concern? a) "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." b) "Don't worry. Your new hip is very strong." c) "Use of a cushioned toilet seat helps to prevent dislocation." d) "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."

D

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing a) pupillary changes. b) nuchal rigidity and Kernig's sign. c) motor loss in the legs that exceeds that in the arms. d) raccoon's eyes and Battle's sign.

A (indicates leak in system)

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? a) Continuous bubbling in the water-seal chamber. b) Respiratory rate greater than 16 breaths/minute. c) Fluctuation of fluid in the water-seal chamber. d) Fluid in the chest tube.

A (think of 3 P's - to compensate for fluid loss r/t polyruria, heart rate increases)

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level? a) rapid, thready pulse b) arm and leg trembling c) slow, shallow respirations d) cool, moist skin

C (decrease RF falls)

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? a) Use pillows to support the client's head. b) Assist the client to the restroom every hour. c) Instruct the client to remain in bed. d) Remind the client to ask for assistance when turning.

A (W/ compartment synd release myoglobin from damaged muscle cells that become trapped in renal tubule and can lead to acute renal failure)

A client with a fracture develops compartment syndrome. Which sign should alert the nurse to impending organ failure? a) dark, scanty urine b) jaundice c) generalized edema d) crackles

B

A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which solution would the nurse expect to administer? a) I.V. total parenteral nutrition and insulin coverage b) I.V. normal saline and glucocorticoids c) I.V. lactated Ringer's solution and packed cells d) I.V. 5% dextrose and dopamine

D (uses contrast dye)

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a) Administer a sedative as ordered. b) Immobilize the neck before the client is moved onto a stretcher. c) Place a cap over the client's head. d) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

B

A client with bladder cancer had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? a) The skin wasn't lubricated before the pouch was applied. b) The pouch faceplate doesn't fit the stoma. c) A skin barrier was applied properly. d) Stoma dilation wasn't performed.

A (4 major metastasis sites = liver, lymph nodes, lung, bone, brain)

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? a) liver b) colon c) reproductive tract d) white blood cells (WBCs)

C

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it a) is a respiratory depressant. b) is a respiratory stimulant. c) may induce bronchospasm. d) inhibits the cough reflex.

D

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? a) Contact the health care provider (HCP). b) Auscultate the lungs to detect abnormal breath sounds. c) Encourage the client to cough and deep breathe. d) Elevate the head of the bed 30 to 45 degrees.

A (ICP highest in early morning b/c of mild hypoventilation that occurs in the morning)

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next? a) Notify the health care provider (HCP). b) Tell the client that this is normal because intracranial pressure (ICP) fluctuates throughout the day. c) Instruct the client to increase fluid intake prior to going to bed to prevent headache in the morning. d) Advise the client to request pain medication from the health care provider (HCP).

B (increased stiffness in AM)

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? a) Exercising in the evening before going to bed is beneficial. b) Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. c) The time of day when exercise is performed isn't important. d) Exercising immediately upon awakening allows the client to participate in activities when they have the greatest amount of energy.

D (C is hypothyroidism)

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? a) bradycardia, thirst, and anxiety b) polyuria, polydipsia, and polyphagia c) dry skin, bradycardia, and somnolence d) sweating, tremors, and tachycardia

A (RF hypovolemia) (Insulin is second priroity)

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the healthcare team take first? a) Initiate fluid replacement therapy. b) Correct diabetic ketoacidosis. c) Determine the cause of diabetic ketoacidosis. d) Administer insulin.

D

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving a) O+ blood to an A+ client. b) B- blood to an AB+ client. c) O- blood to an O+ client. d) A+ blood to an A- client.

D

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem? a) a hemolytic reaction to mismatched blood b) a hemolytic reaction to Rh-incompatible blood c) a hemolytic reaction caused by bacterial contamination of donor blood d) a hemolytic allergic reaction caused by an antigen reaction

B (HOB should be elevated 30 degrees at least to pv aspiration and neck swelling)

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? a) Foley catheter bag containing 500 ml of amber urine b) the client lying in a lateral position, with the head of bed flat c) a piggyback infusion of levofloxacin d) serosanguineous drainage on the dressing

D (r/t diuresis) (would have met acidosis, not alkalosis) (Elevated ketones and acetone is DKA)

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? a) elevated serum acetone level b) serum ketone bodies c) serum alkalosis d) below-normal serum potassium level

C

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? a) aortic regurgitation b) complete heart block c) pericardial tamponade d) left-sided heart failure

D (SOB r/t retained secretions, wheezing r/t resp infl... will have productive cough and fever)

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) sore throat and abdominal pain b) nonproductive cough and normal temperature c) hemoptysis and dysuria d) dyspnea and wheezing

C (indicates internal bleeding = RF hemorrhage)

A nurse is assessing a client who has a history of a bleeding peptic ulcer. What assessment findings should the nurse report immediately? a) abdominal cramping; slow, regular pulse; warm, pale skin b) warm, dry skin; hypotension; bounding, regular pulse c) abdominal distension; cool, clammy skin; weak, thready pulse d) strong, irregular pulse; lower abdominal pain; cool, dry skin

C (D is when you flex the neck the hips and knees also flex)

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive? a) Lichtheim's sign b) Babinski's reflex c) Kernig's sign d) Brudzinski's sign

D (secondary to diffuse osteoporosis and osteolytic lesions)

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for a) chronic liver failure. b) acute heart failure. c) hypoxemia. d) pathologic bone fractures.

B

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? a) hematuria b) massive proteinuria c) increased serum albumin level d) weight loss

B (abduction is AWAY from midline, Adduction is TOWARD midline)

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document? a) Adduction b) Abduction

B

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a) Pallor, bradycardia, and reduced pulse pressure b) Pallor, tachycardia, and a sore tongue c) Sore tongue, dyspnea, and weight gain d) Angina pectoris, double vision, and anorexia

A (pulmon edema = bilateral crackles)

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings? a) Bronchial edema and constriction have worsened. b) The asthma attack has resolved, and airflow is restored. c) The administered albuterol (salbutamol) has been effective. d) The client has developed acute pulmonary edema.

A (b/c of reduced aldosterone secretion)

A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see? a) serum potassium level of 6.8 mEq/L (6.8 mmol/L) b) blood urea nitrogen (BUN) level of 2.3 mg/dl (0.1 mmol/L) c) serum sodium level of 156 mEq/L (156 mmol/L) d) serum glucose level of 236 mg/dl (13.1 mmol/L)

C

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: a) hypercalcemia. b) hypernatremia. c) hyperkalemia. d) hypokalemia.

A

A nurse is caring for a client with a pulmonary infection secondary to acquired immunodeficiency syndrome (AIDS). Which intervention would be most effective to manage night sweats? a) Administer an antipyretic medication prophylactically as needed before the client goes to sleep. b) Change the bed linens as needed to prevent skin breakdown. c) Administer tepid sponge baths in the early evening to prevent the night fever. d) Encourage fluids to maintain hydration; keep fluids at the bedside at night.

A (holds the joint in a functional position)

A nurse is caring for a client with burns on their legs. Which nursing intervention will help to prevent contractures? a) applying knee splints b) elevating the foot of the bed c) hyperextending the client's legs d) performing shoulder range-of-motion (ROM) exercises

A (ABCs)

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention? a) Control the pain and support breathing and oxygenation. b) Decrease the anxiety and reduce the workload on the heart. c) Reduce the nausea and vomiting and stabilize the blood glucose. d) Monitor and manage potential complications.

C (ABCs - decrease RF aspiration)

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority? a) Aspirate the PEG tube prior to each feeding. b) Flush the PEG tube with water before and after each feeding. c) Elevate the head of the bed during and after the PEG tube feedings. d) Cleanse the skin around the PEG tube site each shift.

C, E

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, the nurse correctly identifies which ECG changes associated with an evolving MI? Select all that apply. a) notched T-wave b) presence of a U-wave c) T-wave inversion d) prolonged PR-interval e) ST-segment elevation

C

A nurse is explaining the use of ceftriaxone and doxycycline to a client with gonorrhea. The client asks the nurse the reason for two antibiotics. What is the nurse's best response? a) "Gonorrhea is resistant to treatment, so taking more than one antibiotic improves treatment success." b) "The combination of these two antibiotics reduces the risk of a reoccurring gonorrhea infection." c) "Often people infected with gonorrhea are also infected with chlamydia, which requires a different antibiotic." d) "This combination of medications will eradicate the gonorrhea infection faster than a single antibiotic."

A (could indicate complication perforation... others are expected s/s)

A nurse is performing focused assessment on a client admitted with a paralytic ileus. Which finding requires further action? a) client requesting another blanket and "feeling cold" b) abdominal distension and a client feeling "bloated" c) client reporting breath that smells like feces d) noting a lack of bowel movement since admission

A

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? a) The dressing should keep the wound moist. b) The wet-to-damp dressing should be tightly packed into the wound. c) The dressing should be allowed to dry out before removal. d) A plastic sheet-type dressing should cover the wet dressing.

B (normal urine pH = 4.5-8) (normal urine specific gravity is 1.002-1.035)

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? a) specific gravity of 1.03 b) urine pH of 3.0 c) absence of protein d) absence of glucose

A (decorticate = cerebral dysfunction... both r/t increased ICP)

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates a) dysfunction in the brain stem. b) dysfunction in the spinal column. c) dysfunction in the cerebrum. d) risk for increased intracranial pressure.

B

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? a) no increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test b) a decreased TSH level c) an increase in the TSH level after 30 minutes during the TSH stimulation test d) below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

A

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed? a) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. b) Ask the assistive personnel to notify the provider of the low pulse oximetry level. c) Complete the assessment of the new client before attending to the client who underwent laminectomy. d) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the provider.

B (causes twisting motion)

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching? a) drying the dishes b) sweeping the front porch c) making the bed walking from side to side d) sitting outside on firm cushions

B (leaking anastomosis will cause peritonitis)

After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis? a) diarrhea with fat in the stool b) pain, fever, and abdominal rigidity c) feelings of fullness and nausea after eating d) palpitations, pallor, and diaphoresis after eating

A

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) water-seal chamber b) collection chamber c) air-leak chamber d) suction control chamber

A (ABCs)

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? a) the client with heart failure who is having some difficulty breathing b) the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today c) the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site d) the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on

D (pv the brace from causing friction on skin. Cotton material absorbs perspiration)

After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching? a) "I will apply lotion before putting on the brace." b) "I will be sure to pad the area around my iliac crest." c) "I can use baby powder under the brace to absorb perspiration." d) "I should wear a thin cotton undershirt under the brace."

C

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting a) 18 to 20 g of a simple carbohydrate. b) 25 to 30 g of a simple carbohydrate. c) 15 g of a simple carbohydrate. d) 2 to 5 g of a simple carbohydrate.

A

An autograft is taken from the client's left leg. The nurse should care for the donor site by: a) keeping the site clean and dry. b) covering it with an occlusive dry dressing. c) wrapping the extremity with an elastic bandage. d) applying a pressure dressing.

A

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates that teaching was successful? a) "I clean my teeth gently several times per day." b) "I replace my toothbrush every month." c) "I lubricate my lips with petroleum jelly." d) "I use an alcohol-based mouthwash every morning."

C

At a public health fair, a nurse teaches a group of women about breast cancer awareness. What is most important for the nurse to include in teaching about the warning signs of breast cancer? a) fever and erythema of the breast b) breast changes during menstruation c) nipple discharge and a breast nodule d) breast discomfort and multiple movable nodules

B (thoracic curvature can invade lung's space)

During a scoliosis screening in a college health center, a student asks the public health nurse about the consequences of untreated scoliosis. The nurse identifies one of the direct complications as a) osteoporosis of the vertebra. b) impingement on pulmonary function. c) spontaneous spinal cord injury. d) pituitary hyposecretion.

C (pH close to normal indicates compensation - on high side of normal. CO2 low. HCO3 normal. The inverse indicates resp in nature)

During shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance is the client most likely experiencing? a) compensated metabolic acidosis b) compensated metabolic alkalosis c) compensated respiratory alkalosis d) uncompensated respiratory alkalosis

A (expected. peristalsis has not yet returned.)

During the evening shift on the day of a client's bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. The nurse should: a) record the amount of drainage on the client's chart. b) irrigate the tube with normal saline solution. c) call the health care provider. d) increase the IV infusion rate.

D

Following an emergency cholecystectomy, the client has a Jackson-Pratt drain with closed suction. After 4 hours, the drainage unit is full. What should the nurse do? a) Notify the surgeon. b) Remove the drain and suction unit. c) Check the dressing for bleeding. d) Empty the drainage unit.

B

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? a) every 4 hours, at specified times b) with each meal and snack c) in the morning and at bedtime d) three times daily between meals

B (a would be late menopause, c would be being childless)

Risk factors for the development of breast cancer include: a) early menopause (before age 40). b) early onset of menstruation. c) having had more than two children. d) breastfeeding.

D

The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse? a) Turn the client on the left side. b) Assess client's blood pressure. c) Keep arm elevated. d) Contact the healthcare provider.

D, E (if unresponsive, can't drink OJ) (Breath sounds not priority during hypoglycemia)

The nurse finds a client in a long term care facility, after the evening meal, to be unresponsive with cold, clammy skin to touch. A finger stick blood glucose level reveals 21 mg/dL. What are the nurse's immediate priority actions? Select all that apply. a) Encourage the client to drink orange juice. b) Alert the family to the change in condition after the client is stable. c) Identify if the client has clear breath sounds. d) Notify the healthcare provider of hypoglycemic event. e) Administer as needed glucagon 1 mg intramuscularly now.

D (suspect pinched/kinked catheter if blood can't be aspirated)

The nurse has been able to draw the daily blood specimen from a client's Hickman catheter only after requesting that the client raise the arms and cough. The client asks the nurse why this is necessary. The nurse should tell the client: a) "The catheter tends to collapse every time we exert pressure." b) "A fibrin sheath has grown over the tip of the catheter." c) "Your catheter probably is pinched between the clavicle and a rib." d) "The catheter may be lodged against a blood vessel wall."

A

The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. Which indicates the instillation is effective? a) The secretions are thinned. b) The client coughs. c) There is humidification for the respiratory tract. d) There is minimal friction when the catheter is passed into the tracheostomy tube.

D (called refractory hypoxemia)

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? a) severe, unexplained electrolyte imbalance b) elevated carbon dioxide level c) metabolic acidosis d) hypoxia not responsive to oxygen therapy

B

The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first? a) bradycardia b) alteration in level of consciousness c) raccoon eyes and battle sign d) slurred speech

A (+ goosebumps, pounding h/a and sweating)

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for: a) sudden, severe hypertension b) bradycardia c) paralytic ileus d) hot, dry skin

B (can indicate FVO. This med can impair renal fxn)

The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider? a) intermittent nausea b) a 3-kg weight gain over 2 days c) a temperature of 99°F (37.2°C) orally d) constant fatigue

A

The nurse is assessing an 80-year-old client who has scald burns on both hands and forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? a) Refer the client to a burn center. b) Cover the burns with a sterile dressing. c) Clean the wounds with warm water. d) Apply antibiotic cream.

B (think of interventions like NG)

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? a) metabolic acidosis b) metabolic alkalosis c) respiratory acidosis d) hypercalcemia

D (other RF = blood transfusion, past tx chronic hemodialysis, born to mom with hep C, drug use, needlestick injuries)

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client: a) has a history of exercise-induced asthma. b) is a scientist and is frequently exposed to multiple chemicals. c) traveled to Central America recently and ate uncooked vegetables. d) has a known history of sexually transmitted disease.

A

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? a) metabolic acidosis b) respiratory acidosis c) metabolic alkalosis d) respiratory alkalosis

D (tinea capitis)

The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? a) Allow hair to air dry after shampooing. b) Wash hair with a dandruff-preventing shampoo. c) Keep hair length short and well trimmed. d) Avoid sharing combs and brushes.

B, C, E, F

The nurse is carrying out the plan of care for this client after the craniotomy. Which action(s) should the nurse take? Select all that apply. a) Report a narrowing pulse pressure to the neurosurgeon. b) Monitor the level of consciousness. c) Administer dexamethasone as prescribed. d) Position the client supine, with the head turned to the nonoperated side. e) Maintain the head of the bed at 30 degrees. f) Pad the side rails of the bed. g) Report an ICP of 9 mm Hg to the neurosurgeon.

D

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do? a) Increase the length of time for walking. b) Include more potassium in the diet. c) Perform leg circles and ankle pumps. d) Seek consultation from the health care provider.

B, C, D, E, F (Addison's dx = do not produce enough steroids from adrenal cortex. Will need lifelong steroid replacement. Dental work, infections and surgery require a change in dosage)

The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply. a) Addison's disease will resolve over a few weeks, requiring no further treatment. b) Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations. c) Fatigue, weakness, dizziness, and mood changes need to be reported to the health care provider (HCP). d) A medical identification bracelet should be worn. e) Family members need to be informed about the warning signals of adrenal crisis. f) Dental work or surgery will require adjustment of daily medication.

A, B, D

The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease. What should the nurse instruct the client to do? Select all that apply. a) Avoid a diet high in fatty foods. b) Avoid beverages that contain caffeine. c) Eat three meals a day, with the largest meal being at dinner in the evening. d) Avoid all alcoholic beverages. e) Lie down after consuming each meal for 30 min. f) Use over-the-counter (OTC) antisecretory agents rather than prescriptions.

B (A is incorrect b/c doesn't fix root cause)

The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? a) "I should take antihistamines to decrease the itching I'm experiencing." b) "It's safe to apply a non-perfumed lotion to my skin." c) "A heating pad, set on the lowest setting, will help decrease my discomfort." d) "I can apply an over-the-counter cortisone ointment to relieve the dryness."

D (painless, moist ulcer w/ serous d/c that is very infectious)

The nurse is obtaining a health history from a client with a sexually transmitted disease. Which description from the client indicates the likelihood of syphilis? "In my genital area I have: a) ...a wart." b) ...itching." c) ...tender pimples." d) ...a moist ulcer."

A (pleural effusion - collection of fluid b/t layers of lung = decreased chest wall movement on that side)

The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client? a) decreased breath sounds on the affected side b) normal bronchial breath sounds c) hyperresonance on percussion d) wheezing on auscultation

C

The nurse is repositioning a client with a chest tube in bed when the chest tube accidentally becomes disconnected from the chest tube container. What is the nurse's priority action at this time? a) Call for assistance and cover the insertion site with clean, dry gauze. b) Call for assistance and then cover the wound with a sterile dressing. c) Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. d) Encourage the client to breathe slowly while the wound is covered.

D

The nurse should instruct a client who is using crutches to bear weight primarily on which part of the body? a) upper arms b) elbows c) axillae d) hands

B

The rate at which IV fluids are infused is based on the burn client's: a) lean muscle mass and body surface area (BSA) burned. b) total body weight and BSA burned. c) total BSA and BSA burned. d) height and weight and BSA burned.

D (All others = n/a to subarachnoid block)

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? a) "Avoid eating milk products for 24 hours." b) "Avoid drinking liquids until the gag reflex returns." c) "Notify a nurse if you experience blood in your urine." d) "Remain supine for the time specified by the physician."

A (indicates rupture)

What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved? a) preparation for emergency surgery b) initiation of antibiotic therapy c) referral for dietary revision d) modification of pain management strategies

B

When assessing a client with left-sided heart failure, the nurse expects to note a) jugular vein distention. b) air hunger. c) ascites. d) pitting edema of the legs.

D

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should: a) dress the client, explaining each step of the process as it is completed. b) encourage the client to wear clothing designed especially for people who have had a CVA. c) advise the client to ask for help when dressing. d) teach the client to put on clothing on the affected side first.

C

Which action has the highest priority in the care of a client with chronic renal failure? a) Apply corticosteroid creams to relieve itching. b) Achieve pain control with analgesics. c) Maintain a low-sodium diet. d) Measure abdominal girth daily.

A

Which action should the nurse take to provide effective emergency care at the accident site for a victim with a heat burn? a) Pour cool water over the burned area. b) Apply a mild antiseptic ointment to the area. c) Rinse the area with a warm, mild soap solution. d) Apply clean, dry dressings to the area.

A (means binge eating)

Which dietary instruction would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? a) Avoid crash dieting. b) Restrict carbohydrate intake. c) Decrease sodium in the diet. d) Eat six small meals a day.

C (indicates hypoxia) (B is wrong b/c 100 mL/hr of drng or less is normal in early postop period)

Which finding alerts the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? a) increased blood pressure and decreased pulse and respiratory rates b) sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours c) restlessness and shortness of breath d) urine output of 180 mL during the past 3 hours

C

Which instruction should the nurse give the client who has undergone chest surgery to prevent shoulder ankylosis? a) Turn from side to side. b) Raise and lower the head. c) Raise the arm on the affected side over the head. d) Flex and extend the elbow on the affected side.

B (A segment of the terminal ileus that collects urine from the ureters is used to form the conduit... so urine with some mucus is expected)

Which instruction would a nurse include in the discharge teaching for a client who has an ileal conduit? a) "Decrease your fluid intake." b) "Mucous in the pouch is expected." c) "It is only necessary to wear the appliance pouch at bedtime." d) "You can decrease fecal collection in the pouch by watching your diet."

D

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? a) pain b) altered level of consciousness c) fluid balance d) anaphylactic reaction

A

Which is a risk factor for testicular cancer? a) undescended testes b) sexual relations at an early age c) seminal vesiculitis d) epididymitis

B (reduces amt of fecal material in GI tract and decreases stimulation)

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client: a) maintains a daily record of intake and output. b) verbalizes the importance of small, frequent feedings. c) uses a heating pad to decrease abdominal cramping. d) accepts that a colostomy is inevitable at some time in his life.

A (r/t inflammation)

Which laboratory finding is expected when a client has diverticulitis? a) elevated white blood cell count b) elevated serum blood urea nitrogen concentration c) elevated red blood cell count d) decreased platelet count

D (Brachytherapy - Internal radiation so RN must use principles of time, distance and shielding) (Not C b/c radiation will have a cumulative effect)

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer? a) female nurse with 10 years' experience who suspects she may be pregnant b) male nurse who has floated to this unit from the operating room c) male nurse who is also assigned to another client receiving brachytherapy d) female nurse with 3 years' experience working in oncology

C

Which progression would be expected in a pt with myasthenia gravis? a) muscle pain, difficulty speaking, headaches, and arthritic changes b) atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving c) muscle weakness, difficulty swallowing, double vision, and difficulty speaking d) muscle inflammation, choking when eating, nearsightedness, and painful joints

A (obesity increases intra-abd pressure)

Which risk factor would most likely contribute to the development of a client's hiatal hernia? a) being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) b) having a sedentary desk job c) being 40 years old d) using laxatives frequently

C (s/s = chest pain, cyanosis, SOB, high HR and RR, etc)

Which sign indicates that a client with a fracture of the right femur may be developing a fat embolus? a) muscle spasms in the right thigh b) numbness in the right leg c) acute respiratory distress syndrome d) migraine-like headaches

D

Which signs and symptoms accompany a diagnosis of pericarditis? a) low urine output secondary to left ventricular dysfunction b) pitting edema, chest discomfort, and nonspecific ST-segment elevation c) lethargy, anorexia, and heart failure d) fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

B (D would overwhelm the heart)

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome? a) The client is fluid overloaded and needs I.V. fluid slowly to prevent circulatory overload and collapse. b) The client is severely dehydrated and needs 2 to 3 L of I.V. fluid rapidly. c) The client is in need of a dextrose solution containing normal saline solution for gradual rehydration. d) The client is severely dehydrated and needs 10 L of I.V. fluid over the first 24 hours.

A (B is incorrect b/c these contains large amounts of alcohol)

Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis? a) using a soft toothbrush to provide oral hygiene b) rinsing the mouth with a commercial mouthwash before and after each meal c) cleansing the gums and oral mucosa with an oral swab with an astringent every shift d) keeping dentures in place to decrease development of edema

C (remember ABCDs)

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects a) actinic keratoses. b) squamous cell carcinoma. c) melanoma. d) basal cell carcinoma.

D

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? a) D-dimer, red blood cell count, and partial thromboplastin time b) thrombin time, fibrinogen, and hemoglobin level c) platelet count, red blood cell count, and hemoglobin d) platelet count, prothrombin time, and partial thromboplastin time