MedSurg ATI Exam
A nurse in the emergency room is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor vehicle accident. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor. D. Rhonchi
A
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of actinic keratosis? A. Rough, dry, scaly lesion B. Firm nodule with crust C. Pearly papule with ulcerated center D. irregularly shaped lesion with blue tones
A
A nurse is assessing a client who is 24 hours post op following an above the elbow amputation. Which of the following findings should the nurse identify as a priority? A. Report of muscle spasms B. Inability to get dressed without assistance C. Report of feelings of anger D. Refusal to look at the affected limb
A
A nurse is caring for a client who is postop following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure? A. calcium B. sodium C. Potassium D. phosphorous
A
A nurse is planning care for a client who has iron deficiency anemia. Which of the following interventions should the nurse include in the plan? A. Administer ferrous sulfate B. Increase dietary intake of folic acid. C. Initiate weekly vitamin B12 injections. D. Initiate a blood transfusion
A
A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? A. Shakiness B. Urinary frequency C. Dry mucous membranes D. Excess thirst
A
A nurse is teaching a client about their diagnosis of systemis lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. THe nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? A. Exercise B. Pregnancy C. Infection D. Sunlight
A
Which one of the following rates indicates normal sinus rhythm? A. P waves occurring at 0.16 sec before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. An irregular ventricular rate of 125/min with a wide QRS pattern
A
__________ measures the amount of air the lungs can hold after maximum inhalation. A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume
A
A nurse on a medical surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings is an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Wheezing
A Dyspnea occurs due to reduced blood flow to the lungs Tachycardia, not bradycardia, is a seen in patients with pulmonary embolisms. Tracheal deviation is seen in patietns with pneumothorax
Which of the following medications can be prescribed to prevent adverse GI effects of takin an NSAID? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
A this is a histamine blocking agent
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment should the nurse don prior to providing client care? SATA A. Gown B. Gloves C. Mask D. Hair cover E. Goggles
A and B. droplet precautions are not necessary. AIDS is not transmitted via airborne/droplet
Which of the following are risk factors for osteoporosis? A. Female gender B. Decreased intake of phosphate-containing foods C. Several hours of sun exposure/day. D. Increased estrogen E. Increased phosphate-containing foods F. Anorexia history
A, E, F.
A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.2 in) in size, elevated, and solid with very distinct borders. The nurse should document the findings as which of the following skin lesions? A. papules B. macules C. wheals D. vesicles
A.
A nurse is monitoring a client who has active pulmonary TB and was placed on airborne precautions. This client is scheduled for a chest x-ray. Which of the following actions should the nurse take? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable Chest X ray in the client's room. D. Place an N95 respirator on the client.
A.
A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that a client understands how to prevent transmission of the STI? A. "I will bring my sexual partner in for treatment." B. "Now that I've had my first dose of medicine, I can resume sexual activity." C. "Once i have been treated, it is no longer necessary to use condoms." D. "Once treatment is completed and I am free of symptoms, I don't have to return to the clinic."
A.
A nurse is caring for a client who is postoperative following a bilateral adrenalectomy. The nurse should expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic effects? A. Compensate for decrease in cortisol levels B. Inhibit glucose metabolism C. Act as a diuretic to maintain urine output D. Decrease susceptibility to infections.
A. clients will have increased glucose levels, fluid retention, increased risk for infection.
A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly gray color of the affected eardrum
A. Mastoiditis refers to inflammation of the temporal bone behind the ear. A red, thick eardrum is also a manifestation of mastoiditis.
A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes
A. During this stage it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis. Rhinitis and Sore throat are not manifestations of inhalation anthrax. Swollen lymph nodes can be a clinical manifestation of cutaneous anthrax
A nurse is reviewing a client's repeat laboratory results 4 hours after administering FFP. Which of the following lab results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit
A. FFP is rich in clotting factors and is administered to treat acute clotting disorders. The desired effect is a decreased prothrombin time.
Which medication is best for treating stress ulcers? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
A. H2 RAs are best for stress ulcers
A nurse is caring for a client who is 4 hr postop following a laparoscopic cholecystecomy. Which of the following findings is expected? A. Right shoulder pain B. Urine output 20 mL/hr C. Temp 101.1F (38.4C) D. O2 92%
A. Right upper shoulder pain occurs to gas (CO2) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent position can help with client discomfort.
A nurse is providing discharge instructions to a client who is postop following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color
A. ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. Redness around the skin rather than blanching is an indication of potential malignancy. Darkening of a mole, rather than fading, is associated with potential malignancy.
A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease. Which of the following nutrients should be increased in her diet? A. Calcium B. Phosphorous C. Potassium D. Sodium
A. A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. All the other nutrients will be elevated due to reduced ability of the kidneys to excrete things
A nurse is teaching a client who has CKD. Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorous D. Eat a diet high in protein.
A. A client who has CKD should limit fluid intake to prevent hypervolemia
A nurse is teaching a client with HIV about the early manifestations of AIDS. WHich of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated WBC count." C. "You can expect an increase in BP and edema." D. "You can expect weight gain."
A. Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. Clients with AIDS are more likely to have a decreased WBC count due to the destroyed CD4-T cells. Clients with AIDS experience hypotension due to adrenal insufficiency.
A nurse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the disease. Which of the following statements by the client indicates an understanding of the teaching? A. My cells are resistant to the effects of insulin B. My body breaks down sugars too efficiently C. My pancreas does not produce insulin D. My body produces antibodies against pancreatic beta cells
A. Clients with T2DM have insulin resistance and a decrease in the secretion of insulin by the pancreatic beta cells. Does not have enough insulin produced by pancreatic beta cells to break down enough glucose.
A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)
A. GGT is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.
A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."
A. I will be on a special shower table. warm water will be used, soft washcloths and gauze will be used to gently debride the wounds, and most blisters will remain intact unless they are large.
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. I will need to take methotrexate even if I'm in remission B. I'm thankful that this type of lupus only affects the skin C. Each day I should apply sunblock with a sun protection factor of 15 D. A mild fever is common with SLE and usually does not require medical intervention
A. Methotrexate is an immunosuppressive medication given during remission to help prevent exacerbation. This medication is also given when exacerbations occur to reduce the severity of manifestations. You should use sunblock SPF 30 at least. An elevated temperature is an indication of an exacerbation and should be reported to the provider.
A client has a new diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? A. Relieve the client's pain B. Encourage the client to increase fluid intake C. Monitor the client's I/O D. Strain the client's urine
A. Pain associated with renal calculi is severe and can lead to shock, therefore it is the priority action
A nurse in the ED is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? A. Immobilize the limb at the level of the heart. B. Apply a tourniquet to the affected limb. C. Use a sterile scapula to incise the wound. D. Apply ice to the skin over the snakebite wound.
A. You want to limit the spread of venom. Any constrictive clothing or jewelry should be removed before the swelling worsens, and the affected limb should be immobilized at the level of the heart.
A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the bed pan every 2 hours B. Limit the client's daily fluid intake until he is no longer continent C. Request a prescription for an indwelling urinary catheter from the client's provider D. Ambulate the client to the bathroom every 30 min
A. ambulating a client with hemiplegia puts them at risk for falls, fluid intake should be 2-3L/day to promote urine production, use a bed pan for bladder training
A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions
A. chicken breast and vegetables are low in cholesterol. Shrimp, rice, cheese, eggs, and liver are high in cholesterol
A nurse is providing teaching to a client who had cervical cancer and is rescheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching. A. I need to lie still in bed during my brachytherapy B. I will have an implant placed once a month during the brachytherapy C. I must stay at least 3 feet away from others between brachytherapy treatments D. The nurse should teach the client that the blood in the urine is not expected after brachytherapy treatment. The client should notify the provider immediately if she develops this manifestation.
A. you want to prevent dislodgement. brachytherapy treatments are 1-2 times a week there are no restrictions regarding contact with others the nruse should teach the client that blood in the urine is NOT expected... notify the provider immediately
A nurse is assessing a client who has a new diagnosis of a detached retina. The nurse should anticipate the client to report which of the following manifestations? (SATA) A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision
AB Double vision is a manifestation of multiple sclerosis.
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent uric acid stones. Which of the following suggestions should the nurse make? SATA A. take allopurinol as prescribed B. exercise several times a week C. Limit intake of foods high in purine D. decrease daily fluid intake E. avoid citrus juices
ABC allopurinol is an anti gout medication that reduces uric acid levels, exercise will help because immobility is a risk factor for stone formation, purine increases the risk for uric acid formation (organ meats, poultry, fish, red wine, gravies). Citrus juices help alkalinize the urine, which helps prevent uric acid formation.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (SATA) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased HR E. Fever
ABD
A nurse on an oncology unit is providing discharge teaching to an adolescent female who received bone marrow transplant for leukemia. Which of the following information should be included in the teaching? SATA A. Take your temp twice each day B. You may return to school if you feel strong enough C. It is important to always wear shoes D. Clean your toothbrush weekly with isopropyl alcohol E. Avoid using tampons
ACE Clients should avoid crowded places and should limit their visitors to people who are healthy. A client with a bone marrow transplant is immunosuppressed and needs to wear shoes, avoid tampons, and rinse the toothbrush once a week in the dishwasher or with bleach.
A client who has ARDS will exhibit which of the following? (SATA) A. PaO2 50 mm Hg B. Rhonchi C. Hypopnea D. Hyperpnea
AD
A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (SATA) A. Tachycardia and hypertension B. Respiratory rate 16/min C. Negative Chvostek's sign D. Laryngeal stridor and hoarseness E. Positive Trousseau's sign
ADE Chvostek's sign (positive) indicates hypocalcemia, occurs when the parathyroid glands are removed and regulation of serum calcium is impaired. Trousseau's sign is an indication of hypocalcemia, which is a complicaiton of thyroid removal.
(Addison's or Cushing's?) Disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). This disease occurs when the adrenal glands do not produce enough of the hormone cortisol, and, in some cases, the hormone aldosterone
Addison's
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a squamous cell carcinoma? A. Rough, dry, scaly lesion B. Firm nodule with crust C. Pearly papule with ulcerated center D. irregularly shaped lesion with blue tones
B
A nurse is caring for a client who is 3 days post op following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg.
B
A nurse is preparing to administer methotrexate to a client who has rheumatoid arthritis. The nurse should identify that which of the following findings is an adverse effect of the medication? A. Hallucinations B. Pruritis C. Hand and foot syndrome D. Tinnitus
B
During an asthma attack, a client will experience which kind of manifestations? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor. D. Rhonchi
B
Which of the following medications should be prescribed to a patient with multiple sclerosis experiencing muscle spasms? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
B
Which of the following wounds will be expected to heal by secondary intention? A. Partial-thickness burn B. Stage 3 pressure ulcer C. Surgical incision D. Dehisced sternal wound
B
Which one of the following choices are manifestations of pernicious anemia? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice and an enlarged liver D. Petechiae and ecchymosis
B
Which type of skin cancer is the most serious? A. Basal cell carcinomas B. Melanomas C. Actinic keratoses D. Squamous cell carinomas
B
__________ measures the amount of air a client can exhale after maximum inhalation. A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume
B
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from whcih of the following sources? A. cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen
B homographs are cadaver skin
A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia
B Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. Manifestations include Raynaud's syndrome, muscle weakness, arthritis, dry mucous membranes. Contractures develop with advanced systemic scleroderma unless a client follows a regimen of range of motion and muscle-strengthening exercises.
A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to correct the alignment in bed B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C. Lift the rope off the pulley while the client rocks back and forth to reposition D. Lift the weight manually while another staff member moves the client up in bed.
B.
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse take first? A. Obtain sample menus from the dietician to give to the client B. Ask the client to identify the types of foods she prefers C. Identify the recommended range for the client's blood glucose D. Discuss long-term complications that can result from nonadherence to the dietary plan
B.
A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. What is this? A. Orthopnea B. Cheyne-Sokes C. Paradoxical D. Kussmaul
B. Cheyne stokes respirations can be the result of a drug overdose or increased ICP and can precede death Kussmaul respirations = a pattern of hyperventilation that occurs in a DKA patient Paradoxical respirations occurs in clients who sustained chest injuries
A nurse is assessing a client who is in the EARLY stages of Hep A. Which of the following should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces
B. the other options are LATE manifestations
A nurse is providing discharge teaching to a client following an open radical prostatectomy. The client is going home with an indwelling catheter. Which of the following statements by the client indicates an understanding of the teaching? A. I will be able to take a tub bath in 1 week B. I will change the catheter drainage bag once each week C. I will use suppositories to prevent constipation D. I will regain my bladder control once the catheter is removed
B. The client should shower for the first 2-3 weeks. The client should use stool softeners, not suppositories. Bladder control may not return right away and may need to practice Kegel exercises. Urinary incontinence can last for 1-2 years following surgery
A nurse is evaluating the lab values of a client who is in the resuscitation phase following a major burn. Which of the following lab findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/L
B. The nurse should anticipate a low sodium level, low albumin level, elevated potassium level, and elevated hemoglobin level due to movement of fluids into interstitial space and loss of fluids/electrolytes.
A nurse in the ED is assessing a client who was in a motor vehicle crash 2 days ago and has sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis
B. The triad of neurological changes, petechial rash, and hypoxemia are findings of fat embolism syndrome.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN
B. Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. WHich of the following actions should the nurse take? A. Contimue to monitor for manifestations of a transfusion reaction. B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. C. continue the transfusion and repeat the type and crossmatch D. prepare to administer a dose of diphenhydramine IV.
B. a client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. the nurse should stop the transfusion and infuse 0.9 NaCl with new tubing. A client whose blood type is B can only receive type B of AB plasma.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atria pressure D. Decreased pulmonary artery pressure
B. pulmonary congestion occurs due to right sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and the hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right sided heart failure. Pulmonary artery pressure increases as a result of back-up from stenosis of the mitral valve. Cardiac output is decreased because the left ventricle is receiving insufficient blood volume to pump out.
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 sec before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. An irregular ventricular rate of 125/min with a wide QRS pattern
B. the nurse should interpret this finding as atrial flutter, which indicates a lack o fconduction between the atria and ventricles. The additional atrial beats are not conducting.
A nurse in a provider's office is assessing a client's skin lesions. The nurse notes a small, solid, flat, discolored lesion with variable borders. The nurse should document the findings as which of the following skin lesions? A. papules B. macules C. wheals D. vesicles
B. A macule is flat, variably shaped, and small, typically smaller than 10 mm in diameter. A macule is a change in the skin color. Freckles and the rash associated with rubella are types of macules.
Which of the following medications are best for treating GERD? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
B. PPIs are best for GERD
A nurse is providing teaching to a client who has type 1 diabetes mellitus about exercise. Which of the following statements should the nurse include in the teaching? A. You should exercise during a peak insulin time B. Wear a medical alert identification tag when you exercise C. Exercise can decrease the effect of insulin and cause the blood glucose levels to increase D. You will get the most benefit from exercise when your glucose levels are higher than normal
B. Exercise can potentiate the effects of insulin and cause the blood glucose levels to decrease, you also don't want to exercise if blood glucose is greater than 250 mg/dL
A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following information should the nurse include in the teaching? A. You will need to continue to use some form of birth control for 6 months B. You might experience manifestations of menopause C. Do not lift anything heavier than 15 lbs D. Pain or burning on urination is an expected outcome of this surgery
B. Pregnancy is no longer possible, since the uterus and ovaries are removed manifestations of menopause may occur (hot flashes, night sweats, vaginal dryness). The client should not lift anything heavier than 5-10lbs Burning or pain on urination can indicate a UTI and should be reporeted.
Autonomic dysreflexia is a neurologic emergency that occurs in clients who have a spinal cord injury above level what? A. T4 B. T 6 C. C 4 D. C 6
B. T6
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? A. AN assistive device to use when the client is ambulating. B. Heat paraffin therapy applied to the client's joints. C. Gentle massage of the client's hands D. Active range of motion exercises on the client's affected joints.
B. The elevated ESR indicates an acute inflammatory process due to the client's rheumatoid arthritis. The use of warm paraffin relieves the stiffness of the client's joints and provides comfort. Massage direclty on the joints can cause aggravation. Passive or isometric exercises are preferred over active range of motion exercises.
A nurse is caring for a client who is 72 hours postop following an above the knee amputation. Which of the following actions should the nurse take? A. Elevate the residual limb on a soft pillow B. Assist the client to a prone position ever 4 hr. C. Reapply a bandage to the residual limb every 12 hrs. D. Apply dressings to the site in a proximal to distal direction.
B. The nurse should assist the client to a prone position for 20-30 min every 3-4 hrs following an amputation because is reduces the risk of flexion contractures. A bandage should be reapplied every 4-6 hrs to assist in preparation for a prosthetic limb. Bandages should be applied in distal-proximal direction to prevent restriction of blood flow. The nurse should avoid elevating the limb because this position increases the risk for flexion contractures
A nurse is preparing a 24-hour urine specimen for a client who is suspected to have pheochromocytoma. Which of the following laboratory tests from the 24-hour urine specimen should the nurse use to assess the client's condition? A. Creatinine clearance B. Vanillylmandelic acid (VMA) C. 17-hydroxycorticosteroids (17-OHS) D. Protein
B. This test determines if the client has pheochromocytoma, which measures the level of catecholamine metabolites in a 24 hr urine sample. Pheochromocytoma is a tumor of the adrenal gland that causes excess release of the catecholamines epinephrine and norepinephrine, which are hormones that regulate blood pressure and heart rate.
A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer? A. The client is a hairdresser B. The client uses tobacco C. The client is over 60 years of age D. The client has frequent urinary tract infections
B. Tobacco use is the greatest risk factor for developing bladder cancer. The other answers are true, but B is MOST true.
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? A. elevated blood pressure B. Involuntary muscle spasms C. cold intolerance D. weight loss
B. involuntary muscle spasms is an indication of hypoparathyroidism. Weight loss and elevated blood pressure are manifestations of hyperthyroidism/thyroid storm
A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching A. I will ask my provider to change my contraception to an intrauterine device B. I will notify my doctor before I have dental procedures C. I will avoid using antiseptic mouthwash during my oral care D. I will wear a mask when I go out in public
B. the client should notify the provider prior to invasive procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.
A nurse is planning care for a client who has cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? A. check the client's blood glucose for hypoglycemia B. Check the client's urine specific gravity C. weigh the client weekly D. insert an indwelling catheter for the client
B. you want to assess for fluid volume overload. The nurse should weigh the client at the same time each day. The nurse should save all urine output to accurately record it every 24 hours. The nurse should assess for hyperglycemia because hypercortisolism elevates blood glucose.
Manifestations of Autonomic Dysreflexia include: (SATA) A. Tachycardia B. Bradycardia C. Flushing of face and neck D. Pallor E. Extreme hypertensiom F. Extreme hypotension
BCE
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting at the bedside. Which of the actions should the nurse take first? A. provide oxygen B. place the client in side-lying position C. provide privacy D. lower the client to the floor
D
A client who has severe kidney failure is at risk for the development of what? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
C
A nurse in a provider's office is assessing a client's skin lesions resulting from an allergic reaction. The nurse notes that the patient has transient, elevated, irregularly-shaped lesions caused by localized edema .The nurse should document the findings as which of the following skin lesions? A. papules B. macules C. wheals D. vesicles
C
A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? A. Purple striae on the chest and abdomen B. Butterfly rash across bridge of the nose C. Bronze pigmentation of skin D. Jaundice of the face and sclera
C
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a basal cell carcinoma? A. Rough, dry, scaly lesion B. Firm nodule with crust C. Pearly papule with ulcerated center D. irregularly shaped lesion with blue tones
C
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. confluent, honey-colored crusted lesions. B. Large, tender nodule located on a hair follicle. C. Unilateral, localized, nodular skin lesions. D. A fluid-filled vesicular rash in the genital region.
C
A nurse is preparing to administer capecitabine IV to a client who has breast cancer. The nurse should identify that which of the following findings is an adverse effect of the medication? A. Hallucinations B. Pruritis C. Hand and foot syndrome D. Tinnitus
C
A nurse is preparing to care for a group of clients after receiving a change of shift report. Which of the following clients should the nurse assess first? A. A client who has benign prostatic hyperplasia and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophogeal cancer and reports painful swallowing.
C
A nurse is teaching a client who has AIDS about the transmission of Pneumocystitis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching? A. PCP is sexually transmitted from person to person. B. You were most likely exposed to a contaminated surface, such as a drinking glass. C. PCP results from an impaired immune system. D. You may have contracted PCP from a family pet.
C
A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? A. You will be NPO for 8 hours following the procedure B. An allergy to shellfish is a contraindication to this procedure C. You will need to be on bed rest following the procedure D. A creatinine clearance is needed prior to the procedure
C
A nurse is teaching a group of young adults about the health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? A. apply a broad-spectrum sunscreen 5 min before sun exposure B. wear a sun visor instead of a hat C. avoid exposure to midday sun D. use a tanning booth instead of sunbathing outdoors.
C
Which of the following promotes wound healing? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium
C
Which one of the following indicates a PVC? A. P waves occurring at 0.16 sec before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. An irregular ventricular rate of 125/min with a wide QRS pattern
C
__________ measures the amount of air in the lungs after normal expiration. A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume
C
A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. first degree frostbite B. second degree frostbite C. third degree frostbite D. fourth degree frostbite
C 1st degree- the affected area is reddened and waxy 2nd degree - skin of affected area has large, fluid filled blisters 4th degree - skin of affected area is frozen, blisters do not appear, client's muscles and bones are affected
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated BP B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food
C As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension results. Bowel sounds are silent with bowel perforation.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hours after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
C Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3-6 hrs following the onset of acute pancreatitis. The amylase level peaks in 20-30 hrs and returns to expected range in 2-3 days.
A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone
C colchicine is an anti inflammatory gout medication used in conjunction with probenecid in acute gout attacks.
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? A. output equal to the instilled irrigant B. report of bladder spasms C. Viscous urinary output with clots D. Report of a strong urge to urinate
C this indicates arterial bleeding
A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching? A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt and peaches
C A turkey and cheese sandwich is high in protein, carbohydrates, and sodium. Addison's disease requires a diet low in potassium and high in sodium, carbs, and protein.
A nurse is assessing a client who has a new diagnosis of labyrinthitis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly gray color of the affected eardrum
C Bilateral nystagmus can be a manifestation of labyrinthitis
A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? A. Take a photograph of the peripheral IV site B. Obtain and record the client's vital signs C. Stop the infusion D. Identify all medications administered through the IV site for the past 24 hours.
C chemotherapy agents are vesicants that can cause extensive tissue damage if extravasion occurrs
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. endoscopic sclerotherapy B. liver lobectomy C. liver transplant D. transjugular intrahepatic portal-systemic shunt placement
C fulminant hepatic failure is most often caused by Hep A, and causes hepatic encephalopathy. Liver transplantation is the best treatment for these clients.
A nurse is teacbig a client who has TB about a new prescription for Rifampin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food." B. "I need to take a B complex vitamin while taking this medication." C. I can expect this medication to turn my skin orange." D. "I can expect this medication to make my vision blurry."
C.
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis. B. Pericarditis C. Ventricular Dysrhythmias D. Pulmonary Emboli
C. After an MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following should the nurse include in teaching? A. "If the test is positive, it means you have an active case of Tb" B. "If the test is positive, you should have another TB skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2-3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the TB substance."
C. An area of induration after 48-72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another TB test is necessary. A client with a positive skin test should have a chest x ray to rule out active TB.
A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from chemotherapy? A. Gingival hyperplasia B. Hirsutism C. Pancytopenia D. Weight gain
C. weight loss, metallic taste in mouth, nausea, vomiting, alopecia are all other adverse effects. Hirsutism is generally caused by cushing's syndrome in women (excessive body or facial hair)
A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with S-T segment depression B. Relief of chest pain with deep inspiration. C. Dyspnea with hiccups D. Chest pain that increases when sitting upright.
C. A client with pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.
When a client has an airway obstruction, which of the following lung sounds will be heard? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor. D. Rhonchi
C. A loud crowing-like sound often able to be heard without a stethoscope.
A nurse is assessing a client who has Guillain-Barre syndrome. WHich of the following findings should the nurse expect? A. Tonic clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness
C. Guillain-Barre syndrome is also called inflammatory demyelinating polyneuropathy. This is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? A. hospitalization is required when administering each treatment. B. The maximum effect of the medication will occur in 6 months C. Hypertension is a common adverse effect of this medication. D. Blood transfusions are needed with each treatment.
C. Hypertension is a common adverse effect of epoetin alfa because of the rise in production of erythrocytes and other RBC types. Epoetin alfa is a synthetic version of human erythropoeitin. Epoetin alfa is self-administered at home and the effects will occur in 2-3 months.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision
C. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.
A nurse is assessing for cardiac tamponade on a client who had a coronary artery bypass graft. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus. D. Check for a pulse deficit
C. The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. A client who has cardiac tamponade will have hypertension because of the sudden decrease in cardiac output from the fluid compressing the atria and the ventricles. Heart sounds will be muffled.
A nurse is providing teaching to a client who has a new diagnosis of Maniere's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake
C. This is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements.
Which one of the following choices are manifestations of sickle cell anemia? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice and an enlarged liver D. Petechiae and ecchymosis
C. An enlarged spleen is also present
A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client indicates further teaching is needed? A. "This medication will take 4 weeks for me to notice relief in my joints." B. "I can take an antacid with this medication for indigestion." C. "I can take this medication with aspirin." D. "The naproxen gets down easier when I crush it and put it in applesauce."
C. Avoid taking this medication with other NSAIDs because it can increase the risk for bleeding and GI ulceration.
Which of the following medications should the nurse identify as a treatment for rheumatoid arthritis? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
C. Celecoxib is a type of NSAID used to relieve some of the manifestations caused by RA in adults. This medication can also be prescribed for osteoarthritis, spondylitis, and painful menstruation.
A nurse is caring for a client who is postop following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care? A. Empty the collection pouch when it is 2/3 full B. Expect urine outflow into the pouch to begin 1-2 days following surgery C. Change the collection pouch early in the morning D. Place an aspirin in the collection pouch to control oder.
C. Early in the morning because this is when urine output is reduced. Aspirin placement in the pouch can cause an ulceration to the stoma. Urine outflow should not be delayed after surgery and output should be monitored every hour by the nurse and then every 4-8 hours after the immediate post op period. Empty the pouch when 1/3 full.
A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can get this disease by getting a tattoo."
C. Hep A is transmittted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, uncooked shellfish. Hep B is transmitted through needles.
Which value is concerning? A. Cholesterol level 195 mg/dL B. HDL greater than 40 mg/dL C. LDL level greater than 100 mg/dL D. Triglyceride level less than 150 mg/dL
C. LDL should be below 100
A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A. foods high in vitamin C B. foods low in fat C. foods high in fiber D. foods low in calories
C. Longer-term, low-fiber eating habits lead to straining during bowel movements, causing the development of diberticula. High fiber foods help maintain active motility of the GI tract
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips
C. Night sweats and fevers. Anorexia and weight loss are clinical manifestations of TB
A nurse is assessing a client who has Grave's disease. Which of the following findings should the nurse expect the client to display. A. constipaiton B. cold intolerance C. difficulty sleeping D. anorexia
C. The client can have difficulty sleeping due to anxiety from the overproduction of thyroid hormone. The client will experience an increased appetite, weight loss, heat intolerance, and diarrhea.
A nurse is providing preoperative teaching for a client who has colorectal cancer and is to undergo placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? A. It will be a relief to not have any further rectal pain B. I will need to sit on a rubber donut when I am out of bed in the chair C. I can have only liquids for 2 days before the surgery D. The colostomy will start working about 7 days after the surgery
C. The client should consume full or clear liquids only for 24-48 hrs before surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis. The colostomy should function within 2-4 days. The client should sit on foam pads or soft pillows. Rectal pain and itching may occur even after healing of client's incisional wound
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. APply pressure to the puncta after instilling the medication D. Place each drop of the medication directly on to the client's cornea
C. The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1-2 minutes afterwards to prevent systemic absorption of the medication. The client should look upward, gently close eyes (not blink)
A nurse is providing discharge teaching to a client who is postop following a right mastectomy for breast cancer. The client will be discharged with two jackson-pratt drains. Which of the following information should the nurse include in the teaching? A. Empty the drainage bag tubes once per day B. Showering is permitted before the drainage tubes are removed C. The drainage tubes often are removed at the same time as the stitches D. Do not begin exercising the arm until the provider removes the drainage tubes
C. This usually happens within 7-10 days. Normal and nonstrenuous exercise is ok before drain removal. Baths should be taken instead of showers until the stitches and tubes are removed. Drainage tubes should be emptied twice a day and the amount of drainage should be recorded.
A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty. Which of the following statements should the nurse identify as an understanding of the teaching? A. I will wear a continuous movement machine on my knee for 24 hr/day B. I should avoid taking NSAIDs after surgery C. I should wear elastic stockings on both of my legs D. I will begin exercising my legs the day after surgery
C. VTE is a common complication after orthopedic surgery
Which of the following medications are best for treating bleeding esophageal varices? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
C. Vasopressin constricts the splanchic bed and decreases portal pressure. Also constructs the distal esophogeal and proximal gastric veins, which reduces inflow to the portal system.
Which of the following wounds will be expected to heal by primary intention? A. Partial-thickness burn B. Stage 3 pressure ulcer C. Surgical incision D. Dehisced sternal wound
C. With primary intention, a clean wound is closed mechanically, leaving a well-approximated edge and minimal scarring.
A nurse is providing teaching to a client who has TB and a presciption for isonazid. Which of the following instructions should the nurse include? A. It is necessary to take this medication for the rest of your day to prevent recurrence B. Your provider will monitor your thyroid function while you are taking this medication C. You should take this medication on an empty stomach D. It is recommended to take this medication with an antacid
C. clients should take the medication either 1 hr before or 2 hrs after
A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following findings are expected? A. weight gain B. Oliguria C. Vaginal bleeding D. Back pain
C. the most common manifestation of cervical cancer is painless vaginal bleeding. Pelvic and chest pain, weight loss, and dysuria are manifestations of cervical cancer too.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? A. Administer ferrous sulfate B. Increase dietary intake of folic acid. C. Initiate weekly vitamin B12 injections. D. Initiate a blood transfusion
C. the nurse should initiate B12 injections for a client with pernicious anemia, then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 in teh GI tract.
A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. cover the insertion site with a hydrocolloid dressing B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse
C. this maintains negative pressure in the chest to prevent air entry into the pleural space. pain medication should be provided before removal. The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the chest tube.
A nurse is assessing a client who is postop following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus. Which of the following lab values should be assessed for DI? A. BUN B. Blood glucose C. Urine ketones D. Specific gravity
D
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of the medication? A. Hallucinations B. Pruritis C. Hand and foot syndrome D. Tinnitus
D
Which of the following medications is used to relieve pain in clients who have gout? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
D
Which one of these rhythms indicates ventricular tachycardia? A. P waves occurring at 0.16 sec before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. An irregular ventricular rate of 125/min with a wide QRS pattern
D
___________ measures the amount of air in the lungs after forced expiration. A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume
D
A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks why they need two tubes. The nurse informs the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space
D the upper tube is for removing air from the pleural space
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a malignant melanoma? A. Rough, dry, scaly lesion B. Firm nodule with crust C. Pearly papule with ulcerated center D. irregularly shaped lesion with blue tones
D they often occur on upper back and lower legs
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following solutions? A. 0.45% NaCl B. D5 in 0.9% NaCl C. D10W D. 0.9% NaCl
D.
A nurse is teaching a client who has genital herpes about self-management. WHich of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to clean lesions. B. Wear a condom during sexual activity when lesions are present. C. Take a sitz bath once per day. D. Apply a warm compress to the lesions.
D. The client should take 3-4 sitz baths per day to relieve discomfort, avoid sexual acitivty when lesions are present, and use a mild soap to clean lesions then pat dry.
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. Move between the bed and the wheelchair once every 2 hours. B. Make sure that your caregiver massages your skin daily. C. Use a rubber ring when sitting at the bedside D. SHift your weight in the wheelchair every 15 min.
D. the client should change position at least every hour, and avoid massages over bony prominences
A nurse is working with an assistive personnel who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make? A. Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox B. Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant C. A client who has herpes zoster is not contagious if blisters are present on the skin. D. Herpes zoster is not contagious to people who have had chickenpox
D. varicella is a causative agent of both chickenpox and herpes zoster. The virus is contagious to people who have not had chickenpox or the varicella vaccine. Herpes zoster is MOST contagious while fluid-filled blsiters are present on the skin. Adults do not develop a natural immunity to chickenpox.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. WHich of the following manifestations should the nurse expect? A. Increased BP B. Decreased HR C. Yellowing of the skin D. Boardlike abdomen
D. The client will have a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.
A nurse is caring for a client who is receiving TPN therapy and has just returned to the room following physical therapy. THe nurse notes that the infusion pump for the TPN is turned off. After restarting the pump, the nurse should monitor for which of the following findings? A> Hypertension B> Excessive thirst. C. Fever D. Diaphoresis
D. The nurse should recognize the potential for development of hypoglycemia due to the sudden withdrawal of the TPN solution. Other manifestations of hypoglycemia include: weakness, anxiety, confusion, hunger.
A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing skin cancer? A. Age over 60 B. Genetic predisposition C. Light-skinned race D. Overexposure to sun light
D. The rest are true, but D is most true
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? A. Plethoric appearance of facial skin B. Glossitis and weight loss C. Jaundice and an enlarged liver D. Petechiae and ecchymosis
D. the client who has aplastic anemia will have these manifestations. Dyspnea on exertion can also be present. In aplastic anemia, all 3 major blood components (RBC, WBC, platelets) are reduced or absent, known as pancytopenia. Manifestations usually develop gradually.
A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates an understanding of the teaching? A. I will take the medication in teh evening B. I will drink a full glass of milk with the medication C. I will take the medication at mealtime D. I will sit upright after taking the medication
D. A client should sit upright for 30 minutes after taking this medication to prevent esophogeal irritation and ulceration. Alendronate should be taken at least 30 minutes before food, in the morning, and may require a calcium supplement later in the day due to the adverse effect of hypocalcemia
A client who has thick sputum production of obstruction from a foreign body has which kind of lung sounds? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor. D. Rhonchi
D. These are dry, low-pitched, snore-like noises produced in teh throat
A nurse is teaching a client about the prostate specific antigen test (PSA). Which of the following statements should the nurse make? A. You should fast for 8 hours after the PSA test B. Annual PSA screening should begin at age 40 C. Expected PSA values will decrease as you get older D. You should not ejaculate for 24 hours prior to the PSA test
D. Ejaculation within 24 hours prior to the test can cause falsely elevated levels of PSA.
A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates an understanding of the teaching? A. I will do my best to try to get him to eat something B. I will lay him flat if his breathing becomes shallow C. I will use an electric blanket to keep him warm D. I will continue to talk to him even when he is sleeping
D. Hearing is the last sense to leave in the dying process. A warm blanket should be used, but not an electric blanket. A client who is approaching death should be positioned with the head elevated or on the side, not lying flat. A client close to death often refuses nourishment and they should not be forced to eat or drink.
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. A nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision. C. Onset of progressive dementia D. Reddish-purple skin lesions.
D. Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented lesions that can be firm, flat, raised, or nodular.
A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? A. Irregular cardiac rhythm B. Numbness in the hands C. Muscle cramps D. Facial edema
D. Superior vena cava syndrome is a medical emergency resulting from partial occlusion of the superior vena cava, leading to a decreased blood flow through the vein. (this does not affect cardiac arrythmias because it is just an alteration in vascular flow). Most cases are associated with cancers involving the client's upper chest. Early manifestations are facial and upper extremity edema.
A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following statements indicates an understanding of the information? A. I will not need to have a urinary catheter following this procedure. B. I will expect my urine to be cloudy after having this procedure. C. At least I won't have leakage of urine after having this procedure. D. I will feel the urge to urinate following this procedure.
D. analgesics can help relieve this discomfort. A catheter will be needed at first to help monitor bleeding and urine output
A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors should the nurse identify for placing the client at the greatest risk for developing breast cancer? A. Obesity B. ORal contraceptive use C. Alcohol use D. Over 50 years of age
D. is the most true. obesity and oral contraceptive place clients at a low but increased risk. EXCESSIVE alcohol consumption causes a slight risk for developing breast cancer.
A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the providers? A. Red-orange discoloration of urine B. Unexpected weight gain C. Ringing in the ears D. Decreased visual acuity
D. optic neuritis is an adverse effect of ethambutol. Blindness can result if the medication is not terminated immediately. Anorexia is an adverse effect of both of these medications. Discolored urine is an expected side effect. Tiniitus is not an adverse effect.
A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? A. recap the needle on the syringe B. schedule a nurse to administer future injections for this client C. explain to the client that the syringe should be disposed of in the bathroom trash can D. place the syringe in a puncture-proof disposal container
D. safety first! then educate!
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. Because most of my colon is still intact and functioning, my stool will be formed. B. My stoma will appear large at first, but it will shrink over the next several weeks. C. My colostomy will begin to function 2-6 days after surgery D. My diet will have to change to a soft diet after surgery
D. the client can return to a regular diet and there are not any food restrictions.
A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? A. raising the bed linens off the client's feet to prevent plantar flexion B. keeping the client's heels off the bed to prevent pressure ulcers C. positioning the client off of the operative site while in bed D. preventing dislocation of the hip in position changes or movement.
D. the nurse should place a wedge-shaped pillow between the client's legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement. regular pillows and rolled blankets should position the client off of the operative site while in bed.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (SATA). A. Lost vision can improve with eye drops B. Administer eye drops as needed for vision loss C. Glasses will be necessary to correct the accompanying presbyopia D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow or aqueous humor.
DE Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of schlemm. Eyedrops should be administered on a regular schedule, and prevent further vision loss but don't improve current vision loss.
