401 EAQ
Which type of hypersensitivity reaction will occur in the client who mistakenly received ABO-incompatible blood from a donor? 1 Type I 2 Type II 3 Type III 4 Type IV
Type II
CARDIO
CARDIO
After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, which action would the nurse take? 1 Strip the chest tube catheter. 2 Check the system for air leaks. 3 Decrease the amount of suction pressure. 4 Recognize that the system is functioning correctly.
Check the system for air leaks.
The nurse is counseling a client with type 1 diabetes about choosing food items that are low in carbohydrate (CHO) content. Which food selection made by the client indicates effective teaching? 1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice
Skim milk
The nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? 1 The client who has dry oral mucous membranes from mouth breathing 2 The client who has a nasogastric tube in place for gastric decompression 3 The client who has many visitors and spends much time sitting in a chair 4 The client who has an upper respiratory infection and spends much time sleeping
The client who has many visitors and spends much time sitting in a chair
RESPIRATORY
RESPIRATORY
When a client arrives in the emergency department after prolonged exposure to cold weather, which clinical manifestations will the nurse expect to find? Select all that apply. One, some, or all responses may be correct. 1 Stupor 2 Erythema 3 Increased anxiety 4 Rapid respirations 5 Paresthesia in affected body parts
Stupor Paresthesia in affected body parts
Which instruction given by the nurse promotes healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach? 1 "Decrease fluid intake." 2 "Increase high-fiber food intake." 3 "Bend over from the waist to pick up fallen objects." 4 "Brush teeth regularly with a medium-bristle brush."
"Increase high-fiber food intake."
After the nurse teaches a client about self-management techniques for smoking cessation, which client statement indicates the need for further teaching? 1 "I should list the reasons why I should stop smoking." 2 "I should visit all the places where I started smoking." 3 "I should remove all ashtrays and lighters from my home." 4 "I should try replacing tobacco with sugarless mints and gum."
"I should visit all the places where I started smoking."
The nurse identifies which clinical manifestations as being characteristic of hyperthyroidism? Select all that apply. One, some, or all responses may be correct. 1 Diaphoresis 2 Weight loss 3 Constipation 4 Protruding eyes 5 Cold intolerance
Diaphoresis Weight loss Protruding eyes
How would the nurse document this rhythm for a client who has just arrived in the emergency department? 1 Atrial flutter 2 Atrial fibrillation 3 Second-degree heart block 4 Supraventricular tachycardia
Atrial flutter
ENDOCRINE
ENDOCRINE
Which clinical manifestations in a client indicate a hyperfunctional thyroid gland? Select all that apply. One, some, or all responses may be correct. 1 Anemia 2 Diarrhea 3 Weight loss 4 Decreased appetite 5 Distant heart sounds
Diarrhea Weight loss
GASTROINTESTINAL
GASTROINTESTINAL
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. Which is a therapeutic nursing response when the client refuses all visitors? 1 Listen to the client's fears. 2 Encourage the client to socialize. 3 Place a sign on the door indicating visitor restrictions. 4 Darken the client's room by pulling the drapes.
Listen to the client's fears.
The nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in the client's diet? Select all that apply. One, some, or all responses may be correct. 1 High fat 2 Low sodium 3 High vitamins 4 Moderate protein 5 Low carbohydrates
Low sodium High vitamins Moderate protein
Which nursing action will be most helpful in preventing transmission of influenza in crowded communities? 1 Teaching correct hand-washing techniques 2 Demonstrating how to cover the mouth when coughing 3 Educating about the importance of having annual vaccinations 4 Giving antiviral medications within 48 hours of symptom development
Educating about the importance of having annual vaccinations
After the nurse has presented a staff education session on the use of adenosine for supraventricular tachycardia, which statement by a staff member indicates that the teaching has been effective? 1 "We will need a crash cart available at the client's bedside." 2 "We will plan to schedule the anesthesiologist to be available." 3 "The medication should be injected over at least 1 to 2 minutes." 4 "Infusion of normal saline will be needed before medication injection."
"We will need a crash cart available at the client's bedside."
The nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. Which common clinical manifestations would the nurse include in the teaching program? Select all that apply. One, some, or all responses may be correct. 1 Anemia 2 Rectal pain 3 Rectal bleeding 4 Change in bowel habits 5 Severe abdominal distention
Anemia Rectal bleeding Change in bowel habits
When caring for a client who has hemopneumothorax and a chest tube, which prescribed action by the health care provider would the nurse question? 1 Autotransfuse the blood in the collection chamber after 6 hours. 2 Disconnect the drainage system from suction to ambulate the client. 3 Add sterile water to the suction control chamber to maintain 20 cm of suction. 4 Use a dressing impregnated with petroleum jelly around the chest tube insertion site
Autotransfuse the blood in the collection chamber after 6 hours.
The nurse providing immediate postoperative care to a client who had an abdominoperineal resection would assess for which clinical indicator of complications? 1 Blood in the nasogastric tube 2 Return of bowel sounds 3 Absence of output from the stoma 4 Bloody drainage on the abdominal and rectal dressings
Bloody drainage on the abdominal and rectal dressings
A client exhibits dysphasia, dry mouth, drooping eyelids, blurred vision, vomiting, and diarrhea. Within 24 hours, the client develops bilateral cranial nerve impairment and descending weakness. Which bioterrorism agent presents with these clinical manifestations? 1 Plague 2 Anthrax 3 Botulism 4 Smallpox
Botulism
When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect? 1 Decreased white blood cell count 2 Elevated serum troponins I and T 3 Decreased creatine kinase-MB (CK-MB) 4 Decreased B-type natriuretic peptide (BNP)
Elevated serum troponins I and T
IMMUNOLOGIC AND INFECTIOUS DISEASE
IMMUNOLOGIC AND INFECTIOUS DISEASE
Which medications inhibit tumor necrosis factor-alpha (TNF)-a in clients treated for rheumatoid arthritis (RA)? Select all that apply. One, some, or all responses may be correct. 1 Anakinra 2 Infliximab 3 Abatacept 4 Etanercept 5 Golimumab
Infliximab Etanercept Golimumab
A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. Which would the nurse be prepared to administer to the client? 1 A low-residue diet 2 Intravenous therapy 3 Total parenteral nutrition 4 An oral electrolyte solution
Intravenous therapy
Which clinical manifestation is indicative of the fluid and electrolyte imbalance associated with a parathyroidectomy? 1 Constipation 2 Muscle spasms 3 Hypoactive reflexes 4 Increased specific gravity
Muscle spasms
Which finding would be of most concern when the nurse assesses a client with emphysema? 1 Barrel chest 2 Oral cyanosis 3 Pursed-lip expiration 4 Respirations 26 breaths per minute
Oral cyanosis
A client with type 2 diabetes travels frequently and asks how to plan meals during trips. Which is the best response by the nurse? 1 "You can order diabetic foods on most airlines and in restaurants." 2 "Plan your food ahead and carry it with you from home." 3 "Monitor your blood glucose level frequently and eat accordingly." 4 "Choose the foods you normally do and follow your food plan wherever you are.
"Choose the foods you normally do and follow your food plan wherever you are."
Discharge planning for a client with chronic pancreatitis includes dietary education. Which client statement indicates to the nurse that further teaching is needed? 1 "I must eat foods high in calories." 2 "I should avoid alcoholic beverages." 3 "I will eat more often but in smaller amounts." 4 "I can eat foods high in fat now that the acute stage is over."
"I can eat foods high in fat now that the acute stage is over."
Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? 1 P wave 2 T wave 3 PR interval 4 QRS interval
QRS interval
The nurse is caring for a client 2 days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? 1 Sooty 2 Frothy 3 Yellow 4 Tenacious
Sooty
A client experienced a wheal and flare reaction to a skin test after a mosquito bite. Which type of hypersensitivity reaction did the client experience? 1 Type I 2 Type II 3 Type III 4 Type IV
Type I
The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. 1 Administer intravenous (IV) levothyroxine. 2 Avoid use of corticosteroids. 3 Give IV normal saline. 4 Wait for laboratory results before treating. 5 Monitor blood pressure every 4 hours.
Administer intravenous (IV) levothyroxine. Give IV normal saline.
Which client with human immunodeficiency virus (HIV) exhibits the clinical manifestations associated with a Histoplasma capsulatum infection?
Client D: nonreproductive cough, hypoxemia, elevated temp, weight loss
A client experiences ineffective control of type 1 diabetes. The client's study results indicate that a sudden decrease in blood glucose level is followed by rebound hyperglycemia. When this event occurs, which action would the nurse take? 1 Give the client 8 oz (240 mL) of orange juice. 2 Seek a prescription to increase the insulin dose at bedtime. 3 Encourage the client to eat smaller, more frequent meals. 4 Collaborate with the primary healthcare provider to alter the insulin prescription
Collaborate with the primary healthcare provider to alter the insulin prescription.
Which sexually transmitted infection is caused by human papillomavirus? 1 Gonorrhea 2 Genital herpes 3 Chlamydia infection 4 Condylomata acuminata
Condylomata acuminata
Which action would the nurse take first when a client who has heart failure reports fatigue and has an increase in heart rate from 90 beats/minute to 120 beats/minute while ambulating? 1 Have the client sit down and rest. 2 Check the client's oxygen saturation. 3 Notify the client's health care provider. 4 Activate the hospital rapid response team.
Have the client sit down and rest.
Which viral infection will cause the nurse to observe for warts on the hands, feet, or genitals? 1 Poxvirus 2 Rhabdovirus 3 Epstein-Barr virus 4 Papillomavirus
Papillomavirus
Which action would the nurse include in the plan of care of a client on the first postoperative day after total laryngectomy? 1 Position client in semi-Fowler position while in bed 2 Remind client that coughing may slow wound healing 3 Change pressure dressings and packing every 12 hours 4 Assist client with head and neck range-of-motion exercises
Position client in semi-Fowler position while in bed
Which intervention would the nurse do postoperatively to reduce the risk of thyroid storm after a client has undergone subtotal thyroidectomy? 1 Provide a high-calorie diet. 2 Prevent infection at the surgical site. 3 Encourage postoperative breathing exercises. 4 Demonstrate how to support the neck after surgery.
Prevent infection at the surgical site.
A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to which major deficiency? 1 Ferrous sulfate 2 Protein 3 Ascorbic acid 4 Linoleic acid
Protein
When preparing a client who is scheduled for a pulmonary function test (PFT) because of possible adult-onset asthma, which action would the nurse take? 1 Have client use the prescribed as needed bronchodilator before testing. 2 Teach client how to take a deep breath and exhale forcefully. 3 Explain the reason for not eating for 6 hours before testing. 4 Check to be sure that the informed consent form is signed
Teach client how to take a deep breath and exhale forcefully.
A client states a desire to follow a total vegetarian (vegan) diet. The client requests assistance in planning a menu to ensure adequate protein quality. Which suggestion should the nurse make? 1 Add milk to grains to provide complete proteins. 2 Use eggs with plant foods to provide essential amino acids. 3 Add cheese to beans to provide a balance of different proteins. 4 Use a mixture of plant proteins to provide essential amino acids
Use a mixture of plant proteins to provide essential amino acids.
A client who is having presurgical testing before a colon resection and possible colostomy says to the nurse, "If I have this surgery, I know that my partner will no longer want to be near me." Which is an appropriate initial nursing response? 1 "You seem concerned that your partner will reject you." 2 "You are wondering about the effect on your sexual relations." 3 "You are probably underestimating your partner's love for you." 4 "You seem worried that the surgery will change how your partner sees you.
"You seem worried that the surgery will change how your partner sees you."
The nurse is providing education, including specific information about what to expect postoperatively, for a client who is scheduled for gastric bypass surgery. Which is an appropriate instruction? 1 "You will need to take medications in a liquid form." 2 "You will need to lie on the right side for 1 hour after meals." 3 "You will need to follow a high-carbohydrate diet once eating is resumed." 4 "You will need patient-controlled analgesia for approximately 1 week after surgery."
"You will need to take medications in a liquid form."
When planning discharge teaching for a client who had coronary artery bypass graft (CABG) surgery using a vein graft, which information will the nurse include? 1 Call immediately if you experience any incisional pain. 2 Mild fever is expected for several weeks after a CABG. 3 Elevate the leg that provided the vein graft whenever you are sitting. 4 Avoid walking or light housework until after the follow-up appointment.
Elevate the leg that provided the vein graft whenever you are sitting.
Which prescribed medications would the nurse anticipate initiating for a client with a Clostridium difficile-associated disease (CDAD)? Select all that apply. One, some, or all responses may be correct. 1 Penicillin 2 Fidaxomicin 3 Ciprofloxacin 4 Metronidazole 5 Vancomycin
Fidaxomicin Metronidazole Vancomycin
Which throat manifestations are the key features in a client with acute viral pharyngitis? Select all that apply. One, some, or all responses may be correct. 1 Petechiae on the soft palate 2 Scant or no tonsillar exudate 3 Slight erythema of the pharynx and tonsils 4 Severe hyperemia of the pharyngeal mucosa 5 Erythema of the tonsils with yellow exudates
Scant or no tonsillar exudate Slight erythema of the pharynx and tonsils
Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? 1 Count the pulse at another site. 2 Notify the primary health care provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.
Verify the pulse by using a Doppler.
Which of these clients in the vascular clinic would the nurse assess first? 1 40-year-old with 30 pack-year cigarette history who reports tingling in both feet 2 42-year-old who takes antihypertensive medication and reports bilateral 4+ ankle swelling 3 65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension 4 70-year-old with peripheral arterial disease who reports severe lower leg burning and numbness
65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension
Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas? 1 Milk 2 Cheese 3 Coffee 4 Cabbage
Cabbage
A client experiences melena, and gastric cancer is discovered. A partial gastrectomy is performed, a jejunostomy tube is surgically implanted, and a nasogastric (NG) tube for suctioning is placed. What would the nurse expect regarding NG drainage during the first 24 hours after surgery? 1 Minimal to no drainage 2 Contains some blood and clots 3 Contains large amounts of frank blood 4 Similar to coffee grounds in color and consistency
Contains some blood and clots
When assessing a client with a type IV delayed hypersensitivity reaction, which clinical manifestations would the nurse expect? Select all that apply. One, some, or all responses may be correct. 1 Edema 2 Bruising 3 Ischemia 4 Induration 5 Tissue damage 6 Hematuria
Edema Ischemia Induration Tissue damage
When a client with chronic obstructive pulmonary disease is going to have a 6-minute walk test, which equipment will the nurse need to gather? 1 Pulse oximeter 2 Stethoscope 3 Blood pressure cuff 4 Syringe and needle
Pulse oximeter
Which finding supports the diagnosis of a hyperfunctioning of the adrenal glands? 1 Serum sodium of 130 mEq/L (130 mmol/L) 2 Serum bicarbonate of 24 mEq/L (24 mmol/L) 3 Blood urea nitrogen of 12 mg/dL (4.29 mmol/L) 4 Serum potassium of 2.8 mEq/L (2.8 mmol/L)
Serum potassium of 2.8 mEq/L (2.8 mmol/L)
When a client is diagnosed with microvascular angina, which topics would the nurse include in client teaching? Select all that apply. One, some, or all responses may be correct. 1 Use of daily aspirin 2 Tobacco cessation techniques 3 Benefits of coronary artery bypass graft surgery 4 Management of usual daily activities to avoid symptoms 5 Use of nitroglycerin to prevent and treat anginal symptoms
Use of daily aspirin Tobacco cessation techniques Management of usual daily activities to avoid symptoms Use of nitroglycerin to prevent and treat anginal symptoms
Which findings would the nurse expect when taking the health history and assessing a client with active pulmonary tuberculosis? Select all that apply. One, some, or all responses may be correct. 1 Fever 2 Dry cough 3 Night sweats 4 Frothy sputum 5 Engorged neck veins 6 Blood-tinged sputum
fever night sweats blood-tinged sputum
Which clinical manifestations support a client's diagnosis of cryptosporidiosis? Select all that apply. One, some, or all responses may be correct. 1 Seizures 2 Diarrhea 3 Confusion 4 Weight loss 5 Blurred vision
Diarrhea Weight loss
When the nurse is assessing a client with laryngeal cancer who has had radical neck surgery, which finding requires the most rapid action? 1 Crackles at both lung bases 2 Blood pressure 102/54 mm Hg 3 Client report of severe neck pain 4 Rapid oozing of blood at neck incision
Rapid oozing of blood at neck incision
When assessing clients in a mass casualty incident, in which order would the triage nurse assign these clients to be seen by health care providers?
In a major disaster, the object is to get the greatest number of survivors treated as rapidly as possible. Critically ill clients who can survive with care are the highest priority to receive services quickly. Tension pneumothorax causes lung collapse and rapid hypoxemia, but can be successfully treated with insertion of a chest tube. Open fractures of long bones are frequently associated with arterial injuries that may result in hemorrhage, but rapid treatment with intravenous solutions and transport to surgery is lifesaving. A laceration of a large muscle is not immediately life threatening and wound care can be delayed. A wrist sprain will result in minimal disability and treatment can be delayed while clients with more severe injuries are managed. A client with a crushing head injury is likely to have had a severe traumatic brain injury and is not likely to survive. In the setting of mass casualty incident, this client would be the lowest priority to be managed.
Arrange the procedure for posterior palpation of the thyroid gland in sequence. 1. Place both thumbs on the nape of the client's neck. 2. Stand behind the client. 3. Ask the client to swallow water so that the thyroid will move up. 4. Use the index and middle fingers of both hands to feel the thyroid isthmus. 5. Ask the client to flex the neck slightly forward and to the right. 6. Palpate the sternocleidomastoid muscle with the index and middle fingers.
2, 1, 4, 5, 6, 3,
