Acute - Module 6
_____: The anterior lobe of the pituitary gland, which makes up about 70% of the gland.
Adenohypophysis
What are the common cancers related to tobacco use? (Select all that apply). A) Cardiac cancer. B) Lung cancer. C) Cancer of the tongue. D) Skin cancer. E) Cancer of the larynx
Answer: B, C, E. Organs exposed to the carcinogens in tobacco (lungs, tongue, larynx) are most likely to develop cancer. Oral cancer is also a risk with "smokeless" tobacco.The heart does not contain cells that divide; therefore, cardiac cancer is unlikely. Skin cancer generally is related to repeated sun and other ultraviolet exposure, such as that found with tanning beds.
What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? (Select all that apply). A) Stroke. B) Diarrhea. C) Ototoxicity. D) Cardiomyopathy. E) Nephrotoxicity.
Answer: C, E. Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity.Cardiomyopathy and stroke are not serious side effects of antiviral agents. Diarrhea is a mild side effect associated with antibiotic therapy.
The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? A) Poison ivy. B) Autoimmune hemolytic anemia. C) Allergic asthma. D) Rheumatoid arthritis.
Answer: C. Allergic asthma is a clinical manifestation of type I hypersensitivity.Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.
_____: Enlarged popliteal bursa.
Baker's cyst
_____: A complex group of microorganisms that functions within a "slimy" gel coating on medical devices.
Biofilm
_____: A class of immunomodulating drugs that attempt to modify the course of disease. Also called biologics.
Biological response modifiers (BRMs; biologics)
_____: Immature, unspecialized (undifferentiated) cells that are capable of becoming any type of blood cell, depending on the body's needs.
Blood stem cells
_____: Clinical manifestations that are caused by Clostridium difficile as a potential result of antibiotic therapy use, especially in older adults.
C. difficile-associated disease (CDAD)
_____: A complex, multi-step process by which blood forms a protein-based structure (clot) in an appropriate area of tissue injury to prevent excessive bleeding while maintaining whole-body blood flow (perfusion).
Clotting
_____: Increased blood flow to an area.
Hyperemia
_____: Slow-growing.
Indolent
_____: The conversion of fats to acids in the body.
Ketogenesis
_____: A reduction in the number of white blood cells.
Leukopenia
_____: A form of vitamin B12 deficiency anemia characterized by abnormally large precursor cells.
Macrocytic anemia
_____: Bone spur.
Osteophyte
_____: Dry, waxy swelling of the front surfaces of the lower legs.
Pretibial myxedema
_____: The most common type of gout; results from one of several inborn errors of purine metabolism.
Primary gout
_____: The breakdown of proteins to provide fuel for energy when liver glucose is unavailable.
Proteolysis
_____: Inflammation of the retina. Also used as a general term for vision problems.
Retinopathy
_____: The family of viruses that includes the human immune deficiency virus.
Retroviruses
_____: Additional tumor that is established when cancer cells move from the primary location to another area in the body. Also called metastatic tumor.
Secondary tumors
_____: System of classifying clinical aspects of a cancer tumor.
Staging
_____: The tissues that respond specifically to a given hormone.
Target tissues
When reviewing the laboratory values of a client who has chronic obstructive pulmonary disease and pneumonia, the nurse observes these findings. Which one does the nurse report to the provider immediately? A) International normalized ratio (INR) 2.1 B) Serum chloride 96 nEq/L (mmol/L) C) Serum sodium 117 mEq/L (mmol/L) D) pH 7.28
ANS: C. All of the values are out of the normal range. The only one that is at a critical level, given the client's diagnoses of COPD and pneumonia, is the serum sodium level. This client is in danger of seizures and action must be taken immediately to prevent complications.
The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin? 1. Assess the client's oral mucosa. 2. Assess the client's metatarsals. 3. Assess the client's capillary refill time. 4. Assess the sclera of the client's eyes.
ANSWER: 1. 1. To assess for cyanosis (blueness) in individuals with dark skin, the oral mucosa and conjunctiva should be assessed because cyanosis cannot be assessed in the lips or fingertips. 2. Metacarpals are the fingers, which should not be assessed for cyanosis. 3. Capillary refill time is not a reliable indicator for cyanosis in individuals with dark skin. 4. The nurse should assess the conjunctiva for paleness, indicating hypoxemia; the sclera is assessed for jaundice. TEST-TAKING HINT: The test taker must realize that assessing different nationalities or races requires different assessment techniques and data.
The client diagnosed with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client? 1. Take Imodium, an antidiarrheal, over-thecounter (OTC) for diarrhea. 2. Limit exercise for several weeks until a tolerance is achieved. 3. The stools may be very dark, and this can mask blood. 4. Eat only red meats and organ meats for protein.
ANSWER: 3. 1. Iron is constipating; an antidiarrheal is contraindicated for this drug. 2. Iron can cause gastrointestinal distress and tolerance to it is built up gradually; exercise has nothing to do with tolerating iron. 3. The stool will be a dark green-black, which can mask the appearance of blood in the stool. 4. The client should eat a well-balanced diet high in iron, vitamins, and protein. Fowl and fish are encouraged. TEST-TAKING HINT: The test taker could eliminate option "4" as a possible answer because of the absolute word "only." Health-care professionals usually encourage the client to limit red and organ meats.
The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)? 1. Nodules in the subcutaneous layer and bone deformity. 2. Renal involvement and pleural effusions. 3. Joint stiffness and pain. 4. Raynaud's phenomenon and skin rash.
ANSWER: 3. 1. Nodules and bony deformity are symptoms of RA but not of SLE. 2. Organ involvement occurs in SLE but not RA. 3. Joint stiffness and pain are symptoms occurring in both diseases. 4. Raynaud's phenomenon and skin rashes are associated with SLE. TEST-TAKING HINT: There are a number of illnesses sharing the same symptoms. The test taker must be aware of the symptoms that distinguish one illness from another
_____: The percentage and actual number of mature circulating neutrophils; used to measure a patient's risk for infection. The higher the numbers, the greater the resistance to infection.
Absolute neutrophil count (ANC)
_____: Acute adrenal insufficiency; a life-threatening event in which the need for cortisol and aldosterone is greater than the available supply.
Addisonian crisis
_____: A clumping action that results during the antibody-binding process when antibodies link antigens together to form large and small immune complexes.
Agglutination
_____: The presence of albumin in the urine.
Albuminuria
_____: The widespread reaction that occurs in response to contact with a substance to which the person has a severe allergy (antigen); characterized by blood vessel and bronchiolar smooth muscle involvement causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction; results in cell damage and the release of large amounts of histamine, severe hypovolemia, vascular collapse, decreased cardiac contraction, and dysrhythmias, and causes extreme whole-body hypoxia.
Anaphylaxis
_____: The inability to mount an immune response to an antigen.
Anergy
A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? A) Bradycardia. B) Headache. C) Infection. D) Metaboic alkalosi.s
Answer: B. A client complaint of a headache is an adverse effect of norepinephrine (Levophed). This drug is a vasopressor and can cause headache.Norepinephrine does not suppress the immune system. Tachycardia, not bradycardia, and metabolic acidosis, not alkalosis, are adverse effects of norepinephrine.
A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? A) Abdominal cramping. B) Orthostatic hypotension C) Cool, clammy skin D) Rapid, deep respirations
Answer: C. A) Abdominal cramping is an expected finding with hyperglycemia. B) Hyperglycemia can cause dehydration, resulting in hypotension. C) Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion. D) Rapid, deep respirations are an expected finding with hyperglycemia.
_____: The quality of making a substance weaker; for example, antigens that are used to make vaccines are specially processed to make them less likely to grow in the body.
Attenuated
_____: Antibodies directed against self tissues of cells.
Autoantibodies
_____: The presence of bacteria in the bloodstream.
Bacteremia
_____: Normal cells growing in the wrong place or at the wrong time.
Benign tumor cells
_____: A governmental designation indicating that a drug has at least one serious side effect and must be used with caution.
Black box warning
_____: Immature cell that divides.
Blast phase cell
The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A) Encourage oral fluids. B) Keep head of bed elevated. C) Oxygen therapy at 4 L/min as needed D) Bedrest with bathroom priveleges only
C
_____: In patients with systemic sclerosis, the combination of calcinosis (calcium deposits), Raynaud's phenomenon, esophageal dysmotility, sclerodactyly (scleroderma of the digits), and telangiectasia (spider-like hemangiomas).
CREST syndrome
_____: A supplement that may play a role in strengthening cartilage.
Chondroitin
_____: Having a slow onset and symptoms that persist for an extended period.
Chronic
_____: The practice of grouping patients who are colonized or infected with the same pathogen.
Cohorting
_____: The ability of an infection, such as influenza, to be transmitted from person to person.
Communicable
_____: A continuous grating sensation caused when irregular cartilage or bone fragments rub together and which may be felt or heard as a joint is put through passive range of motion; also, a crackling sensation that can be felt on a patient's chest, indicating that air is trapped within the tissues.
Crepitus
_____: Small protein hormones produced by white blood cells.
Cytokines
_____: Double vision.
Diplopia
_____: The amount of time it takes for a tumor to double in size.
Doubling time
_____: Painful sexual intercourse.
Dyspareunia
_____: Strategies to reduce the fatigue associated with chronic and disabling conditions, such as allowing rest periods and setting priorities.
Energy conservation
_____: A chronic pain syndrome characterized by pain and tenderness at specific sites in the back of the neck, upper chest, trunk, low back, and extremities along with fatigue, sleep disturbances, and headache.
Fibromyalgia syndrome (FMS)
_____: Warmth, redness, swelling, pain, and decreased function.
Five cardinal symptoms of inflammation
_____: Delay in gastric emptying.
Gastroparesis
_____: Abnormal enlargement of the breasts in men.
Gynecomastia
_____: Infection control protocol that refers to both handwashing and alcohol-based hand rubs.
Hand hygiene
_____: A severe and potentially lethal respiratory disease that is a complication of hantavirus infection carried by mice and rats.
Hantavirus pulmonary syndrome
_____: Antigen that is present on the surfaces of nearly all body cells as a normal part of the person and acts as an antigen only if it enters another person's body.
Human leukocyte antigens (HLAs)
_____: A type of immunity provided by antibodies circulating in body fluids.
Humoral immunity
_____: Decreased blood oxygen levels; hypoxia.
Hypoxemia (hypoxemic)
_____: Having proper functioning of the body's ability to maintain itself and defend against disease.
Immunocompetent
_____: A substance normally secreted by the gastric mucosa and needed for intestinal absorption of vitamin B12. A deficiency of intrinsic factor and the resulting failure to absorb vitamin B12 lead to pernicious anemia.
Intrinsic factor
_____: A type of breathing that occurs when excess acids caused by the absence of insulin increase hydrogen ion and carbon dioxide levels in the blood. This state triggers an increase in the rate and depth of respiration in an attempt to excrete more carbon dioxide and acid.
Kussmaul respiration
_____: The time between the initiation of a cell and the development of an overt tumor.
Latency period
_____: The decomposition or splitting up of fat to provide fuel for energy when liver glucose is unavailable.
Lipolysis
_____: A systemic infectious disease that is caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick. Signs and symptoms include a large "bull's-eye" circular rash, malaise, fever, headache, and muscle or joint aches.
Lyme disease
_____: Persistently enlarged lymph nodes.
Lymphadenopathy
_____: Referring to large blood vessels.
Macrovascular
_____: Referring to cancer.
Malignant
_____: Altered cell growth that is serious and, without intervention, leads to death; cancer.
Malignant cell growth
_____: Cytokine made by macrophages, neutrophils, eosinophils, and monocytes.
Monokine
_____: Open sores on mucous membranes.
Mucositis
_____: Muscle aches/muscle pain.
Myalgia
_____: A net loss of protein that occurs when the breakdown (degradation) of protein exceeds buildup (synthesis).
Negative nitrogen balnace
_____: A deficiency of all three cell types (red blood cells, white blood cells, and platelets) of the blood.
Pancytopenia
_____: The ability to cause disease.
Pathogenicity
_____: Adequate arterial blood flow to the peripheral tissues (peripheral perfusion) and blood that is pumped by the heart to oxygenate major body organs (central perfusion).
Perfusion
_____: An inflammation of the tissue (pericardium) surrounding the heart.
Pericarditis
_____: Skin lesion around the nail bed.
Periungual lesions
_____: A form of retinopathy associated with diabetes mellitus in which a network of fragile new blood vessels develops, leaking blood and protein into surrounding tissue. The new blood vessels are stimulated by retinal hypoxia that results from poor capillary perfusion of the retinal tissues. New blood vessels grow in the retina, onto the iris, and into the back of the vitreous. The vitreous contracts and pulls away from the retina, causing blood vessels to break and bleed into the vitreous.
Proliferative diabetic retinopathy
_____: A type of local anesthesia that blocks multiple peripheral nerves in a specific body region.
Regional anesthesia
_____: A technique that allows for collection of red blood cells from a joint drain over a specific time frame, which then can be reinfused directly back into the patient's systemic circulation.
Reinfusion system
_____: Surgical replacement of a prosthesis that has loosened and is causing pain.
Revision arthroplasty
_____: A granulomatous disorder of unknown cause that can affect any organ but most often involves the lung.
Sarcoidosis
_____: Hard, or hardening.
Sclerotic
_____: The likelihood that infecting bacterial organisms will be killed or stopped by a particular antibiotic drug. Sensitivity is determined by testing different antibiotics against the organisms. Organisms are sensitive if the antibiotic is effective in stopping their growth; organisms are resistant if the antibiotic is not effective.
Sensitivity
_____: The type of shock that occurs when large amounts of toxins and endotoxins produced by bacteria are released into the blood, causing a whole-body inflammatory reaction.
Septic shock
_____: A type III hypersensitivity reaction that develops first as a skin rash and occurs within 3 to 21 days of the administration of antivenin (Crotalidae) polyvalent. This allergic response is often accompanied by other manifestations such as fever, arthralgias (joint pains), and pruritus (itching).
Serum sickness
_____: The progression of sepsis with an amplified inflammatory response.
Severe sepsis
_____: Inflammation of the oral mucosa; characterized by painful single or multiple ulcerations that impair the protective lining of the mouth. The ulcerations are commonly referred to as "canker sores."
Stomatitis
_____: Reddish purple streaks on the skin. Also called stretch marks.
Striae
_____: Tending to produce birth defects.
Teratogenic
_____: A reduction in the number of blood platelets below the level needed for normal coagulation, resulting in an increased tendency to bleed.
Thrombocytopenia
_____: Blood vessel inflammation.
Vasculitis
_____: Secretion of the posterior pituitary gland. Also known as antidiuretic hormone or ADH.
Vasopressin
_____: A form of immunohemolytic anemia (in which the immune system attacks a person's own red blood cells for unknown reasons) that occurs with immunoglobulin G antibody excess and may be triggered by drugs, chemicals, or other autoimmune problems.
Warm antibody anemia
_____: Radiation that is generated by machine.
x-ray
_____: Gout involving hyperuricemia.
Secondary gout
_____: Laboratory testing that is performed to identify pathogens by detecting antibodies to the organism.
Serologic testing
_____: An increased number of immature neutrophils found on a differential count in patients with infections; can be characterized by changes in percentages of different types of leukocytes. Also known as left shift.
Shift to the left
_____: A high-pitched crowing sound caused by laryngospasm or edema above or below the glottis; heard during respiration
Stridor
_____: Characteristic round, movable, nontender swelling under the skin of the arm or fingers in patients with severe rheumatoid arthritis.
Subcutaneous nodule
_____: Partial joint dislocation.
Subluxation
_____: The surgical removal of part of the thyroid tissue.
Subtotal thyroidectomy
_____: Transient loss of consciousness (blackouts), most commonly caused by decreased perfusion to the brain.
Syncope
_____: The surgical removal of synovium.
Synovectomy
_____: Affecting the body system as a whole.
Systemic
_____: The formation of a blood clot (thrombus) within a blood vessel.
Thrombosis
_____: A hormone produced and secreted by the parafollicular cells of the thyroid gland to help regulate serum calcium levels; secreted in response to excess plasma calcium.
Thyrocalcitonin (TCT or calcitonin)
_____: Abnormal dryness of the mouth caused by a severe reduction in the flow of saliva.
Xerostomia
A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? A) Glucose. B) Potassium. C) Calcium. D) Lymphocyte count.
"Answer: A. A) Blood glucose is elevated in a client who has Cushing's disease. B) Potassium is below the expected reference range in a client who has Cushing's disease. C) Calcium is below the expected reference range in a client who has Cushing's disease. D) The lymphocyte count is below the expected reference range in a client who has Cushing's disease."
Which signs and symptoms does the nurse expect to find in clients with any type of anemia? (Select all that apply.) A) Exercise intolerance B) Fatigue C) Glossitis D) Jaundice E) Leukopenia F) Microcytic red blood cells G) Paresthesias of the hands and feet H) Tachycardia
ANS: A, B, H. With any type of anemia, the number or quality of red blood cells is low, thus reducing oxygen perfusion to all tissues. This results in fatigue with exercise intolerance. Tachycardia is a compensatory mechanism to help maintain oxygen perfusion. Jaundice is present only when anemia is caused by red blood cell damage/destruction with release of hemoglobin and not by anemia caused by blood loss or deficiencies of iron or B12. Glossitis is associated only with deficiencies of folic acid and B12. Iron deficiency anemia results in microcytic red blood cells, whereas B12 deficiency causes macrocytic red blood cells. Red blood cell size is not affected by most other types of anemia. Paresthesias of the hands and feet are associated with B12 deficiencies severe enough to alter nerve function.
The health care provider prescribes acetaminophen for a client with osteoarthritis. What health teaching will the nurse provide for this client regarding this drug? (Select all that apply.) A) "Don't take more than 3000-4000 mg of this drug each day." B) "Stop taking the drug if unusual bleeding occurs and call your health care provider." C) "Tell your health care provider if you notice any yellowing of your skin or eyes." D) "Expect fluid accumulation in your legs and feet that usually gets worse during the day." E) "Check over-the-counter drugs to see if they contain acetaminophen."
ANS: A, C, E. The daily dosing of acetaminophen must be limited because it can cause liver toxicity and damage. Yellowing of skin or eye sclera can indicate liver damage.
Which tumor features are most closely associated with malignant cells rather than benign cells? (Select all that apply.) A) Aneuploidy B) Growth by expansion C) Highly differentiated D) Large nuclear-to-cytoplasmic ratio E) Migratory F) Tight adhesion
ANS: A, D, E. As indicated in Table 21-1, as well as in the text, malignant cells have lost the distinctive appearance of parent cells and have an anaplastic morphology with a large nuclear-to-cytoplasmic ratio. Loss of some surface proteins, especially fibronectin, allows them to migrate. Benign cells grow by expansion, whereas cancer cells grow by invasion. Benign cells retain their differentiated features and functions. They also have fibronectin, which keeps them tightly adherent.
Which client report indicates to the nurse that spinal cord compression may be present? A) The client reports having a headache for the past 7 hours. B) The client has reduced breath sounds in the left lung. C) The client has worsening mid-thoracic back pain. D) Pedal edema is now present bilaterally.
ANS: C. One of the first symptoms of spinal cord compression in a patient with cancer is new onset or worsening back pain as the disintegrating bones press and compress spinal nerves. Headache is not associated with spinal cord compression.
With which client will the nurse apply pressure to an injection site for 5 minutes because of an increased risk for bleeding? A) 28-year-old who has had type 1 diabetes for 15 years B) 42-year-old newly diagnosed with type 2 diabetes C) 58-year-old with chronic hypertension and heart failure D) 62-year-old with extensive liver damage from cirrhosis
ANS: D. The liver is critically important in blood clotting because it produces a number of the clotting factors. Whenever liver function is reduced, such as with liver damage from cirrhosis, the production of clotting factors is below normal and the risk for bleeding greatly increases, even after the minor trauma of an intramuscular injection.
The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.
ANSWER: 1, 2, 3, 4, 5. 1. The nurse should always address the airway when a client is seriously ill. 2. The client must be assessed for fluid volume deficit and then for fluid volume excess after fluid replacement is started. 3. The electrolyte imbalance of primary concern is depletion of potassium. 4. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. 5. The nurse must ensure the client's fluid intake and output are equal. TEST-TAKING HINT: The test taker must select all answer options that apply. Do not try to outguess the item writer. In some instances all options are correct.
The nurse has identified the concept of cellular deviation for a client diagnosed with chronic myelogenous leukemia. Which intervention should the nurse implement? Select all that apply. 1. Screen visitors for infection before allowing them to enter the room. 2. Assess the client's vital signs every four (4) hours. 3. Do not allow fresh fruits and vegetables on diet trays. 4. Monitor the client's white blood cell count. 5. Place the client on droplet isolation. 6. Check the client's bone marrow results daily.
ANSWER: 1, 2, 3, 4. 1. The client is at risk of infection because of the lack of mature WBCs in the circulating blood. Leukemia is a disease process involving the hematological system. White blood cells are produced in the bone marrow. The nurse screens visitors for infection because there are insufficient functioning white blood cells to protect the client from developing an infection if exposed to a virus or bacteria. 2. The client should be monitored for infection; one way to do this is to monitor the temperature. 3. Fresh fruits and vegetables may have bacteria on the skins, which could expose the client to infection. 4. The WBC count indicates the presence or absence of granulocytes, also called neutrophils or segmented neutrophils. 5. The client might be placed on Reverse Isolation or Neutropenic precautions because the client is at risk from anyone entering the room; however, there is no reason to suspect the client is a risk to others, which droplet precautions is initiated to prevent. 6. Bone marrow biopsies are not performed daily. TEST-TAKING HINT: The test taker must answer "Select all that apply" questions by viewing each option as true/false.
The nurse identified a concept of metabolism for a client diagnosed with diabetes mellitus type 1. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Teach the client to perform self glucose monitoring. 2. Instruct the client about complications of high-glucose levels. 3. Instruct the client to inspect the feet daily. 4. Explain the need to carry a source of quickacting proteins. 5. Encourage the client to have regular eye exams.
ANSWER: 1, 2, 3, 5. 1. The client with diabetes should be taught to perform self glucose monitoring. 2. In order to maintain a healthy lifestyle the client should be aware of the consequences of not controlling the blood glucose. 3. Diabetes affects all tissues in the body. The feet are particularly at risk for the development of foot sores. 4. The client should carry sources of quickacting carbohydrates, not protein. 5. Diabetes can cause retinal changes and detachment. TEST-TAKING HINT: The nurse should be able to teach common information to the client.
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.
ANSWER: 1, 2, 4. 1. Fluids are restricted to 500 to 600 mL per 24 hours. 2. Orientation to person, place, and time should be assessed every two (2) hours or more often. 3. A safe environment, not a stimulating one, is provided. 4. Urine and serum osmolality are monitored to determine fluid volume status. 5. The client should be weighed daily. TEST-TAKING HINT: The test taker should notice numbers: Is assessing the client's level of consciousness every two (2) hours enough, or is weighing the client every three (3) days enough?
The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider (HCP) if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.
ANSWER: 1, 2, 5. 1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. 2. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 3. Ketones indicate a breakdown of fat and must be reported to the HCP because they can lead to metabolic acidosis. 4. Blood glucose levels and ketones must be checked every three (3) to four (4) hours, not daily. 5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range. TEST-TAKING HINT: This is an alternate-type question having more than one correct answer. The test taker should read all options and determine if each is an appropriate intervention.
Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply. 1. Coping. 2. Hematologic regulation. 3. Tissue perfusion. 4. Clotting. 5. Clinical judgment.
ANSWER: 1, 2. 1. Coping could be applied to any diagnosis of a cancer. 2. Hematologic regulation is the top priority identified for a client with lymphoma because the client has a problem with the cells produced by the bone marrow. 3. Tissue perfusion is not associated with lymphoma. 4. Clotting is not associated with lymphoma. 5. Clinical judgment is a concept for the nurse, not the client. TEST-TAKING HINT: The test taker must consider each option in a "Select all that apply" question as a true/false option. The lymphocytes are produced on the bone marrow; the test taker has to remember pathophysiology of the disease process.
The client with an acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which interventions should the nurse implement? Select all that apply. 1. Monitor the client's bowel sounds. 2. Monitor the client's food intake. 3. Assess the client's intravenous site. 4. Provide oral and nasal care. 5. Monitor the client's blood glucose.
ANSWER: 1, 3, 4, 5. 1. The return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hours thereafter. 2. The client will be NPO secondary to the chronic pancreatitis, and the client cannot eat with a nasogastric tube. 3. The nurse should assess for signs of infection or infiltration. 4. Fasting and the N/G tube increase the client's risk for mucous membrane irritation and breakdown. 5. Blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus. TEST-TAKING HINT: This alternative-type question requires the test taker to select all interventions appropriate for the client's diagnosis. The test taker should evaluate each answ+B9er independently as to whether it is appropriate or not.
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands
ANSWER: 1. 1. A decrease in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss. 2. These are signs of hyperthyroidism. 3. These are signs of hyperthyroidism. 4. These are signs of parathyroidism TEST-TAKING HINT: Often if the test taker does not know the specific signs/symptoms of the disease but knows the function of the system affected by the disease, some possible answers can be ruled out. Tetany and stiffness of the hands are related to calcium, the level of which is influenced by the parathyroid gland, not the thyroid gland; therefore, option "4" can be ruled out.
The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell (WBC) count differential. 2. A large number of WBCs that decreases after the administration of antibiotics. 3. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level. 4. Red blood cells (RBCs) that are larger than normal.
ANSWER: 1. 1. A left shift indicates immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia. 2. Leukocytosis (elevated WBCs) is normal in the presence of an infection, but it should decrease as the infection clears. 3. A low hemoglobin and hematocrit level indicates anemia and can be caused by a number of factors. Anemia does occur in leukemia, but it is not diagnostic for leukemia. 4. Red blood cells larger than normal occur in macrocytic anemias (vitamin B12 and folic acid deficiency). They are not characteristic of leukemia. TEST-TAKING HINT: The test taker should recognize elevated WBCs resolve with antibiotics as an infection. Option "3" is not specific enough to be the correct answer
The nurse is assessing a client diagnosed with vaso-occlusive crisis. Which indicates the client is not meeting an appropriate stage of growth and development according to Erikson? 1. The 32-year-old client does not have a significant other and is on disability. 2. The 28-year-old client is actively involved in the care of a six (6)-year-old child. 3. The 40-year-old client has a full-time job and cares for an aged parent. 4. The 19-year-old client is a full-time college student and has many friends.
ANSWER: 1. 1. According to Erikson's growth and development stages, the 32-year-old should be in the Intimacy versus Isolation stage. In this stage the client should have developed a close relationship with another human being, have a job, and become self-supporting. This client is not meeting Erikson's expected stage of development for his age. 2. This client is caring for a child; based on this statement the client is meeting Erikson's growth and development stages. 3. This client is caring for a parent and working. Based on this statement the client is meeting Erikson's growth and development stages. 4. This client is actively involved in preparing for a career and has friends. Based on this statement this client is meeting Erikson's growth and development stages. TEST-TAKING HINT: The test taker must be aware of the cause of psychological changes as growth across the life span occurs. Basic psychology principles are frequently used by nurses to assess the client's status. The test taker has to memorize the stages of development.
Which signs/symptoms should the nurse expect to assess in the client diagnosed with an insulinoma? 1. Nervousness, jitteriness, and diaphoresis. 2. Flushed skin, dry mouth, and tented skin turgor. 3. Polyuria, polydipsia, and polyphagia. 4. Hypertension, tachycardia, and feeling hot.
ANSWER: 1. 1. Insulinoma is a tumor of the islet cells of the pancreas that produces insulin. The signs/symptoms of an insulinoma are signs of hypoglycemia. 2. These are signs/symptoms of hyperglycemia. 3. These are signs/symptoms of hyperglycemia. 4. These are signs/symptoms of hyperthyroidism.
Which signs/symptoms should the nurse expect to assess in the client diagnosed with Sjögren's syndrome? 1. Complaints of dry mouth and eyes. 2. Complaints of peripheral joint pain. 3. Complaints of muscle weakness. 4. Complaints of severe itching.
ANSWER: 1. 1. Sjögren's syndrome is an autoimmune disorder causing inflammation and dysfunction of exocrine glands throughout the body. Dry mouth and eyes are some of the signs/symptoms. 2. Peripheral joint pain may be a symptom of rheumatoid arthritis. 3. Muscle weakness is a symptom of a variety of disease processes and syndromes but not of Sjögren's syndrome. 4. Severe itching is not a symptom of this syndrome.
The nurse is caring for a client with suspected fibromyalgia. Which diagnostic test confirms the diagnosis of fibromyalgia? 1. There is no diagnostic test to confirm fibromyalgia. 2. A positive antinuclear antibody test. 3. A magnetic resonance imaging (MRI) shows fibrosis. 4. A negative erythrocyte sedimentation rate (ESR).
ANSWER: 1. 1. The diagnosis of fibromyalgia is based on the history and physical assessment. There is no laboratory or diagnostic test for fibromyalgia. However, tests may be performed to rule out other diagnoses. 2. This test is not used to diagnose fibromyalgia. 3. An MRI is not used to diagnose fibromyalgia. 4. An ESR does not support the diagnosis of fibromyalgia.
Which client problem has priority for the client diagnosed with acute pancreatitis? 1. Risk for fluid volume deficit. 2. Alteration in comfort. 3. Imbalanced nutrition: less than body requirements. 4. Knowledge deficit.
ANSWER: 2. 1. The client will be NPO to help decrease pain, but it is not the priority problem because the client will have intravenous fluids. 2. Autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness, and muscle guarding. 3. Nutritional imbalance is a possible client problem, but it is not priority. 4. Knowledge deficit is always a client problem, but it is not priority over pain. TEST-TAKING HINT: The test taker should apply Maslow's hierarchy of needs when selecting the priority problem for a client. After airway, pain is often priority.
Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? 1. Weakness and fatigue. 2. Ptosis and diplopia. 3. Breathlessness and dyspnea. 4. Weight loss and dehydration.
ANSWER: 2. 1. These are musculoskeletal manifestations of myasthenia gravis. 2. These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral blurred vision. 3. These are respiratory manifestations of myasthenia gravis. 4. These are nutritional manifestations of myasthenia gravis. TEST-TAKING HINT: The keys to answering this question are the adjectives "ocular" and "facial." This information should make the test taker rule out options "1," "3," and "4" even if the test taker doesn't know what "ptosis" or "diplopia" means.
The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview? 1. "Do you become short of breath during activity?" 2. "How heavy are your menstrual periods?" 3. "Do you have a history of deep vein thrombosis?" 4. "How often do you have migraine headaches?"
ANSWER: 2. 1. Thrombocytopenia is low platelets and would not cause shortness of breath. 2. Because thrombocytopenia causes bleeding, the nurse should assess for any type of bleeding that may be occurring. A young female client would present with excessive menstrual bleeding. 3. The problems associated with ITP are bleeding, not clotting. 4. ITP does not cause migraine headaches
Which is the primary goal of care for a client diagnosed with sickle cell anemia? 1. The client will call the HCP if feeling ill. 2. The client will be compliant with medical regimen. 3. The client will live as normal a life as possible. 4. The client will verbalize understanding of treatments.
ANSWER: 3. 1. All clients should know when to notify the HCP. This is not the primary goal of living with a chronic illness. 2. The client should be compliant with recommendations, but this is a lifestyle choice and not the primary goal. 3. The primary goal for any client coping with a chronic illness is that the client will be able to maintain as normal a life as possible. 4. This is a goal for a client with knowledgedeficit problems.
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.
ANSWER: 3. 1. Steroid medications mask the development of infections because steroids suppress the immune system's response. 2. SLE does not metastasize, or "spread"; it does invade other organ systems, but steroids do not prevent this from happening. 3. The main function of steroid medications is to suppress the inflammatory response of the body. 4. Steroid medications can delay the healing process, theoretically making scarring worse. TEST-TAKING HINT: Steroids are a frequently administered medication class. The test taker must know the common actions, side effects, adverse effects, and how to administer the medications safely
The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.
ANSWER: 3. 1. The acceptable level for an A1c for a client with diabetes is between 6% and 7%, which corresponds to a 120- to 140-mg/dL average blood glucose level. 2. This result is not within acceptable levels for the client with diabetes, which is 6% to 7%. 3. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications. 4. An A1c of 13% is dangerously high; it reflects a 300-mg/dL average blood glucose level over the past three (3) months. TEST-TAKING HINT: The test taker must know normal and abnormal diagnostic laboratory values. Laboratory values vary depending on which laboratory performs the test.
The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which priority intervention should be implemented by the nurse? 1. Start an IV with D5W. 2. Notify the health-care provider. 3. Perform a bedside glucose check. 4. Give the client some orange juice.
ANSWER: 3. 1. The client may need IV medication, but in this case if it is needed, it is 50% dextrose. 2. The HCP might be notified, but the nurse needs to assess the client first. 3. These are symptoms of an insulin reaction (hypoglycemia). A bedside glucose check should be done. Pancreatic islet tumors can produce hyperinsulinemia or hypoglycemia. 4. Treating the client is done after the nurse knows the glucose reading. TEST-TAKING HINT: The test taker should remember the function of the pancreas. This leads the test taker to look for interventions for hypoglycemia.
The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which preprocedure instruction should the nurse teach? 1. Prepare to be admitted to the hospital after the procedure for observation. 2. If something happens during the procedure, then emergency surgery will be done. 3. Do not eat or drink anything after midnight the night before the test. 4. If done correctly, this procedure will correct the blockage of the stomach.
ANSWER: 3. 1. The client should stay in the outpatient department after the procedure for observation unless the HCP determines a more extensive work-up should be completed. 2. This is not the type of procedure where the results warrant an emergency surgery. A cardiac catheterization sometimes results in an emergency surgery and the client is prepared for this possibility, but this is not the case with an ERCP. 3. The client should be NPO after midnight to make sure the stomach is empty to reduce the risk of aspiration during the procedure. 4. The possible blockage is of the duodenum, common bile duct, or pancreatic outlet. TEST-TAKING HINT: The nurse should never preface any instruction with "if done correctly" because this sets the nurse, HCP, and facility up for a lawsuit. The client is NPO for any procedure or surgery where the client will receive general or twilight sleep anesthesia.
The client is admitted to the medical department with a diagnosis of rule-out (R/O) acute pancreatitis. Which laboratory values should the nurse monitor to confirm this diagnosis? 1. Creatinine and (BUN). 2. Troponin and (CK-MB). 3. Serum amylase and lipase. 4. Serum bilirubin and calcium.
ANSWER: 3. 1. These laboratory values are monitored for clients in kidney failure. 2. These laboratory values are elevated in clients with a myocardial infarction. 3. Serum amylase increases within two (2) to 12 hours of the onset of acute pancreatitis to two (2) to three (3) times normal and returns to normal in three (3) to four (4) days; lipase elevates and remains elevated for seven (7) to 14 days. 4. Bilirubin may be elevated as a result of compression of the common duct, and hypocalcemia develops in up to 25% of clients with acute pancreatitis, but these laboratory values do not confirm the diagnosis. TEST-TAKING HINT: The test taker must be able to identify at least two (2) laboratory values that reflect each organ function prior to taking the NCLEX-RN. There is no testtaking hint to help select the correct answer; this is knowledge.
The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.
ANSWER: 3. 1. This blood glucose level is elevated, but not life threatening, in the client diagnosed with type 2 diabetes. Therefore, a less experienced nurse could care for this client. 2. Hypoglycemia is an acute complication of type 1 diabetes, but it can be managed by frequent monitoring, so a less experienced nurse could care for this client. 3. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse. 4. A plasma osmolarity of 280 to 300 mOsm/L is within normal limits; therefore, a less experienced nurse could care for this client. TEST-TAKING HINT: The test taker must select the client with an abnormal, an unexpected, or a life-threatening sign/symptom for his or her disease process and assign this client to the most experienced nurse.
Which situation might cause the nurse to think that the client has von Willebrand's (vW) disease? 1. The client has had unexplained episodes of hematemesis. 2. The client has microscopic blood in the urine. 3. The client has prolonged bleeding following surgery. 4. The female client developed abruptio placentae.
ANSWER: 3. 1. Vomiting blood is not a situation that would indicate the client has von Willebrand's disease. 2. Microscopic blood in the urine is not a sign of von Willebrand's disease. 3. von Willebrand's disease is a type of hemophilia. The most common hereditary bleeding disorder, it is caused by a deficiency in von Willebrand's (vW) factor and is often diagnosed after prolonged bleeding following surgery or dental extraction. 4. Abruptio placentae is not a situation that might cause von Willebrand's disease. TEST-TAKING HINT: The test taker must be knowledgeable about vW factor to be able to answer this question. Risk factors or situations are facts that need to be memorized.
Which signs/symptoms indicate the client with hypothyroidism is not taking enough thyroid hormone? 1. Complaints of weight loss and fine tremors. 2. Complaints of excessive thirst and urination. 3. Complaints of constipation and being cold. 4. Complaints of delayed wound healing and belching
ANSWER: 3. 1. Weight loss and fine tremors make the nurse suspect the client is taking too much thyroid hormone because these are symptoms of hyperthyroidism. 2. Excessive thirst and urination are symptoms of diabetes. 3. If the client were not taking enough thyroid hormone, the client would exhibit symptoms of hypothyroidism such as constipation and being cold. 4. This indicates Cushing's disease.
Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? 1. "I just don't seem to have any appetite anymore." 2. "I have a bowel movement about every three (3) to four (4) days." 3. "My skin is really becoming dry and coarse." 4. "I have noticed all my collars are getting tighter."
ANSWER: 4. 1. Decreased appetite is a symptom of hypothyroidism, not hyperthyroidism. 2. Constipation is a symptom of hypothyroidism. 3. Dry, coarse skin is a sign of hypothyroidism. 4. The thyroid gland (in the neck) enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter. TEST-TAKING HINT: If the test taker does not know the answer, sometimes thinking about the location of the gland or organ causing the problem may help the test taker select or rule out specific options.
The client is diagnosed with severe irondeficiency anemia. Which statement is the scientific rationale regarding oral replacement therapy? 1. Iron supplements are well tolerated without side effects. 2. There is no benefit from oral preparations; the best route is IV. 3. Oral iron preparations cause diarrhea if not taken with food. 4. Very little of the iron supplement will be absorbed by the body.
ANSWER: 4. 1. Iron supplements can be poorly tolerated. The supplements can cause nausea, abdominal discomfort, and constipation. 2. There is benefit from oral preparations, but in severe cases of iron deficiency, the client may need parenteral replacement. 3. Iron supplements cause constipation and should be taken one (1) hour before a meal or two (2) hours after a meal for the best absorption of the medication. As much as 50% of the iron is not absorbed when taken with food. 4. At best only about 20% to 35% of the medication is absorbed through the gastrointestinal (GI) tract
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? 1. The client complains of joint stiffness and the knees feel warm to the touch. 2. The client has experienced one (1)-kg weight loss and is very tired. 3. The client requires a heating pad applied to the hips and back to sleep. 4. The client is crying, has a flat facial affect, and refuses to speak to the nurse
ANSWER: 4. 1. Joint stiffness and joints warm to the touch are expected in clients diagnosed with RA. 2. Clients diagnosed with RA have bilateral and symmetrical stiffness, edema, tenderness, and temperature changes in the joints. Other symptoms include sensory changes, lymph node enlargement, weight loss, fatigue, and pain. A one (1)-kg weight loss and fatigue are expected. 3. The use of heat is encouraged to provide comfort for a client diagnosed with RA. 4. The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP. TEST-TAKING HINT: The test taker should not automatically assume only physiological data require immediate intervention. There will be times when a psychological need will have priority. Because options "1," "2," and "3" are all expected in a client with RA, the psychological need warrants intervention by the nurse.
Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern
ANSWER: 4. 1. Safety is an important issue for the client, but this is not the priority client problem. 2. The client's psychological needs are important, but psychosocial problems are not priority over physiological problems. 3. Clients with this syndrome may have choking episodes and are at risk for inability to swallow as a result of the disease process, but this is not the priority nursing problem because weight loss is not an expected complication of this syndrome. 4. Guillain-Barré syndrome has ascending paralysis causing respiratory failure. Therefore, breathing pattern is priority. TEST-TAKING HINT: Knowledge of the disease process causes the test taker to select option "4," but applying Maslow's hierarchy of needs and choosing a client problem addressing airway is always a good option if the test taker is not sure of the correct answer.
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.
ANSWER: 4. 1. These signs/symptoms, along with sleep disturbances and nervousness, support the diagnosis of Creutzfeldt-Jakob disease. 2. These signs/symptoms support the diagnosis of Parkinson's disease. 3. These are signs/symptoms of trigeminal neuralgia. 4. Ascending paralysis is the classic symptom of Guillain-Barré syndrome. TEST-TAKING HINT: The test taker should try to remember at least one or two signs/symptoms of disease processes, and ascending paralysis is an unusual sign/symptom specific to this syndrome.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention? 1. T 99, P 102, R 22, and BP 132/68. 2. Hyperplasia of the gums. 3. Weakness and fatigue. 4. Pain in the left upper quadrant
ANSWER: 4. 1. These vital signs are not alarming. The vital signs are slightly elevated and indicate monitoring at intervals, but they do not indicate an immediate need. 2. Hyperplasia of the gums is a symptom of myeloid leukemia, but it is not an emergency. 3. Weakness and fatigue are symptoms of the disease and are expected. 4. Pain is expected, but it is a priority, and pain control measures should be implemented. TEST-TAKING HINT: If all the answer options contain expected events, the test taker must decide which is priority—and pain is a priority need.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen? 1. The client complains of shortness of breath. 2. The skin is dry, intact, and without redness. 3. The pricked blood tests positive for allergens. 4. A pruritic wheal and erythema occur.
ANSWER: 4. 1. This is a sign of an anaphylactic reaction to an allergen and will not happen during this test because of the small amount of allergen used. 2. This indicates a negative test and the client is not sensitive to the allergen. 3. The skin reaction, not the blood pricked, indicates a positive or negative test. 4. During this test, a drop of diluted allergenic extract is placed on the skin and then the skin is punctured through the drop. A positive test causes a localized pruritic wheal and erythema, which occurs in five (5) to 20 minutes.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of "altered nutrition: less than body requirements." Which collaborative intervention should the nurse include in the plan of care? 1. Continuous feedings via (PEG) tube. 2. Have the family bring in foods from home. 3. Assess for food preferences. 4. Refer to the dietitian.
ANSWER: 4. 1. Tube feedings are collaborative interventions, but the stem did not say the client had a feeding tube. 2. Having family members bring food from home is an independent intervention. 3. Assessment is an independent intervention and the first step in the nursing process. No one should have to tell the nurse to assess the client. 4. A collaborative intervention is to refer to the nutrition expert, the dietitian. TEST-TAKING HINT: The key word in the stem is "collaborative," which means another health-care discipline must be involved. Only options "1" and "4" involve other members of the health-care team. The test taker could eliminate distracter "1" by rereading the stem and realizing the stem did not include the client having a feeding tube.
_____: Having relatively greater intensity; marked by a sudden onset and short duration.
Acute
_____: Infection control guidelines from the U.S. Centers for Disease Control and Prevention; used for patients with infections spread by the airborne transmission route, such as tuberculosis. Negative airflow rooms are required to prevent the airborne spread of microbes.
Airborne precautions
_____: Hair loss.
Alopecia
_____: Diffuse swelling resulting from a vascular reaction in the deep tissues; can occur in a patient having an anaphylactic reaction.
Angioedema
Which factors are possible transmission routes for human immune deficiency virus (HIV)? A) Breast-feeding. B) Anal intercourse. C) Mosquito bites. D) Toileting facilities. E) Oral sex.
Answer: A, B, E. HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions.HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities does not cause transmission of HIV.
Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply). A) Fatigue. B) Changes in color of hair. C) Change in taste. D) Changes in skin of the neck. E) Difficulty swallowing
Answer: A, C, D, E. Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific. The larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area.Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair, but this does not normally occur with radiation therapy.
The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply). A) Assess for fever. B) Observe for bleeding. C) Administer pegfilgrastim (Neulasta). D) Do not permit fresh flowers or plants in the room. E) DO not allow the client's 16-year-old son to visit. F) Teach the client to omit raw fruits and vegetables from the diet.
Answer: A, C, D, F. Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms.Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well. However, very small children, who may get frequent colds and viral infections, may pose a risk.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (Select all that apply). A) Decreased urine output. B) Renal calculi. C) Joint inflammation. D) Butterfly rash. E) Subcutaneous nodules.
Answer: A, C, D. A) Decreased urine output, due to kidney damage, is a manifestation of SLE. B) Lupus nephritis, not renal calculi, is a manifestation of SLE. C) Joint inflammation is a common manifestation of SLE D) A scaly rash on the face, commonly known as the "butterfly rash," is a common manifestation of SLE. E) Subcutaneous nodules are manifestations of rheumatoid arthritis.
A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? (Select all that apply). A) Moon-shaped face. B) Hearing loss. C) Osteoporosis. D) Increased risk of infection. E) Weight loss.
Answer: A, C, D. A) Long-term corticosteroid therapy causes characteristics of iatrogenic Cushing's syndrome, including a moon-shaped face, a potbelly, and a buffalo hump. B) Long-term corticosteroid therapy can cause cataracts and glaucoma, but it does not cause hearing loss. C) Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. D) Increased risk of infection is an adverse effect of long-term corticosteroid therapy due to suppression of the immune system. It reduces the phagocytic actions of macrophages and neutrophils, thus increasing the risk of infection. E) Long-term corticosteroid therapy is more likely to cause weight gain due to the fluid and sodium retention these medications cause.
"The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? (Select all that apply). A) "I am 78 years old, and I was treated and cured of syphilis many years ago." B) "In 1986, I received a transfusion of platelets." C) "Seven years ago, I was released from a penitentiary." D)"I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." E) "At 68, I am going to get married for the fourth time.""
Answer: A, C, E. People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV.HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A) Increased hematocrit. B) High urine specific gravity. C) Low BUN. D) Decreased heart rate.
Answer: A. A) An increased hematocrit is an expected finding resulting from dehydration. B) Increased urine output leads to diluted urine and a low urine specific gravity. C) An increase in BUN levels is an expected finding resulting from dehydration. D) Tachycardia is an expected finding with diabetes insipidus.
A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect? A) Hirsutism. B) Weight loss. C) Increased skin thickness. D) Decreased blood pressure.
Answer: A. A) Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production. B) Weight gain is an expected finding of Cushing's disease. C) Thinning of the skin is an expected finding of Cushing's disease. D) Elevated blood pressure is an expected finding of Cushing's disease.
A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? A) Fluconazole (Diflucan). B) Trimethoprim/sulfamethoxazole (Bactrim). C) Rifampin (Rifadin). D) Acyclovir (Zovirax).
Answer: A. Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Candidiasis is a fungal infection.Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.
The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? A) Testing of stool specimens for occult blood B) Teaching about the importance of dietary fiber C) Referring clients for colonoscopy procedures D) Giving vitamin and mineral supplements
Answer: A. Testing of stool specimens for occult blood is done according to a standardized protocol and can be delegated to nursing assistants.Client education and teaching is within the scope of practice of the RN, not of the LPN or nursing assistant. Referral for further care needs to be performed by the RN. Administration of medications is beyond the nursing assistant's scope of practice and should be done by licensed nursing professionals.
The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? A) Client with type 1 diabetes whose insulin pump is beeping "occlusion" B) Newly diagnosed client with type 1 diabetes who is reporting thirst C) Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) D) Client with type 2 diabetes with a blood pressure of 150/90 mm Hg
Answer: A. The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.
The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? A) Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily B) Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C) Client with Graves' disease who is experiencing increasing anxiety and diaphoresis D) Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy
Answer: A. The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN.A client with vocal hoarseness and difficulty swallowing is at risk for airway complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency. This is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for hypocalcemia, bleeding, and airway compromise and requires assessment by an experienced nurse.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a serum sodium level of 105 mEq/L (105 mmol/L). Which request by the health care provider does the nurse carry out first? A) Administer infusion of 150 mL of 3% NaCl over 3 hours. B) Draw blood for hemoglobin and hematocrit (H&H). C) Insert an indwelling catheter and monitor urine output. D) Weigh the client on admission and daily thereafter.
Answer: A. The first intervention the nurse performs is to administer an infusion of 150 mL of 3% NaCl over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma.Drawing blood for an H&H, inserting an indwelling catheter for urine monitoring, and weighing the newly admitted client are not top priority interventions.
When preparing a client for allergy testing, the nurse provides the client with which instruction? A) "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." B) "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." C) "Aspirin in a low dose may be taken before testing." D) "You can take antihistamine nasal sprays before testing."
Answer: A. The nurse should tell the client that, "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test for this reason.Nasal sprays like fluticasone propionate (Flonase) to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine. Allergists recommend that aspirin be withheld before testing.
A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? A) Cold intolerance. B) Tremors. C) Lethargy. D) Sunken eyes.
Answer: B. A) A client who has hyperthyroidism has heat intolerance. B) Findings of hyperthyroidism include tremors, diaphoresis, and insomnia. C) A client who has hyperthyroidism is restless and irritable. D) A client who has hyperthyroidism can have exophthalmos, which causes a wide-eyed or startled appearance.
The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A) Alopecia. B) Allergy. C) Fever. D) Chills
Answer: B. Allergy is the most common side effect of monoclonal antibody therapy (rituximab), and the nurse must be aware of any allergic reactions the client may exhibit.Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.
A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA? A) Total serum complement, 75 units/mL. B) Positive total antinuclear antibody (ANA) C) Erythrocyte sedimentation rate (ESR), 20 mm/hr D) Beta-globulin level, 1.0 g/dL (10 g/L)
Answer: B. Elevation of total ANA is common in systemic lupus erythematosus, systemic sclerosis, and RA. A serum complement of 75 units/mL is the normal range for total serum complement. An ESR rate of 22 mm/hr is normal for a female. A beta-globulin level of 1.0 g/dL (10 g/L) is normal
The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that the client has an infection or an infection needs to be ruled out? A) Evidence of pus B) Wheezes or crackles. C) Fever of 102°F (38.9°C) or higher D) Coughing and deep breathing
Answer: B. The clinical manifestation that indicates the client with neutropenia has an infection or an infection that needs to be ruled out is wheezes or crackles. Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs.Coughing and deep breathing are not indications of infection but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.
What is the most important environmental risk for developing leukemia? A) Family history. B) Smoking cigarettes. C) Living near high-voltage power lines. D) Direct contact with others with leukemia.
Answer: B. The most important environmental risk for developing leukemia is smoking cigarettes. According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking.Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near high-voltage power lines is not a proven risk factor for leukemia. Leukemia is not contagious.
The nurse notes that the client on a medical surgical unit who is being treated for hyperparathyroidism has a very high urine output. Of these actions, what will the nurse do next? A) Call the primary health care provider. B) Monitor intake and output. C) Perform a cardiac assessment. D) Slow the rate of IV fluids.
Answer: B. The nurse needs to next monitor the client's intake and output. Increased urine output is expected with hyperparathyroidism. Diuretic and hydration therapies are used to promote renal calcium excretion and reduce serum calcium levels.The primary health care provider does not need to be notified. Cardiac assessment is part of the nurse's routine evaluation of the client. Slowing the rate of IV fluids is contraindicated because the client will become dehydrated due to the use of diuretics to increase kidney excretion of calcium.
The client tells the visiting nurse his blood glucose values over the last week have been excellent. Which of these resources does the nurse evaluate to verify the client's statement? A) Fasting blood glucose B) Glycosylated hemoglobin (HbA1c) C) Client's blood glucose log D) Postprandial glucose.
Answer: B. The nurse would evaluate the client's glycosylated hemoglobin (HbA1c). The laboratory result indicates the average blood glucose over several months and is the best indicator of overall blood glucose control.Fasting blood glucose can be used to monitor glucose control, but it is not the best method to evaluate blood glucose over a period of time. Oral glucose testing and urine glucose levels look at one period of time and are not the best methods to look at overall effectiveness of treatment.
A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)? A) Rapid, shallow respirations. B) Decreased urine output C) Blood glucose levels above 300 mg/dL. D) Weight gain of 0.45 kg (1 lb) in 24 hr.
Answer: C. A) Deep Kussmaul respirations are an expected finding with DKA. B) Increased urine output is an expected finding with DKA. C) Blood glucose levels above 300 mg/dL are an expected finding with DKA. Levels above 600 mg/dL are an expected finding with hyperglycemic-hyperosmolar state. D) Weight loss is an expected finding with DKA.
Which client is at greatest risk for developing an infection? A) A 54-year-old man with hypertension B) A 17-year-old girl with a fractured tibia in a cast C) A 65-year-old woman who had coronary bypass surgery 4 days ago D) A 71-year-old man in a nursing home
Answer: C. Older clients such as the 65-year-old people with decreased vascularity to the integumentary system (from the bypass surgery) and compromised skin (surgical incision) are at risk for infection.No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection.
Which client statement indicates in-home stem cell transplantation is not a viable option? A) "We live 5 miles from the hospital." B) "I will have lots of medicine to take." C) "I was a nurse, so I can take care of myself." D) "I don't feel strong enough, but my wife said she would help."
Answer: C. The client statement that indicates that in-home stem cell transplantation is not a viable option is "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own.It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.
The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased laboratory value would be of greatest concern to the nurse because it is not age-related? A) Hemoglobin level B) Red blood cell (RBC) count C) Platelet (thrombocyte) count D) White blood cell (WBC) response
Answer: C. The decreased laboratory value of the greatest concern to the nurse is the 76-year-old client's platelet count. Platelet counts do not generally change with age.Hemoglobin levels in men and women fall after middle age. Iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.
A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? A) "Don't mind this. The disease is causing this." B) "I need to check the client's cortisol level." C) "The disease can sometimes affect emotional responses." D) "Medication is available to help with this."
Answer: C. The nurse's best response is that the disease can affect emotional responses. The client may have inappropriate or psychotic behavior or difficulty concentrating as a result of high blood cortisol levels. Being honest with the family helps them to understand what is happening.Telling the family not to mind the laughter and that the disease is causing it is vague and minimizes the family's concern. Because the diagnosis of Cushing's disease and hypercortisolism has already been made, blood levels do not need to be redrawn. Telling the family that medication is available to help with inappropriate laughing does not assist them in understanding the cause of or the reason for the client's current behavior. This is the perfect opportunity for the nurse to educate the family about the disease.
A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? A) Hold the client's hand and ask about concerns. B) Review the client's platelet (thrombocyte) count. C) Verify that the client has given informed consent. D) Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).
Answer: C. The priority nursing action before a scheduled bone marrow aspiration is done is for the nurse to verify that the client has been given informed consent. A signed permit must be on the client's chart.Cleaning the biopsy site is done before the procedure, but this is not done until consent is verified. Cleaning the site will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.
The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? A) "I will have more energy with this medication." B) "I will take the medication every morning." C) "If I continue to lose weight, I may need an increased dose." D) "If I gain weight and feel tired, I may need an increased dose."
Answer: C. The statement, "If I continue to lose weight, I may need an increased dose," indicates a need for further teaching. Weight loss indicates a need for a decreased dose, not an increased dose.One of the symptoms of hypothyroidism is lack of energy. Thyroid replacement therapy would cause the client to have more energy. The correct time to take thyroid replacement therapy is in the morning. Gaining weight and continuing to feel tired is an indication that the dose may need to be increased.
The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply). A) Massage the legs. B) Keep the legs slightly abducted. C) Use the knee gatch on the bed. D) Apply elastic stockings. E) Administer anticoagulants.
Answer: D, E. Support stockings provide compression, which helps prevent VTE. Anticoagulants also help prevent VTE because they inhibit the formation of blood clots. The legs should never be massaged, because it could cause a blood clot to dislodge. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.
Which is a common clinical manifestation of infectious disease? A) Dry and pink skin. B) Hypothermia. C) Decreased respiratory rate. D) Fever.
Answer: D. Fever (generally a temperature above 101°F [38.3°C]) is a common clinical manifestation of infection.Skin tends to be warm and moist, not dry and pink, when an infectious disease is present. Clients typically have hyperthermia (fever), not hypothermia, when an infectious disease is present, although some clients can have infection without fever. Respiratory rate typically increases, as does the heart rate, with infectious disease.
The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A) "I will need to avoid people with a cold or flu." B) "I will probably lose my hair during this therapy." C) "The goal of this therapy is to put me in remission." D) "After this therapy, I will not need to have any more."
Answer: D. The client statement that indicates a need for additional education about induction therapy is "after this therapy, I won't need to have any more". Induction therapy is not a cure for leukemia, it is a treatment. So, the leukemia client needs more education to understand this. Because of infection risk, clients with leukemia must avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.Because of infection risk, clients with leukemia need to avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.
A pediatric nurse is floated to a medical-surgical unit. Which client is assigned to the float nurse? A) A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease B) A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C) A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D) A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells
Answer: D. The client who is assigned to the pediatric float nurse is the 42-year-old sickle cell disease client receiving a transfusion of packed blood cells. Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion. Therefore, he or she would be assigned to the client with sickle cell disease.Polycythemia vera, aplastic anemia, and folic acid deficiency are problems more commonly seen in adult clients who would be cared for by nurses who are more experienced in caring for adults.
Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? A) Plan the schedule for desensitization therapy for a client with allergies. B) Monitor the client who has just received skin testing for signs of anaphylaxis. C) Educate a client with a latex allergy about other substances with cross-sensitivity to latex. D) Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.
Answer: D. The most appropriate action for the allergy clinic nurse to delegate to a nursing assistant is to remind the client about safety policies. This is within the scope of practice of a nursing assistant.Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Client education is a registered nursing responsibility, requiring broader education and scope of practice.
The nurse is caring for a client with sickle cell disease. Which nursing action is most effective in reducing the potential for sepsis in this client? A) Check vital signs every 4 hours B) Administer prophylactic drug therapy C) Monitor for abnormal laboratory values D) Perform frequent and thorough handwashing
Answer: D. The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to perform frequent and thorough handwashing. Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance.Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug therapy is a major defense against infections that develop in the client with sickle cell disease but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention.
An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? A) Raise the lower extremities. B) Start intravenous (IV) administration of normal saline. C) Reassure the client that appropriate interventions are being instituted. D) Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.
Answer: D. The most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority.Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.
A client with Cushing's disease says that she has lost 1 pound (0.5 kg) What does the nurse do next? A) Auscultate the lungs for crackles. B) Check urine for specific gravity. C) Check the blood pressure. D) Weigh the client.
Answer: D. The nurse would next weigh the client. Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease.Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Increases in blood pressure will correlate with excess water and sodium reabsorption causing fluid retention and weight gain in the client with Cushing's disease.
Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A) Assist the client's spouse in choosing appropriate dietary items. B) Evaluate the client's use of a home blood glucose monitor. C) Inspect the extremities for evidence of poor circulation. D) Assist the client with washing the feet and applying moisturizing lotion.
Answer: D. The nursing action that the home health nurse can delegate to a home health aide who is making daily visits to a newly diagnosed type 2 diabetic client is assisting with personal hygiene. This action is included in the role of home health aides.Assisting with appropriate dietary selections, evaluating the effectiveness of teaching, and performing assessments are complex actions that would be performed by licensed nurses.
A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer? A) Liver. B) Smooth muscle. C) Fatty tissue. D) Brain.
Answer: D. The prefix "glio-" is used when cancers of the brain are named.The prefix "hepato-" is included when cancers of the liver are named. The prefix "leiomyo-" is included when cancers of smooth muscle are named. The prefix "lipo-" is included when cancers of fat or adipose tissue are named.
_____: A foreign protein or allergen that is capable of causing an immune response; protein on the surface of a cell.
Antigen
_____: The occurrence of infection in which the patient's own normal flora overgrows and penetrates the internal environment.
Auto-contamination
_____: A condition in which the tips of the digits fall off spontaneously; can occur in severe cases of Raynaud's phenomenon.
Autoamputation of the distal digits
A patient is brought to the ED with respiratory depression. The patient has a history of COPD. What acid-base imbalance is most likely? A) Metabolic alkalosis. B) Respiratory acidosis. C) Metabolic acidosis and respiratory acidosis. D) Metabolic alkalosis and respiratory alkalosis.
B
_____: A group of diseases that are the major focus of rheumatology (the study of rheumatic diseases); most are musculoskeletal disorders.
Connective tissue disease (CTD)
_____: Infection control guidelines from the U.S. Centers for Disease Control and Prevention; used for patients with infections spread by direct contact or contact with items in the patient's environment, such as pediculosis.
Contact precautions
_____: A method used to administer anesthesia using an IV moderate sedation agent is used in addition to the neuraxial or PNB drug. PNB may be either a single injection or continuous infusion by a portable pump.
Continuous femoral nerve blockade
_____: In the patient with sickle cell disease, periodic episodes of extensive cellular sickling that have a sudden onset and can occur as often as weekly or as seldom as once a year.
Crises
_____: A type of contamination in which organisms from another person or from the environment are transmitted to the patient.
Cross-contamination
_____: A procedure for identifying a microorganism by cultivating and isolating it in tissue cultures or artificial media.
Culture
_____: A progressive deterioration of nerves that results in loss of nerve function (sensory perception). A common complication of diabetes, it often involves all parts of the body.
Diabetic peripheral neuropathy (DPN)
_____: The successful transplantation of cells in the patient's bone marrow.
Engraftment
_____: A round or oval flat or slightly raised rash.
Erythema migrans
_____: Hyperthyroidism caused by excessive use of thyroid replacement hormones.
Exogenous hyperthyroidism
_____: Escape of fluids or drugs into the subcutaneous tissue; a complication of intravenous infusion.
Extravasation
_____: In hematology, an event (e.g., trauma) that occurs outside the blood to cause platelet plugs to form.
Extrinsic factor
_____: A procedure in which healthy normal flora is placed into the lower GI system of the infected patient who does not respond to antibiotic therapy or has recurrent disease .
Fecal microbiota transplantation (FMT)
_____: The combination of rheumatoid arthritis, hepatosplenomegaly (enlarged liver and spleen), and leukopenia.
Felty's syndrome
_____: The breakdown of a clot.
Fibrinolysis
_____: A smooth, beefy red tongue.
Glossitis
_____: Excessive mineralocorticoid production.
Hyperadlosteronism
_____: An increase in the band cells (immature neutrophils) in the white blood cell differential count; an early indication of infection.
Left shift
_____: A type of cancer with uncontrolled production of immature white blood cells in the bone marrow; the bone marrow becomes overcrowded with immature, nonfunctional cells, and the production of normal blood cells is greatly decreased.
Leukemia
_____: Pertaining to abnormal leukemic cells that come from the lymphoid pathways and develop into lymphocytes.
Lymphoblastic
_____: Inflammation of a muscle.
Myositis
_____: Stem cells that are collected from peripheral blood for transplantation into the patient.
Peripheral blood stem cells (PBSCs)
_____: A form of megaloblastic anemia caused by failure to absorb vitamin B12 because of a deficiency of intrinsic factor (normally secreted by the gastric mucosa) needed for intestinal absorption of vitamin B12.
Pernicious anemia
_____: A syndrome of inflammatory arthritis associated with psoriasis, the skin condition characterized by a scaly, itchy rash.
Psoriatic arthritis(PsA)
_____: Any therapy given at a high dose for a short duration.
Pulse therapy
_____: Postoperative leg exercise performed by straightening the legs and pushing the back of the knees into the bed.
Quadriceps-setting exercises
_____: A specific cancer cell type, found in lymph nodes, that is a marker for Hodgkin's lymphoma.
Reed-Sternberg cell
_____: Any disease or condition involving the musculoskeletal system.
Rheumatic disease
Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for greater than four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.
ANSWER: 2. 1. Blood will coagulate if left out for an extended period, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia. TEST-TAKING HINT: The test taker must know the rationale behind nursing interventions to be able to answer this question.
The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."
ANSWER: 2. 1. The client should keep a list of medications being taken and wear a Medic Alert bracelet. 2. Medication for DI is usually taken every eight (8) to 12 hours, depending on the client. The client should keep the medication close at hand. 3. The client is at risk for fluid shifts. Weighing every morning allows the client to follow the fluid shifts. Weight gain indicates too much medication. 4. Tightness in the chest could be an indicator the medication is not being tolerated; if this occurs, the client should notify the healthcare provider. TEST-TAKING HINT: This is an "except" question. This means all answers except one will be actions the client should do. If the test taker missed interpreting this from the stem, then the test taker could jump to the first action the client should do as the correct answer.
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4°F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first? 1. Request arterial blood gases STAT. 2. Administer oxygen via nasal cannula. 3. Start an IV with an 18-gauge angiocath. 4. Prepare to administer analgesics as ordered.
ANSWER: 2. 1. The health-care provider could order STAT ABGs, but caring directly for the client is always the first priority. 2. A pulse oximeter reading of less than 93% indicates hypoxia, which warrants oxygen administration. 3. The nurse should start an 18-gauge IV catheter because the client may need blood, but this is not the nurse's first intervention. 4. The medication will be administered intravenously, so the IV will have to be started before administering the medication. TEST-TAKING HINT: If the test taker can eliminate two (2) options and cannot decide between the other two (2), the test taker should apply a rule such as Maslow's hierarchy of needs and select the intervention that addresses oxygenation or airway
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach? 1. The scan will identify any malignancy in the vascular system. 2. Radiopaque dye will be injected between the toes. 3. The test will be done similar to a cardiac angiogram. 4. The test will be completed in about five (5) minutes.
ANSWER: 2. 1. The scan detects abnormalities in the lymphatic system, not the vascular system. 2. Dye is injected between the toes of both feet and then scans are performed in a few hours, at 24 hours, and then possibly once a day for several days. 3. Cardiac angiograms are performed through the femoral or brachial arteries and are completed in one session. 4. The test takes 30 minutes to one (1) hour and then is repeated at intervals. TEST-TAKING HINT: The test taker must be aware of diagnostic tests used to diagnose specific diseases. Options "1" and "3" could be eliminated because of the words "vascular" and "cardiac"; these words pertain to the cardiovascular system, not the lymphatic system.
The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first? 1. The client who has a 0730 sliding-scale insulin order. 2. The client who received an initial dose of IV antibiotic at 0645. 3. The client who is having back pain at a "4" on a 1-to-10 scale. 4. The client who has dysphagia and needs to be fed.
ANSWER: 2. 1. This client should be seen but not before assessing for a possible anaphylactic reaction. 2. This client has received an initial dose of antibiotic IV and should be assessed for tolerance to the medication within 30 minutes. 3. Pain is a priority but not over a potential lifethreatening emergency. 4. This client can be seen last. A delayed meal is not life threatening. TEST-TAKING HINT: The test taker should determine which client has the most pressing need and rank the options in order. Life-threatening situations have priority.
The client diagnosed with sickle cell anemia is experiencing a vaso-occlusive sickle cell crisis secondary to an infection. Which medical treatment should the nurse anticipate the HCP ordering for the client? 1. Administer meperidine (Demerol) intravenously. 2. Admit the client to a private room and keep in reverse isolation. 3. Infuse D5W 0.33% NS at 150 mL/hr via pump. 4. Insert a 22-French Foley catheter with a urimeter.
ANSWER: 3. 1. Demerol is no longer recommended for long-term pain management because the accumulative effect of normeperidine can cause seizures. 2. The client does not need to be in reverse isolation because other people will not affect the crisis. 3. Increased intravenous fluid reduces the viscosity of blood, thereby preventing further sickling as a result of dehydration. 4. The client needs to be receiving intake and output monitoring, but there is no reason to insert a Foley catheter. TEST-TAKING HINT: The test taker would have to know that sickling is caused by decreased oxygen or dehydration to know this answer. Possibly looking at the word "infection" and increasing fluids may help the test taker select this option.
Which information about reproduction should be taught to the 27-year-old female client diagnosed with Hodgkin's disease? 1. The client's reproductive ability will be the same after treatment is completed. 2. The client should practice birth control for at least two (2) years following therapy. 3. All clients become sterile from the therapy and should plan to adopt. 4. The therapy will temporarily interfere with the client's menstrual cycle.
ANSWER: 2. 1. This is a false promise. Many clients undergo premature menopause as a result of the cancer therapy. 2. The client should be taught to practice birth control during treatment and for at least two (2) years after treatment has ceased. The therapies used to treat the cancer can cause cancer. Antineoplastic medications are carcinogenic, and radiation therapy has proved to be a precursor to leukemia. A developing fetus would be subjected to the internal conditions of the mother. 3. Some clients—but not all—do become sterile. The client must understand the risks of therapy, but the nurse should give a realistic picture of what the client can expect. It is correct procedure to tell the client the nurse does not know the absolute outcome of therapy. This is the ethical principle of veracity. 4. The therapy may interfere with the client's menses, but it may be temporary. TEST-TAKING HINT: Option "3" can be eliminated on the basis that it says "all" clients; if the test taker can think of one case where "all" does not apply, then the option is incorrect.
Which endocrine disorder should the nurse assess for in the client who has a closed head injury with increased intracranial pressure? 1. Pheochromocytoma. 2. Diabetes insipidus. 3. Hashimoto's thyroiditis. 4. Gynecomastia.
ANSWER: 2. 1. This is a tumor of the adrenal medulla. 2. Diabetes insipidus can be caused by brain tumors or infections, pituitary surgery, cerebrovascular accidents, or renal and organ failure, or it may be a complication of a closed head injury with increased intracranial pressure. Diabetes insipidus is a result of antidiuretic hormone (ADH) insufficiency. 3. Hashimoto's thyroiditis causes hypothyroidism. 4. Gynecomastia is abnormal enlargement of breast tissue in men
Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? (Select all that apply.) A) Bony nodes in finger joints B) Subcutaneous nodules C) Severe weight loss D) Joint deformity E) Thrombocytosis
ANS: A, B, C, D, E. All of the choices are signs and symptoms of late rheumatoid arthritis which is a systemic and potentially joint-deforming disease as it progresses.
What health teaching by the nurse is important for clients diagnosed with systemic lupus erythematosus? (Select all that apply.) A) "Take frequent rest periods to prevent fatigue." B) "Avoid green leafy vegetables to prevent bleeding." C) "Avoid sun exposure to prevent disease flare-ups." D) "Report fever to your health care provider immediately" E) "Use a mild soap for bathing to prevent skin irritation."
ANS: A, C, D, E. Systemic lupus erythematosus is a systemic autoimmune disease that causes fatigue, organ failure, and skin lesions and rashes that are worsened by ultraviolet light such as sunlight.
A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A) The client can reduce the dosages of the prescribed drugs. B) The virus is resistant to the current combination of drugs. C) The client no longer has AIDS. D) The drug therapy is effective.
ANS: D. A client diagnosed with AIDS meets the criteria for Stage 3 category of HIV infection. Even when this client's CD4+ T-cell count increases as a result of therapy, the diagnosis of AIDS remains. The fact that the T-cell count has risen indicates that the combination of drugs used for therapy is effective; however, the dosages are not decreased.
The client is placed on neutropenia precautions. Which information should the nurse teach the client? 1. Shave with an electric razor and use a soft toothbrush. 2. Eat plenty of fresh fruits and vegetables. 3. Perform perineal care after every bowel movement. 4. Some blood in the urine is not unusual.
ANSWER: 3. 1. Shaving with an electric razor and using a soft toothbrush are interventions for thrombocytopenia. 2. Fresh fruits and vegetables are limited because they may harbor microbes. 3. Perineal care after each bowel movement, preferably with an antimicrobial soap, is performed to reduce bacteria on the skin. 4. Blood in the urine would indicate a complication and is not expected.
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Excessive thirst. 2. Orthopnea. 3. Ascites. 4. Concentrated urine output.
ANSWER: 4. 1. Excessive thirst is a symptom of diabetes insipidus, which is a deficiency of antidiuretic (ADH) hormone. 2. Orthopnea is difficulty breathing when in the supine position, which is not a sign/symptom of SIADH. 3. Ascites is excess fluid in the peritoneal cavity, which is not a sign/symptom of SIADH. 4. Excess antidiuretic hormone (ADH) causes SIADH, which causes increased water reabsorption and leads to increased fluid volume and scant, concentrated urine
A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? A) Strong, bounding pulse. B) Decreased bowel sounds. C) Tingling and numbness of the hands and feet. D) Diminished deep-tendon reflexes.
Answer: C. A) Hypocalcemia causes a weak, thready pulse. B) Hypocalcemia increases gastrointestinal motility. C) Hypocalcemia causes paresthesias, which usually starts in the hands and feet. D) Hypocalcemia causes hyperactive deep-tendon reflexes.
The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A) Monitoring platelets. B) Administering packed red blood cells. C) Using strict aseptic technique to prevent infection. D) Administering low-dose heparin therapy for clients on bedrest.
Answer: C. Sepsis is a major cause of DIC, especially in the oncology client. The oncology nurse must use strict asepsis to prevent any infection.Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.
Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? A) "My Thera-Band really helps me loosen up my arms." B) "The brace on my lower leg is helping me walk better." C) "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." D) "Water aerobic exercises have helped me sleep better."
Answer: C. Tai chi is an alternative or complementary therapy that focuses on slow, gentle, and relaxing stretching movements and breathing. Thera-Band exercises are used in physical therapy. Splints or braces are used in occupational therapy. Water aerobics is an example of a low-impact exercise, and is not considered an alternative therapy.
The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A) Uses a prepared list and finds out the client's food preferences B) Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) C) Has the client write down everything he or she has eaten for the past week D) Determines who prepares the client's meals and plans an interview with him or her
Answer: C. The best way for the nurse to assess an anemic client's diet is to have the client write down everything he/she has eaten in the last week. Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake.Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating. For instance, the client may like steak but may be unable to afford it. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals.
The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? A) A client with hemolytic anemia B) A client with cirrhosis of the liver C) A client who had an emergency splenectomy D) A client with recently diagnosed sickle cell anemia
Answer: C. The client who is at the highest risk for infection and sepsis is the client who had an emergency splenectomy. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms and is at increased risk for infection.A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client.
The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? A) "I'm letting my husband do most of the cooking, but I help plan the menus." B) "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." C) "My husband is getting used to having sex only once a month." D) "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must."
Answer: C. The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required. Being involved in the meal process is a productive coping strategy. The client's statement about the positive effects of etanercept therapy indicates productive coping because it describes improved mobility. Expressing concerns about the future but then identifying a plan is a productive coping strategy.
After reviewing the laboratory test results, the nurse calls the primary care provider about which client? A) A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% B) A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) C) A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) D) A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0
Answer: C. The nurse calls the PCP about a 46-year-old client with a fever and a WBC of 1500/mm3 (1.5 × 109/L). This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed.An elevated reticulocyte count in the 52-year-old is expected after hemorrhage. A platelet count of 150,000/mm3 (150 × 109/L) in the 49-year-old is normal. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level.
The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes.Physical AssessmentDiagnostic FindingsProvider PrescriptionsLungs clearGlucose 179 mg/dL (9.9 mmol/L)Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L)Right great toe mottled and cold to touchHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L)Client states wears eyeglasses to readAfter completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? A) Poor glucose control. B) Visual changes. C) Respiratory distress. D) Decreased peripheral perfusion.
Answer: D. A cold, mottled right great toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization. This must be reported to the primary health care provider to avoid potential gangrene and amputation.Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.
A nurse is monitoring a client's status 24 hours after a total thyroidectomy. Which of the following findings should the nurse report to the provider? A) Productive cough. B) Pain with hyperextension of the neck. C) Hoarse, weak voice. D) Laryngeal stridor.
Answer: D. A) A productive cough can occur after endotracheal intubation due to a buildup of secretions. B) Pain with hyperextension of the neck is an expected finding after this surgery. The nurse should use pillows to support the client's head and neck. C) A hoarse and weak voice is common after general anesthesia as a result of endotracheal intubation. If hoarseness continues, it could indicate laryngeal nerve damage, which is usually transient. D) Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.
A nurse is teaching the parent of a child about administration guidelines for the human papilloma virus (HPV) vaccine. Which of the following information should the nurse include? A) The vaccine does not protect males. B) One dose is administered at birth and another is administered at age 5. C) The vaccine protects against chlamydia. D) Three doses are administered to adolescents who start the series after age 15.
Answer: D. A) The nurse should inform the parent that the HPV vaccine is equally effective for both males and females. B) The nurse should inform the parent that the HPV vaccine is recommended for children beginning at 11 or 12 years of age. C) The nurse should inform the parent that the HPV vaccine is not effective against chlamydia. D) The nurse should inform the parent that the HPV vaccine is recommended for children beginning at age 11 or 12 years. Children who receive the first dose before age 15 should receive two doses of the HPV vaccine. Adolescents who receive the first dose after age 15 should receive three doses of the HPV vaccine.
A nurse is providing discharge teaching for a client who is HIV-positive. Which of the following instructions should the nurse include in the teaching? A) Clean bathroom surfaces with full-strength bleach. B) Work in the garden for exercise. C) Wash laundry soiled with a body fluid in warm water. D) Discard beverages that have been unrefrigerated for 1 hr.
Answer: D. A) The nurse should instruct the client to clean bathroom surfaces with a 10% bleach solution. B) The nurse should instruct the client to avoid working in the garden because this places the client in close proximity to the bacteria in plants and soil. C) The nurse should instruct the client to wash laundry that is soiled by a body fluid in hot water. D) The nurse should instruct the client to discard beverages that have been unrefrigerated for 1 hr. Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection.
A nurse is caring for a client who has type 2 diabetes mellitus and has hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? A) Blood glucose of 250 mg/dL. B) Serum pH of 7.32. C) Blood glucose of 425 mg/dL. D) Serum pH of 7.45.
Answer: D. A) This laboratory value indicates the client has hyperglycemia. B) This laboratory value indicates the client has diabetic ketoacidosis. C) This laboratory value indicates the client has hyperglycemia. D) A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A) A diagnosis of diabetes treated with insulin and diet B) An exercise regimen of jogging 3 miles four times a week C) A history of cardiac disease. D) Advancing age.
Answer: D. Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases.Diabetes is not known to cause lung cancer. Regular exercise is not a risk factor for lung cancer, nor does having cardiac disease predispose a person to lung cancer.
The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? A) "I must wear a medical alert bracelet stating that I am allergic to bee stings." B) "I need to carry epinephrine with me." C) "My spouse must learn how to give me an injection." D) "I am immune to bee stings now that I have had a reaction."
Answer: D. More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe.The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.
The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? A) Cromolyn sodium (Nasalcrom). B) Desloratadine (Clarinex). C) Fexofenadine (Allegra). D) Zafirlukast (Accolate).
Answer: D. The nurse anticipates that zafirlukast (Accolate) will be prescribed. Zafirlukast is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug. Desloratadine (Clarinex) and fexofenadine (Allegra) are nonsedating antihistamines.
_____: Any substance that changes the activity of the genes in a cell so that the cell becomes a cancer cell.
Carcinogen
_____: Cancer development.
Carcinogenesis
_____: Round lesion in patients who have discoid lupus erythematosus; evident when exposed to sunlight or ultraviolet light.
Discoid lesions
_____: Chemotherapy that uses higher doses more often for aggressive cancer treatment, especially breast cancer.
Dose-dose chemotherapy
_____: Difficulty in breathing or breathlessness.
Dyspnea
_____: Abnormal protrusion of the eyeball (proptosis).
Exophthalmos
_____: (1) The final component of the primary survey that allows for thorough assessment of the trauma patient; (2) in radiation therapy, the amount of radiation that is delivered to a tissue.
Exposure
_____: Infections associated with the provision of health care; for example, microorganisms can enter the body through the genitourinary tract in patients with indwelling urinary catheters.
Health care-associated infection (HAI)
_____: An abnormal number of cells.
Hypercellulariy
_____: The small, closed circulatory system that the hypothalamus shares with the anterior pituitary gland; it allows hormones produced in the hypothalamus to travel directly to the anterior pituitary gland.
Hypothalamic-hypophysial portal system
_____: Antibody.
Immunoglobulin (gamma globulin)
_____: Reactions to exposure to latex in gloves and other medical products; reactions include rashes, nasal or eye symptoms, and asthma.
Latex allergy
_____: A type of B-lymphocyte that remains sensitized but does not start to produce antibodies until the next exposure to the same antigen.
Memory cell
_____: The monthly flow of blood from the genital tract of women.
Menses
_____: Pertaining to leukemias in which the abnormal cells come from the myeloid pathways.
Myelocytic
_____: A pedunculated outgrowth of tissue.
Papilloma
_____: A short-lived B-lymphocyte that begins to function immediately to produce antibodies against sensitizing antigens.
Plasma cell
_____: A flushed appearance of the skin.
Plethoric
_____: The number and appearance of chromosomes; used to describe cancer cells
Ploidy
_____: Reinfection or a second infection of the same type.
Superinfection
_____: Continuous contractions of muscle groups; hyperexcitability of nerves and muscles.
Tetany
_____: Inflammation of the thyroid gland.
Thyroiditis
_____: Chemicals or drugs that cause tissue damage on direct contact or extravasation.
Vesicants
PH - 7.39 CO2 - 69 HCO3 - 69 A) Compensated Metabolic Alkalosis. B) Uncompensated Respiratory Alkalosis. C) Uncompensated Metabolic Alkalosis. D) Partially Compensated Metabolic alkalosis
A
Which statements made by a client who has diabetes insipidus indicate to the nurse that more teaching is needed? (Select all that apply.) A) If I gain more than 2 lbs (1 kg) in a day, I will limit my fluid intake. B) If I become more thirsty, I will take another dose of the drug. C) I will avoid aspirin and aspirin-containing substances. D) I will stop taking the drug for 24 hours before I have any dental work performed. E) I will limit my intake of salt and sodium to no more than 2 g daily. F) I will wear my medical alert bracelet at all times.
ANS: A, C, D, E. With diabetes insipidus (DI), output is excessive and does not vary to match intake. Thus the client is at risk for dehydration and should not limit his or her fluid intake. Although weight gain could indicate water toxicity, other symptoms would also be present. Aspirin is not a contraindication for the drugs used to treat DI and these drugs do not increase the risk for bleeding. Thus, there is no need to stop the drug before dental work. Limiting salt or sodium intake does not manage the problem of DI and is not a recommended action.
Which assessment findings in a client who has neutropenia from cancer chemotherapy indicate to the nurse that severe disseminated intravascular coagulation (DIC) is present? (Select all that apply.) A) The client is bleeding from the nose, IV sites, and rectum. B) The client's temperature is 99°F (37.2°C). C) The client's pulse rate is 130 beats per minute. D) The client's respiratory rate is 24 breaths per minute. E) The client's white blood cell count is 3200/mm3 (3.2 × 109/L) F) The client's hourly urine output is 100 mL
ANS: A, C, D. DIC is a condition in which widespread microthrombi form and use all available circulating clotting factors. When these factors are gone, clotting cannot occur and the client bleeds from any site of trauma, no matter how minor the trauma. Spontaneous bleeding can also occur. The elevated pulse rate is consistent with the hypovolemic shock phase of DIC, as is the increased respiratory rate. Both are attempting to maintain oxygenation to vital organs.
Which physiologic actions result from normal insulin secretion? (Select all that apply.) A) Increased liver storage of glucose of glycogen B) Increased gluconeogenesis C) Increased cellular uptake of blood glucose D) Increased breakdown of lipids (fats) for fuel E) Increased production and release of epinephrine F) Decreased storage of free fatty acids in fat cells G) Decreased blood glucose levels H) Decreased blood cholesterol levels
ANS: A, C, G, H. The main metabolic effects of insulin are to stimulate glucose uptake in skeletal muscle and heart muscle and to suppress liver production of glucose and very-low-density lipoprotein (VLDL). In the liver, insulin promotes the production and storage of glycogen (glycogenesis) at the same time that it inhibits glycogen breakdown into glucose (glycogenolysis). It increases protein and lipid (fat) synthesis and inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). In muscle, insulin promotes protein and glycogen synthesis. In fat cells, it promotes triglyceride storage. Overall, insulin keeps blood glucose levels from becoming too high and helps keep blood lipid levels in the normal range.
A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? (Select all that apply.) A) "Avoid extending your left hip behind you when you sit." B) "Do not flex your hips more than 90 degrees when toileting." C) "You may cross your legs to be more comfortable in a chair." D) "Avoid twisting your body when moving or performing ADLs." E) "Stand on your right leg and pivot into the chair when getting out of bed."
ANS: A, D, E. Intervention choices A, D, and E help prevent hip dislocation or subluxation in patients who have an anterior surgical approach for a total hip arthroplasty. Avoiding flexion is necessary for patients who have a posterior approach.
Which statements regarding care of the client receiving radiotherapy in the form of unsealed radioactive isotopes guide the nurse's care planning? (Select all that apply.) A) The client may have restrictions on who can visit and for how long. B) The client must be in total isolation while the isotopes are in place. C) When "seeds" are used for prostate cancer therapy, the client must have them removed before he leaves the hospital. D) The client's urine and stool must be handled as radioactive material. E) The nurse must ensure that all personnel entering the client's room use appropriate precautions. F) Only those female nurses who are past menopause can be assigned to care for this client.
ANS: A, D, E. While the radioactive elements are within the client, he or she does emit radiation and is a hazard to others. Children and pregnant women may not visit. Other visitors are limited to 30 minutes or less daily. With an unsealed source, the isotopes enter body fluids and are excreted in the urine and stool as radioactive substances. Because the client does emit radiation, all personnel entering the room can be exposed and must use the appropriate precautions, regardless of how short a time period they are present in the room.
Which questions are most important for the nurse to first ask a client who comes to the emergency department with signs of severe angioedema? (Select all that apply.) A) "Are you able to swallow?" B) "When did you last eat or drink?" C) "Do you have an allergy to cortisone?" D) "What drugs do you take on a daily basis"? E) "Is there any possibility that you may be pregnant?" F) "Do any members of your family also have allergies?"
ANS: A, D. The client has severe angioedema that can progress rapidly to laryngeal edema and loss of the airway. The very first question should be to assess symptom severity. Asking whether the client can swallow provides an indication of severity. If the client can still swallow, an immediate intubation or tracheotomy is not needed. Asking what drugs he or she takes can help establish the diagnosis and the cause. It is not necessary to know when the last food or drink was taken. Also, regardless of whether the client is pregnant, interventions for angioedema must be started. It is not helpful during this emergency to know whether other family members also have allergies. This information can be obtained at a later time or from family members. Cortisone is used to treat allergies and does not cause them.
Which actions does the nurse teach a client as primary cancer prevention strategies? (Select all that apply.) A) Avoiding sun exposure B) Having a yearly digital rectal examination C) Having genetic testing for specific colon cancer causing genes D) Performing monthly breast self-examinations E) Quitting cigarette smoking F) Having a mole surgically removed
ANS: A, E, F. Primary prevention strategies are those used to actually prevent cancer development. Such strategies include avoiding known carcinogens (responses A & E), and removal of "at risk" tissue (response F). A yearly digital rectal examination and performing breast self-examination are types of secondary prevention, which is early detection. These actions do not prevent cancer. Having genetic testing assess risk but does not prevent cancer development.
Which statements by a nursing student indicate a need for further teaching by the nurse regarding infection control measures needed to care for a client with possible tuberculosis? (Select all that apply.) A) "I'll wear an isolation gown when providing direct care." B) "I'll wear gloves when emptying the bed pan." C) "I'll wear a mask each time I enter the client's room." D) "I'll use a hand sanitizer when I can't wash my hands." E) "I'll wear goggles to protect my eyes."
ANS: A, E. Tuberculosis is transmitted from an infected person to a susceptible person in airborne particles, called droplet nuclei. Therefore, a gown and goggles are not useful in preventing transmission. Wearing an N95 particulate respirator is most effective in preventing droplet transmission. Gloves and hand hygiene are a part of Standard Precautions that are used when caring for every patient.
Which statement by a client who has tested negative for a BRCA1 mutation (while her sister is positive) indicates to the nurse that the client has correct understanding of the results? A) "I will continue to perform monthly breast self-examinations." B) "It is a relief to know that I have no risk for breast cancer" C) "After I have my next child, I will have my ovaries removed." D) "I will wear softer bras to avoid putting pressure on or irritating my breasts."
ANS: A. Although this woman's risk for breast cancer is much lower because she does not have the BRCA1 mutation, it remains the same (at least) as for the general female population. She should continue to perform breast self-examination on a monthly basis. The BRCA1 mutation is associated with a greatly increased risk for ovarian cancer as well as breast cancer. Because she is negative, her risk for ovarian cancer is low and does not justify an oophorectomy. Breast cancer is not related to the type or tightness of a bra.
Which assessment finding of a client 10 hours after a subtotal thyroidectomy indicates to the nurse possible airway obstruction? A) The client is drooling. B) The oxygen saturation is 97%. C) The dressing has a moderate amount of serosanguinous drainage. D) The client responds to questions correctly but does not open the eyes while talking.
ANS: A. Drooling may be a normal response for some patients while sleeping; however, it is also a major indication of swelling in the neck that could result in airway obstruction. More assessment is needed to determine whether the client is in danger of losing his or her airway. The oxygen saturation is within normal limits for a healthy adult. A moderate amount of drainage may be more than expected but is not an indication of obstruction. After general anesthesia, most clients are sleepy. Not opening his or her eyes during a response to a question is not an indication of airway obstruction.
Which change in laboratory test results of a client with sickle cell disease who was started on therapy with hydroxyurea 4 weeks ago indicates to the nurse that the therapy is effective? A) Increased HgbF from 2% to 10% B) Decreased HgbA from 3% to 2.5% C) Increased platelets from 250,000/mm3 to 300,000/mm3 D) Decreased white blood cells from 8200/mm3 to 7000/mm3
ANS: A. Hydroxyurea stimulate fetal hemoglobin (HgbF) production, which dilutes the amount of HgbS available. Because HgbF does not sickle under low oxygen conditions and because HgbS is reduced, there is less sickling of red blood cells in patients with sickle cell disease. The changes in the levels of HgbA, platelets, and white blood cells are not really significant. The hydroxyurea may lower the white blood cell count, but this can occur even if the drug does not effectively increase the HgbF levels.
Which hormone changes does the nurse expect when a client receives a continuous cortisol infusion for 24 hours when his or her endocrine feedback mechanisms are functioning normally? A) Lower than normal adrenocorticotropic hormone (ACTH) levels; lower than normal corticotropin releasing hormone (CRH) levels B) Lower than normal adrenocorticotropic hormone (ACTH) levels; higher than normal corticotropin releasing hormone (CRH) levels C) Higher than normal adrenocorticotropic hormone (ACTH) levels; lower than normal corticotropin releasing hormone (CRH) levels D) Higher than normal adrenocorticotropic hormone (ACTH) levels; higher than normal corticotropin releasing hormone (CRH) levels
ANS: A. The release of CRH and ACTH is affected by the serum level of free cortisol acting through a negative feedback loop. The stimulus for release of CRH from the hypothalamus, which is responsible for stimulating the release of ACTH from the anterior pituitary gland, is a low blood level of cortisol. A continuous infusion of cortisol for 24 hours would be sensed by the hypothalamus as either adequate or elevated levels of cortisol, not low blood levels of cortisol. As a result, little if any CRH would be released from the hypothalamus and circulating levels would be lower than normal. With low levels of CRH, the anterior pituitary cells are not stimulated to release ACTH; thus circulating levels of this hormone would also be lower than normal. Adequate or elevated blood levels of cortisol inhibit the release of CRH and ACTH.
Which symptoms are most often seen in hypothyroidism? (Select all that apply.) A) Increased appetite B) Cold intolerance C) Constipation D) Hypotension E) Exophthalmia F) Palpitations G) Tremors H) Weight gain
ANS: B, C, D, H. Hypothyroidism slows metabolism way below normal. Appetite is decreased, not increased. The client may not generate sufficient heat to maintain core body temperature. The GI system is slowed, resulting in constipation. Cardiac output decreases leading to hypotension. Exophthalmia is a complication of the Grave's form of hyperthyroidism. Palpitations and tremors occur when the central nervous system and the cardiovascular system are overstimulated by hypermetabolism. They are not associated with hypometabolism. Because metabolism is slowed, caloric use for energy decreases and weight is gained even when intake is not excessive
Which problems does the nurse expect in an older adult as a result of age-related changes in endocrine function? (Select all that apply.) A) Increased basal metabolic rate (BMR) B) Decreased core body temperature C) Dehydration D) Diarrhea E) Hyperglycemia F) Polyuria
ANS: B, C, E, F. The aging process generally causes a decline in the secretion of hormones from endocrine glands, especially those of the thyroid, pancreas, and adrenal glands. Decreased thyroid hormone secretion causes a decrease in overall metabolism and basal metabolic rate. The slower metabolism results in lower core body temperatures and constipation. Decreased adrenal gland secretion limits the ability of the older adult to reabsorb water and sodium or to concentrate urine. This condition increases the risk for dehydration. The decreased secretion of insulin from the pancreas and the decline in metabolism both result in hyperglycemia. When hyperglycemia is present, the osmolarity (osmolality) of the blood increases, causing the adult to have increased thirst and to move interstitial and intracellular fluids into the plasma volume, leading to polyuria. If insufficient fluid intake occurs, this situation also increases the risk for dehydration.
With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? (Select all that apply.) A) Applying lotion during a back rub B) Brushing the client's teeth C) Emptying a Foley catheter reservoir D) Feeding the client E) Filing the client's fingernails F) Providing perineal care
ANS: B, C, F. Standard Precautions for preventing the spread of any type of infection including HIV requires wearing gloves when coming into contact with moist mucous membranes, including oral and perineal membranes. Although saliva has a low concentration of HIV unless blood is present, oral mucous membranes harbor many types of infectious organisms. Standard precautions also require that gloves be worn when contact with urine is possible, including during such tasks as emptying a Foley catheter reservoir. Perspiration is not considered a body fluid with risk for transmission and neither is in contact with the client's intact skin. Feeding the client should not result in direct contact with transmissible fluids and neither should clipping finger nails.
Which white blood cell types are involved in the development of antibody-mediated immunity? (Select all that apply.) A) Basophils B) B-lymphocytes C) Cytotoxic/cytolytic T-cells D) Helper/inducer T-cells E) Macrophages F) Natural killer cells F) Neutrophils
ANS: B, D, E. Basophils, cytotoxic/cytolytic T-cells, natural killer cells, and neutrophils have no role in antibody production, which is the basis of antibody-mediated immunity. Antibody production requires the interaction of macrophages, helper/inducer T-cells, and B-lymphocytes. The macrophages initially recognize and process the antigen. The helper/inducer T-cell presents to and assists the unsensitized B-lymphocyte to recognize the antigen as an invader. The B-lymphocyte then becomes sensitized to the antigen and begins producing antibodies against it.
A client is diagnosed with a foot ulcer infected with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment is appropriate when providing direct client care? (Select all that apply.) A) Mask B) Gloves C) Shoe covers D) Goggles E) Gown
ANS: B, E. A foot ulcer is an open wound that will drain when infected. Therefore, in addition to using gloves as part of Standard Precautions, the nurse needs to wear a gown because MRSA is transmitted via direct contact.
The nurse performing a hematologic assessment on an older adult client identifies the following findings. Which ones does the nurse associate with age-related changes rather than a specific hematologic problem? (Select all that apply.) A) Bleeding gums B) Dry skin on distal extremities C) Pale lips D) Smooth tongue E) Sparse pubic hair F) Bright yellow-tinged sclera
ANS: B, E. Skin on older adults dries with aging and loses color. Color loss makes skin appear pale or slightly yellow-tinged, which is not jaundice; however, bright or dark yellow sclera usually indicate jaundice and should be investigated further. Hair everywhere decreases in thickness and turns gray. Pubic hair loss is common. Bleeding gums are never considered normal and can indicate a periodontal or hematologic problem. Although skin becomes more pale, lips should retain a deep red color. The normal tongue has bumps and shallow creases, even in older adults. A smooth tongue is an indicator of some types of anemia.
The client who received combination chemotherapy 7 days ago for breast cancer calls the oncology clinic to report a temperature of 100.5°F (38.06°C) and has no other symptoms of infection. What is the nurse's best response? A) "This is a normal immune-related response to the chemotherapy." B) "Please go to the nearest emergency room for a full workup for infection." C) "You are most likely dehydrated. Come to the clinic now for IV fluids." D) "There is no concern at this time but call if your temperature reaches 101.5°F (38.6°C)."
ANS: B. Clients with neutropenia, and with this being the 7th day after chemotherapy for breast cancer this client is very likely to be neutropenic, have so few white blood cells that they often do not have the typical symptoms of inflammation and infection. Anti-infective therapy is started when the client's temperature reaches 100°F (37.8°C) to prevent sepsis.
Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? A) 75-year-old client whose blood glucose levels show little variation B) 55-year-old client who has hypoglycemic unawareness C) 80-year-old client with type 2 diabetes mellitus D) 45-year-old client with type 1 diabetes mellitus
ANS: B. Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Teach patients that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness should never use alternate sites for SMBG.
Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A) Activating the viral enzyme "integrase" within the infected host's cells B) Binding of the virus to the CD4+ receptor and either of the two co-receptors C) Clipping the newly generated viral proteins into smaller functional pieces D) Fusing of the newly created viral particle with the infected cell's membrane
ANS: B. Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attached to the CD4 receptor and have its gp41 bound to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited.
The family of a client who had a successful stem cell transplant for leukemia 3 months ago asks the nurse whether they should obtain influenza vaccinations now. How will the nurse respond? A) "No, you need to wait at least two years before receiving any vaccination." B) "Yes, obtain the vaccination now to protect your family member from influenza." C) "If you have no small children in the household, influenza vaccinations are not needed for anyone." D) "Yes, if you and the client are older than 50, you should all receive influenza vaccinations immediately."
ANS: B. Having family members receive the influenza vaccine will help protect the client from this infection. It is not a live-virus vaccine and members of the household can receive it. The client is unable to make sufficient antibodies at this time to make the vaccination effective and, therefore, should not receive it.
Which statement by a client undergoing radioactive iodine (RAI) therapy demonstrates to the nurse that the client has correct understanding of post-procedure precautions? A) "I will wear a wig until my hair grows back in." B) "I will be sure to use only one toilet and not let others use it for 2 weeks." C) "I will avoid crowds and people who are ill to reduce the risk for an infection." D) "I will avoid having a manicure or pedicure during the first month after treatment"
ANS: B. The client's urine will contain small amounts of radioactive iodine that can pose a hazard to others, particularly if it is absorbed through mucous membranes. Until the client has completely cleared this material, he or she should use a separate toilet. Radioactive iodine therapy does not result in significant hair loss, nor does it reduce immunity. There is no risk for exposure of the radioactive material during either a pedicure or a manicure.
The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched? A) Rheumatoid arthritis - leflunomide B) Osteoarthritis - acetaminophen C) Acute gout - allopurinol D) Systemic lupus erythematosus — prednisone
ANS: C. Allopurinol should be prescribed for clients with chronic gout, not acute gout.
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes? A) "Avoid drinking ice-cold beverages." B) "Be sure to check your blood pressure twice daily." C) "Change positions slowly when moving from sitting to standing." D) "Check your hands and feet weekly for areas of numbness or sensation change."
ANS: C. Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults. Although checking blood pressure twice daily is helpful, it does not prevent orthostatic hypotension, nor is there any guarantee that such hypotension will occur during blood pressure measurement. Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy.
A client has a white blood cell change in which the number of suppressor T-cells is well below normal and asks the nurse what type of health problem(s) could be expected as a result of this deficiency. What is the nurse's best response? A) "You will need to receive booster vaccinations more often because your ability to make antibodies is reduced." B) "Try to avoid crowds and people who are ill because you are now more susceptible to bacterial and viral infections." C) "You will be more prone to allergic reactions when exposed to allergens or drugs." D) "Your risk for cancer development is increased."
ANS: C. Suppressor T-cells have the opposite action of helper/inducer T-cells. For optimal CMI, then, a balance between helper/inducer T-cell activity and suppressor T-cell activity must be maintained. This balance occurs when the helper/inducer T-cells outnumber the suppressor T-cells by a ratio of 2:1. When this ratio increases, indicating that helper/inducer T-cells vastly outnumber the suppressor cells, in this case because of way too few suppressor T-cells, overreactions can occur. These include allergies to almost anything, including drugs. Some of these overreactions are tissue damaging and dangerous, as well as unpleasant.
What is the most important precaution for the nurse to teach a client whose platelet counts usually range between 50,000 to 60,000/mm3 (50 × 109/L to 60 × 109/L)? A) "Drink at least 3 liters of fluid daily." B) "Take a multiple vitamin that contains iron." C) "Avoid aspirin and aspirin-containing drugs." D) "Increase your intake of dark green, leafy vegetables."
ANS: C. The normal range of platelets for a healthy adult is 150,000 to 400,000/mm3 (150 × 109/L to 400 × 109/L). This client's platelets are low enough that prolonged bleeding can occur in response to minor trauma. Thus, the client should do nothing that causes platelets to reduce further or lose function. Aspirin is an irreversible platelet inhibitor. Even one dose of aspirin can greatly reduce the function of this client's already low numbers of platelets and greatly increase the risk for excessive bleeding. Neither increased iron nor increased vitamin K (in dark green, leafy vegetables) would improve this client's platelet status. Increasing fluid would not affect this client's ability to form a platelet plug or clot appropriately.
A client diagnosed with acute leukemia tells the nurse that his brother cannot donate stem cells for a transplant because the brother has type O blood and he has type A blood. How will the nurse respond? A) "Don't worry about it. You may not need a stem cell transplant." B) "Because you are of Asian descent, finding a non-related donor will be easy." C) "Blood type and tissue type are not connected. If your brother's tissue type matches yours, you can receive his stem cells." D) "Because Type O blood is considered to be a universal donor and you have type A blood, you can receive your brother's stem cells."
ANS: C. Tissue type and blood type are controlled by different genes and are not related. The donor can be a totally different blood type from the recipient. Many transplant centers are pleased when this is the case because it is easier to determine when donor cells have engrafted (the client's blood type changes to be the same as the donor's). Most clients with acute leukemia are likely to need a stem cell transplant for survival. There are fewer donors available in the North American donor registries for any minority. While it is true that type O blood is the universal donor, this is only for transfusion of blood products, not for stem cells.
The nurse reviewing the laboratory work of a client with hypoparathyroidism finds all the following blood values. For which value does the nurse immediately assess the client's reflexes? A) Sodium 131 mEq/L (mmol/L~) B) Potassium 5.1 mEq/L (mmol/L~) C) Calcium 7.8 mg/dL (1.76 mmol/L~) D) pH 7.33
ANS: D. All of the laboratory values are somewhat out of the normal range but do not reach critical values. Sodium is slightly decreased, potassium is slightly elevated, and pH is a little low. Even though severe hyponatremia can result in seizures, it must be much lower for this complication to occur. Only the serum calcium level is low enough to indicate severe problems and a greatly increased risk for seizure activity. Assessing the client's reflexes can provide a reasonable determination of risk severity.
In the preoperative holding area, the client who is scheduled to have an adrenalectomy for hypercortisolism is prescribed to receive cortisol by intravenous infusion. What is the nurse's best action? A) Request a "time-out" to determine whether this is a valid prescription. B) Ask the client whether he or she usually takes prednisone. C) Hold the dose because the client has a high cortisol level. D) Administer the drug as prescribed.
ANS: D. Although the client has hypercortisolism, removal of the adrenal gland will stop the secretion of this important hormone that is essential for life. Further, the stress of surgery also increases the client's need for this hormone. Supplying the hormone throughout surgery prevents the complication (or at least reduces the risk for) acute adrenal crisis.
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL (mmol/L) and a hemoglobin A1c (A1C) of 5.9%. What is the nurse's interpretation of these findings? A) The client's glucose control for the past 24 hours has been good but the overall control is poor. B) The client's glucose control for the past 24 hours has been poor but the overall control is good. C) The values indicate that the client has poorly managed his or her disease. D) The values indicate that the client has managed his or her disease well.
ANS: D. Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client's FBG is well within the normal range. A1C provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client's A1C level is within the desirable range, indicating good long-term glucose control as well as short-term control.
The nurse is preparing to administer sliding-scale insulin to a client with type 2 diabetes. The medication administration record is as follows: At 1130, the client has a blood glucometer level of 322. Which intervention should the nurse implement? 1. Notify the health-care provider. 2. Administer 10 units of regular insulin. 3. Administer five (5) units of Humalog insulin. 4. Administer 10 units of intermediate-acting insulin.
ANSWER 2. 1. The client's blood glucose level does not warrant notifying the HCP. 2. According to the sliding scale, any blood glucose reading between 301 and 450 requires 10 units of regular insulin, which is fast-acting insulin. 3. Humalog is rapid-acting insulin, but the order reads regular insulin. 4. Intermediate-acting insulin, NPH or Humulin N, is not regular insulin
The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply. 1. Bleeding times are increased and platelet counts decreased. 2. Increased urine osmolality and decreased urine output. 3. Four plus pitting edema of the lower extremities. 4. Confusion, disorientation, delirium. 5. Heart rate 78, blood pressure 124/84, and RR of 20.
ANSWER: 1, 2, 3, 4. 1. SIRS involvement in the hematopoetic system includes prolonged bleeding times and thrombocytopenia. 2. In the prerenal phase and intrarenal phase of SIRS affecting the renal system, urine osmolality increases but urine production decreases because of decreased glomerular filtration. 3. The capillary membranes have a systemic response to the insult, resulting in increased permeability and leaking of fluid into the interstitial spaces (pitting edema). 4. The brain responds poorly to the increased interstitial fluid and can result in confusion, disorientation, and delirium. 5. These vital signs are within normal limits. This indicates a stable client, not one diagnosed with SIRS. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data unexpected for the disease process. In "Select all that apply" questions, each option should be answered as a true/false question.
The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply. 1. Monitor the client's hemoglobin and hematocrit. 2. Move the client to a room near the nurse's desk. 3. Limit the client's dietary intake of green vegetables. 4. Assess the client for numbness and tingling. 5. Allow for rest periods during the day for the client.
ANSWER: 1, 2, 4, 5. 1. The nurse should monitor the hemoglobin and hematocrit in all clients diagnosed with anemia. 2. Because decreased oxygenation levels to the brain can cause the client to become confused, a room where the client can be observed frequently—near the nurse's desk—is a safety issue. 3. The client should include leafy, green vegetables in the diet. These are high in iron. 4. Numbness and tingling may occur in anemia as a result of neurological involvement. 5. Fatigue is the number-one presenting symptom of anemia. TEST-TAKING HINT: This is an alternative-type question requiring the test taker to select multiple correct answers. The test taker could eliminate option "3" because the only clients told to limit green, leafy vegetables are those receiving Coumadin, an oral anticoagulant.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels.
ANSWER: 1, 2, 4. 1. Position changes promote lung expansion, and coughing helps clear secretions from the tracheobronchial tree. 2. This position expands the lungs and alleviates pressure from the diaphragm. 3. The respiratory system and pulse oximeter reading should be assessed more frequently than every shift; it should be done every four (4) hours or more often. 4. The medications should be administered 30 minutes before the meal to provide optimal muscle strength for swallowing and chewing. 5. There is no serum level available for medications used to treat MG; the client's signs/ symptoms are used to determine the effectiveness of this medication. TEST-TAKING HINT: An alternative-type question requests the test taker to select more than one option as the correct answer. The test taker must evaluate each option individually to determine if it is correct. The priority concerns for a client with MG are respiration and eating
The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all that apply. 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members' HLA typed. 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol
ANSWER: 1, 3, 4, 5. 1. All of the bone marrow cells must be destroyed prior to "implanting" the healthy bone marrow. High-dose chemotherapy and full-body irradiation therapy are used to accomplish this. 2. Autologous transfusions are infusions from the client himself or herself. This client has a cancer involving blood tissue. To reinfuse the client's own tissues would be to purposefully give the client cancer cells. 3. The best bone marrow donor comes from an identical twin; next best comes from a sibling who matches. The most complications occur from a matched unrelated donor (MUD). The client's body recognizes the marrow as foreign and tries to reject it, resulting in graft-versus-host disease (GVHD). 4. The CBC must be monitored daily to assess for infections, anemia, and thrombocytopenia. 5. Clients will have at least one multipleline central venous access. These clients are seriously ill and require multiple transfusions and antibiotics. TEST-TAKING HINT: If the test taker knows the definition of "autologous," then option "2" could be eliminated.
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.
ANSWER: 1, 3, 4, 5. 1. Muscle flaccidity is a hallmark symptom of MS. 2. Lethargy is the state of prolonged sleepiness or serious drowsiness and is not associated with MS. 3. Dysmetria is the inability to control muscular action characterized by overestimating or underestimating range of movement. 4. Fatigue is a symptom of MS. 5. Dysphagia, or difficulty swallowing, is associated with MS. TEST-TAKING HINT: These alternative-type questions are difficult because there are several correct answers. The test taker gets credit only if the entire question is answered correctly. The test taker should read each answer option carefully and rule it out as a potential correct answer before moving on to the next option.
The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply. 1. Refer the client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation.
ANSWER: 1, 3, 4, 5. 1. The physical therapist is an important part of the rehabilitation team who addresses the client's muscle deterioration resulting from the disease process and immobility. 2. There is no residual speech deficit from Guillain-Barré syndrome; therefore, this referral is not appropriate. 3. The social worker could help with financial concerns, job issues, and issues concerning the long rehabilitation time for this syndrome. 4. Pain may or may not be an issue with this syndrome. Each client is different, but a plan needs to be established to address pain if it occurs. 5. This is an excellent resource for the client and the family. TEST-TAKING HINT: The physical therapist and social worker are two members of the rehabilitation team who are always appropriate in long-term rehabilitation. Physical therapy addresses complications of immobility; social workers help the client get back home. Any resource referral is an appropriate intervention.
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Solu-Medrol, a glucocorticoid, IV. 2. Request and obtain a STAT chest x-ray. 3. Initiate the rapid response team. 4. Administer epinephrine, an adrenergic blocker, SQ then IV continuous. 5. Assess for the client's pulse and respirations.
ANSWER: 1, 3, 5. 1. Steroid medications decrease inflammation and therefore are one of the treatments for anaphylaxis. 2. A STAT chest x-ray is not indicated at this time. 3. The Rapid Response Team should be called because this client will be in respiratory and cardiac arrest very shortly. 4. Because of its ability to activate a combination of alpha and beta receptors, epinephrine is the treatment of choice for anaphylactic shock. 5. The first step in initiating cardiopulmonary resuscitation is to assess for a pulse and respirations. TEST-TAKING HINT: This is an alternative-type question. If the test taker did not read the sentence "Select all that apply," the fact there are five (5), not four (4), options should alert the test taker to go back and read the stem more closely. Each option must be decided on for itself. The test taker cannot eliminate one option based on the fact another option is correct.
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client's lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.
ANSWER: 1,3,4. 1. The client must give permission to receive blood or blood products because of the nature of potential complications. 2. Most blood products require at least a 20-gauge IV because of the size of the cells. RBCs are best infused through an 18-gauge IV. If unable to achieve cannulation with an 18-gauge, a 20-gauge is the smallest acceptable IV. Smaller IVs damage the cell walls of the RBCs and reduce the life expectancy of the RBCs. 3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of jugular vein distention, peripheral edema, and liver engorgement indicate rightsided failure. 4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration. 5. A keep-open IV of 0.9% saline would be hung. D5W causes red blood cells to hemolyze in the tubing. TEST-TAKING HINT: This is an alternative-type question. This type of question can appear anywhere on the NCLEX-RN examination. Each answer option must be evaluated on its own merit. One will not rule out another. Assessing is the first step of the nursing process. Unless the test taker is absolutely sure that an option is wrong, the test taker could select an option based on "assessing," such as options "3" and "4." Ethically speaking, informed consent should always be given for any procedure unless an emergency life-or-death situation exists. The other options require knowledge of blood and blood product administration.
The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion (CPM) unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.
ANSWER: 1. 1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth. 2. The cell saver has a measuring device; an hourly drainage bag is part of a urinary drainage system. A cell saver is a sterile system that should not be broken until ready to disconnect for reinfusion. 3. The post-anesthesia care unit nurse would not replace the cell saver; it is inserted into the surgical wound. A continuous passive motion (CPM) machine can be attached on the outside of the bandage and started if the surgeon so orders, but this has nothing to do with the blood. 4. The blood has not been crossmatched so there is not a crossmatch number. TEST-TAKING HINT: The test taker could discard option "4" if the test taker realized that the laboratory is not involved with this blood at all. The test taker must have basic knowledge of surgical care.
Which referral should the nurse implement for a client with severe multiple allergies? 1. Registered dietitian. 2. Occupational therapist. 3. Recreational therapist. 4. Social worker.
ANSWER: 1. 1. A dietitian could help the client with any necessary dietary changes for food allergies and with ways to continue to meet nutritional needs. 2. An occupational therapist addresses the client's ability to perform activities of daily living. 3. A recreational therapist works in a psychiatric setting or rehabilitation setting and assists with the client's therapeutic recreational activities. 4. A social worker addresses the client's financial needs.
Which laboratory data make the nurse suspect the client with primary hyperparathyroidism is experiencing a complication? 1. A serum creatinine level of 2.8 mg/dL. 2. A calcium level of 9.2 mg/dL. 3. A serum triglyceride level of 130 mg/dL. 4. A sodium level of 135 mEq/L.
ANSWER: 1. 1. A serum creatinine level of 2.8 mg/dL indicates the client is in renal failure, which is a complication of hyperparathyroidism. The formation of stones in the kidneys related to the increased urinary excretion of calcium and phosphorus occurs in about 55% of clients with primary hyperparathyroidism and can lead to renal failure. 2. This calcium level is within the normal range of 9 to 10.5 mg/dL. 3. This serum triglyceride level is within the normal range of 40 to 150 mg/dL in males and 30 to 140 mg/dL for females. 4. This sodium level is within the normal range of 135 to 145 mEq/L
The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.
ANSWER: 1. 1. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low-sodium level. 2. This is a normal potassium level, and a heightened level of awareness indicates drug usage. 3. This is a normal calcium level and the client is fluid overloaded, not dehydrated, so there would not be tented tissue turgor. 4. This is a normal magnesium level, and a large urinary output is desired. TEST-TAKING HINT: The nurse must know common laboratory values.
Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)? 1. An enlarged forehead, maxilla, and face. 2. A six (6)-inch increase in height of the client. 3. The client complaining of a severe headache. 4. A systolic blood pressure of 200 to 300 mm Hg.
ANSWER: 1. 1. Acromegaly (enlarged extremities) occurs when sustained GH hypersecretion begins during adulthood, most commonly because of a pituitary tumor. 2. Gigantism occurs when GH hypersecretion begins before puberty when the closure of the epiphyseal plates occurs. Note the age of the client. 3. A severe headache is not a symptom of acromegaly. 4. High blood pressure is a sign of pheochromocytoma.
The nurse is assisting the HCP with a bone marrow biopsy. Which intervention postprocedure has priority? 1. Apply pressure to site for five (5) to 10 minutes. 2. Medicate for pain with morphine slow IVP. 3. Maintain head of bed in high Fowler's position. 4. Apply oxygen via nasal cannula at five (5) L/min
ANSWER: 1. 1. After a bone marrow biopsy, it is important that the client form a clot to prevent bleeding. The nurse should hold direct pressure on the site for five (5) to 10 minutes. 2. The nurse might premedicate for pain, but once the procedure is completed, a mild oral medication is usually sufficient to relieve any residual discomfort. 3. The head of the bed can be in any position of comfort for the client. 4. The procedure is performed on the iliac crest or the sternum and does not cause respiratory distress.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? 1. Take the hourly vital signs on a client receiving blood transfusions. 2. Monitor the infusion of antineoplastic medications. 3. Transcribe the HCP's orders onto the medication administration record (MAR). 4. Determine the client's response to the therapy.
ANSWER: 1. 1. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. 2. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. 3. This is the responsibility of the ward secretary or the nurse, not the unlicensed assistive personnel. 4. This represents the evaluation portion of the nursing process and cannot be delegated. TEST-TAKING HINT: The test taker must decide what is within the realm of duties of a UAP. Three (3) of the options have the UAP doing some action with medications. This could eliminate all of these. Option "1" did not say monitor or evaluate or decide on a nursing action; this option only says the UAP can take vital signs on a client who is presumably stable because the infusion has been going long enough to reach the hourly time span.
The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum prothrombin time (PT) level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.
ANSWER: 1. 1. Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately. 2. The PT level is monitored for clients receiving Coumadin, an anticoagulant, which is not ordered for clients with diabetes, type 1 or 2. 3. Glycosylated hemoglobin is a serum blood test usually performed in a laboratory, not in the client's home. The hemoglobin Alc is performed every three (3) months. Selfmonitoring blood glucose (SMBG) should be taught to the client. 4. The client's feet should be checked daily, not weekly. In a week the client could have developed gangrene from an injury the client did not realize he or she had. TEST-TAKING HINT: Always notice the age of a client if it is provided because this is important when determining the correct answer for the question. Be sure to note the adverbs, such as "weekly" instead of "daily."
Which sign/symptom makes the nurse suspect the client has ankylosing spondylitis? 1. Low back pain at night relieved by activity in the morning. 2. Ascending paralysis of the lower extremities up to the spinal cord. 3. A deep ache and stiffness in the hip joints radiating down the legs. 4. Difficulty changing from lying to sitting position, especially at night.
ANSWER: 1. 1. Ankylosing spondylitis is a chronic inflammatory arthritis that primarily affects the spinal cord. The client complains of intermittent bouts of low back pain with the pain worse at night, followed by morning stiffness relieved by activity. 2. Ascending paralysis makes the nurse suspect Guillain-Barré syndrome. 3. A deep ache and stiffness may indicate osteoarthritis, which occurs in weightbearing joints. 4. This is not a symptom of ankylosing spondylitis.
The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes
ANSWER: 1. 1. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications. 2. Pain at a "10" is a priority but not above chest pain. 3. Dysphagia is expected in clients diagnosed with MG. 4. Clients diagnosed with GB syndrome have ascending muscle weakness or paralysis, which could eventually result in the client being placed on a ventilator, but the problem currently is in the distal extremities (the feet) and is not priority over chest pain. TEST-TAKING HINT: When the test taker is deciding on which client has priority, a potentially life-threatening condition is always top priority
The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.
ANSWER: 1. 1. Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland. 2. The client will have decreased fluid volume, and fluid restriction exacerbates a crisis. 3. The client requires a quiet, calm, relaxed atmosphere. 4. The client walks with a stooped posture from fatigue, but gait training is not needed. TEST-TAKING HINT: To answer this question, the test taker must have knowledge of adrenal gland function.
The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client? 1. Demonstrate how to use an EpiPen, an adrenergic agonist. 2. Teach the client to never go outdoors in the spring and summer. 3. Have the client buy diphenhydramine over the counter to use when stung. 4. Discuss wearing a Medic Alert bracelet when going outside.
ANSWER: 1. 1. Clients who are allergic to bee sting venom should be taught to keep an EpiPen with them at all times and how to use the device. This could save their lives. 2. It is unrealistic to think the client will never go outdoors, but the client should be taught to avoid exposure to bees whenever possible. 3. Over-the-counter diphenhydramine (Benadryl) is a histamine-1 blocker, but it is oral and not useful in this situation. 4. The client should wear a Medic Alert bracelet, but it is not priority over ensuring the client knows how to treat a bee sting. Wearing the bracelet does not ensure correct treatment of the bee sting. TEST-TAKING HINT: Answer option "2" is an absolute and should be eliminated as a possible correct answer
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis? 1. Night sweats and fever without "chills." 2. Edematous lymph nodes in the groin. 3. Malaise and complaints of an upset stomach. 4. Pain in the neck area after a fatty meal.
ANSWER: 1. 1. Clients with Hodgkin's disease experience drenching diaphoresis, especially at night; fever without chills; and unintentional weight loss. Early stage disease is indicated by a painless enlargement of a lymph node on one side of the neck (cervical area). Pruritus is also a common symptom. 2. Lymph node enlargement with Hodgkin's disease is in the neck area. 3. Malaise and stomach complaints are not associated with Hodgkin's disease. 4. Pain in the neck area at the site of the cancer occurs in some clients after the ingestion of alcohol. The cause for this is unknown. TEST-TAKING HINT: The test taker must notice the descriptive words, such as "groin" and "fatty," to decide if these options could be correct.
The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."
ANSWER: 1. 1. Clients with this syndrome usually have a full recovery, but it may take up to one (1) year. 2. Only about 10% of clients are left with permanent residual disability. 3. This is "passing the buck." The nurse should answer the client's question honestly, which helps establish a trusting nurse-client relationship. 4. This indicates the nurse does not understand the typical course for a client diagnosed with Guillain-Barré syndrome. TEST-TAKING HINT: The test taker could eliminate option "3" because this is "passing the buck" and is usually not the best action of a nurse. The test taker needs to be knowledgeable of the typical course of this syndrome to be able to answer this question.
The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."
ANSWER: 1. 1. Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease. 2. The client has too much cortisol; this client should not be receiving prednisone, a steroid medication. 3. These are symptoms of hypoglycemia, which is not expected in this client because this client has high-glucose levels. 4. The client is predisposed to osteoporosis and fractures. Contact sports should be avoided. TEST-TAKING HINT: If the test taker is not aware of the disease problem, this question could be answered correctly because of common standard discharge instructions—namely, notify the health-care provider of a fever.
The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.
ANSWER: 1. 1. External heat sources (heating pads, electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse. 2. Assessing the client's temperature every two (2) hours is not needed because the temperature will not change quickly. The client needs thyroid hormones to help increase the client's temperature. 3. The room temperature should be kept warm because the client will have complaints of being cold. 4. The client is fatigued and this is an appropriate intervention but is not applicable to the client problem of "risk for imbalanced body temperature." TEST-TAKING HINT: The test taker must always know exactly what the question is asking. Option "4" can be ruled out because it does not address body temperature. If the test taker knows the normal function of the thyroid gland, this may help identify the answer; decreased metabolism will cause the client to be cold.
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus
ANSWER: 1. 1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce white blood cells of the number and maturity needed to fight infection. 2. Nausea and vomiting are symptoms related to the treatment of cancer but not to the diagnosis of leukemia. 3. The clients are frequently fatigued and have low platelet counts. The platelet count is low as a result of the inability of the bone marrow to produce the needed cells. In some forms of leukemia, the bone marrow is not producing cells at all, and in others, the bone marrow is stuck producing tens of thousands of immature cells. 4. Cervical lymph node enlargement is associated with Hodgkin's lymphoma, and positive acid-fast bacillus is diagnostic for tuberculosis. TEST-TAKING HINT: Option "3" could be eliminated because of the excessive energy. Illness normally drains energy reserves; it does not increase them.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor. 2. The client who states the staff ignores the call light. 3. The client whose vital signs are T 99.9˚F, P 101, R 26, and BP 110/68. 4. The client who is unable to provide a sputum specimen.
ANSWER: 1. 1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration. 2. This is a concern but it can be taken care of after the client with the physical problem. 3. The temperature is slightly elevated and the pulse is one (1) beat higher than normal. This client could wait to be seen. 4. Many clients who have had sputum specimens ordered are unable to produce sputum, but it does not warrant immediate intervention. TEST-TAKING HINT: This is an "except" question asking the test taker to identify abnormal data indicating a life-threatening situation or a complication
The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.
ANSWER: 1. 1. Humulin N peaks in six (6) to eight (8) hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia. 2. The food intake at lunch will not affect the client's blood glucose level at midnight. 3. The client's glucometer reading should be done around 2100 to assess the effectiveness of insulin at 1600. 4. Onset of Humulin N, an intermediate-acting insulin, is two (2) to four (4) hours but it does not peak until six (6) to eight (8) hours. TEST-TAKING HINT: Remember to look at the adjective or descriptor. Intermediate-acting insulin provides the reader a clue: Anything with intermediate action, instead of longer acting, is incorrect.
Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.
ANSWER: 1. 1. Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate. 2. A Glasgow Coma Scale is used for clients with potential neurological deficits and used to monitor for increased intracranial pressure. 3. Babinski's reflex evaluates central nervous system neurological status, which is not affected with this syndrome. 4. Vital signs are a part of any admission assessment but are not a specific assessment intervention for this syndrome. TEST-TAKING HINT: Vital signs are general assessment skills and really do not help specifically diagnose a disease, except for blood pressure, which helps diagnose hypertension. The test taker should know the Glasgow Coma Scale is for head or brain injuries.
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention? 1. The client's BP is 94/60 and AP is 112. 2. Negative Chvostek's and Trousseau's signs. 3. The serum potassium level is 3.5 mEq/L. 4. Ecchymosis at the vascular site access.
ANSWER: 1. 1. Hypovolemia is a complication of plasmapheresis, especially during the procedure, when up to 15% of the blood volume is in the cell separator. 2. Positive Chvostek's and Trousseau's signs (not negative signs) warrant intervention and indicate hypocalcemia, which is a complication of plasmapheresis. 3. This is a normal serum potassium level (3.5 to 5.5 mEq/L), which does not warrant intervention, but the level should be monitored because plasmapheresis could cause hypokalemia. 4. Ecchymosis (bruising) does not warrant immediate intervention. Signs of infiltration or infection warrant immediate intervention. TEST-TAKING HINT: If the test taker has no idea of the answer, then selecting signs of hypovolemia—hypotension and tachycardia—is an appropriate selection if the question asks which data warrant immediate intervention.
Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Petechiae on the anterior chest, arms, and neck. 2. Capillary refill of less than three (3) seconds. 3. An enlarged spleen. 4. Pulse oximeter reading of 95%.
ANSWER: 1. 1. ITP is caused by bleeding from small vessels and mucous membranes. Petechiae, tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal or submucosal layers, and purpura, hemorrhaging into the tissue beneath the skin and mucous membranes, are the first signs of ITP. 2. A capillary refill time (CRT) less than three (3) seconds is a normal assessment finding and would not indicate ITP. 3. A splenectomy is the treatment of choice if glucocorticosteroid therapy does not treat the ITP, but the spleen is not enlarged. 4. ITP causes bleeding, but it does not affect the oxygen that gets to the periphery. TEST-TAKING HINT: Knowing medical terminology—in this case, that thromborefers to "platelets"—the test taker could conclude that an answer option that includes something about bleeding would be the most appropriate selection for the correct answer. Options "2" and "4" could be eliminated as possible answers based on the knowledge that these are normal values.
The client is diagnosed with non-Hodgkin's lymphoma. Which nursing concept should the nurse identify as priority? 1. Immunity. 2. Grieving. 3. Perfusion. 4. Clotting.
ANSWER: 1. 1. Immunity is compromised when the hematopoietic system is impaired. The bone marrow is part of the initial response by the immune system to prevent disease. 2. Grieving is a possible interrelated concept because the client must adjust to the diagnosis but is not priority over a physiological problem. 3. Perfusion is not a concept normally associated with lymphoma. 4. Clotting is not a concept normally associated with lymphoma. TEST-TAKING HINT: The test taker must match the problem with the answer option. Options "3" and "4" would probably be implemented for the client with a bleeding disorder.
The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? 1. "Are you sexually active, and, if so, are you using birth control?" 2. "Have you discussed taking these drugs with your parents?" 3. "Which arm do you prefer to have an IV in for four (4) days?" 4. "Have you signed an informed consent for investigational drugs?"
ANSWER: 1. 1. Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old. 2. Any individual older than age 18 years is considered an adult and does not need to discuss treatment with her parents unless she chooses to do so. 3. The medications can be administered on an outpatient basis, but if an inpatient has intravenous therapy, then IV sites are changed every 72 hours and there is no guarantee an IV will last for four (4) days. 4. These are not investigational drugs and are standard therapy approved by the American College of Rheumatology and the Food and Drug Administration. TEST-TAKING HINT: The age of the client and the fact the client is female could give the test taker an idea of the correct answer. This is a client in the childbearing years.
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment? 1. Immunotherapy is effective in preventing anaphylaxis following a future sting. 2. Immunotherapy will prevent all future insect stings from harming the client. 3. This therapy will cure the client from having any allergic reactions in the future. 4. This therapy is experimental and should not be undertaken by the client.
ANSWER: 1. 1. Immunotherapy does not cure the problem. However, if immunotherapy is done following a reaction, it provides passive immunity to the insect venom (similar to the way RhoGAM prevents a mother who is Rh negative from building antibodies to the blood of a baby who is Rh positive). This is the purpose for immunotherapy in clients who are allergic. 2. This is an untrue statement. 3. There is no cure for allergies to insect venom. 4. This therapy is standard procedure for clients who have severe allergies to insect venom. TEST-TAKING HINT: Answer options "2" and "3" contain forms of absolutes such as "all" and "cure." Rarely is anything absolute in health care. The test taker should be absolutely sure of the correct answer before choosing any answer containing an absolute descriptive word or passage. The stem asks for the rationale and option "4" is giving advice, so it can be eliminated.
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The crossmatch reveals the presence of antibodies that cannot be crossmatched. Which precaution should the nurse implement when initiating the transfusion? 1. Start the transfusion at 10 to 15 mL/hr for 15 to 30 minutes. 2. Re-crossmatch the blood until the antibodies are identified. 3. Have the client sign a permit to receive uncrossmatched blood. 4. Have the unlicensed assistive personnel stay with the client
ANSWER: 1. 1. It can be difficult to crossmatch blood when antibodies are present. If imperfectly crossmatched blood must be transfused, the nurse must start the blood very slowly and stay with the client, monitoring frequently for signs of a hemolytic reaction. 2. The antibodies have been identified. The donor blood does not crossmatch perfectly to the blood of the client. 3. The blood has been crossmatched. Client permits regarding uncrossmatched blood are used for emergency transfusions when time does not allow an attempt to crossmatch. In such a case, O- blood, the universal donor, will be used. 4. The nurse cannot delegate an unstable client to an unlicensed assistive personnel. The nurse must stay with the client
The client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor? 1. Lung sounds, heart sounds, and blood pressure. 2. The client's psychological response to the illness. 3. The client's family's expectations of the hospitalization. 4. Amount of emesis, bile secretions, and mouth ulcers.
ANSWER: 1. 1. Lung sounds assess the respiratory system, and heart sounds and blood pressure assess the circulatory/cardiovascular system. 2. Psychological responses do not assess for MODS. 3. The family's expectations do not assess for MODS. 4. Emesis is not particularly associated with MODS and bile secretions and mouth ulcers have no correlation with MODS. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data expected for the disease process. Physiological problems are high priority according to Maslow and often warrant immediate intervention.
Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? 1. "I will not have any menstrual cycles because of this disease." 2. "I should avoid people who have respiratory infections." 3. "I should not take a hot bath or swim in cold water." 4. "I will drink at least 2,500 mL of water a day."
ANSWER: 1. 1. MG has no effect on the ovarian function and the uterus is an involuntary muscle, not a skeletal muscle, so the menstrual cycle is not affected. 2. Infections can result in an exacerbation and extreme weakness. 3. An extremely hot or cold environment may cause an exacerbation of MG. 4. This will help the client mobilize and expectorate sputum. TEST-TAKING HINT: This question is an "except" question and is asking the test taker to select the option which is not appropriate for the client's disease process. Three (3) answers will be appropriate; sometimes if the test taker rethinks the question and asks, "Which statements indicate the client understands the teaching?" this will help identify the correct answer.
The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral? 1. Alcoholics Anonymous. 2. Leukemia Society of America. 3. A hematologist. 4. A social worker.
ANSWER: 1. 1. Most clients diagnosed with folic acid deficiency anemia have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. A referral to Alcoholics Anonymous would be appropriate. 2. There is no connection between folic acid deficiency and leukemia; therefore, this referral would not be appropriate. 3. A hematologist may see the client, but nurses usually don't make this kind of referral; the HCP would make this referral if the HCP felt incapable of caring for the client. 4. The social worker is not the most appropriate referral. TEST-TAKING HINT: The stem asks the test taker to decide which referral is most appropriate. Option "4" might be appropriate for a number of different clients, but nothing in the stem indicates a specific need for social services. The test taker must decide which could be a possible cause of folic acid deficiency anemia.
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A? 1. Epistaxis. 2. Petechiae. 3. Subcutaneous emphysema. 4. Intermittent claudication.
ANSWER: 1. 1. Nosebleeds, along with hemarthrosis, cutaneous hematoma formation, bleeding gums, hematemesis, occult blood, and hematuria, are all signs/symptoms of hemophilia. 2. Petechiae are tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal or submucosal layers, but they are not signs of hemophilia. 3. Subcutaneous emphysema is air under the skin, which may occur with chest tube or tracheostomy insertion. 4. Intermittent claudication is severe leg pain that occurs from decreased oxygenation to the leg muscles. TEST-TAKING HINT: If the test taker knows that hemophilia is a bleeding disorder, the test taker should eliminate any answer options that don't address bleeding—in this case, options "3" and "4."
The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the client at risk for diabetes? 1. Nutrition. 2. Sensory perception. 3. pH regulation. 4. Medication.
ANSWER: 1. 1. Nutrition encompasses obesity, and obesity is a risk factor for developing diabetes mellitus type 2. 2. Sensory perception may be a problem for clients who have diabetes because ophthalmological issues occur as a result of high blood glucose levels on a prolonged period of time but are not antecedents. 3. The concept of pH is a situation that can occur as a result of DM1 but not DM2 because acidosis results from lactic acid buildup from no insulin production from the pancreas. Type 2 diabetes clients still produce some insulin. Insulin resistance is the issue in type 2 diabetes. 4. Medication is given to treat diabetes but not to cause it. TEST-TAKING HINT: The test taker must know risk factors for developing a disease process.
The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client? 1. The O- unit. 2. The A+ unit. 3. The B+ unit. 4. Any Rh+ unit.
ANSWER: 1. 1. O2 (O-negative) blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB1 is considered the universal recipient because a person with this blood type has all the antigens on the blood.) 2. A+ blood contains the antigen A that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 3. B+ blood contains the antigen B that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 4. This client does not have antigens A or B on the blood. Administration of these types would cause an antigen-antibody reaction within the client's body, resulting in massive hemolysis of the client's blood and death. TEST-TAKING HINT: This is a knowledge-based question that requires memorization of the particular facts regarding blood typing. Three of the possible answer options have a positive (1) Rh factor; only one has a negative (2) Rh factor
The nurse is preparing to administer morning medications. Which medication should the nurse administer first? 1. The pain medication to a client diagnosed with RA. 2. The diuretic medication to a client diagnosed with SLE. 3. The steroid to a client diagnosed with polymyositis. 4. The appetite stimulant to a client diagnosed with OA.
ANSWER: 1. 1. Pain medication is important and should be given before the client's pain becomes worse. 2. Unless the client is in a crisis, such as pulmonary edema, this medication can wait. 3. Steroids do not have precedent over pain medication and should be administered with food. 4. Clients diagnosed with OA are usually overweight and do not require appetite stimulants. The nurse should question this medication before administering the medication. TEST-TAKING HINT: When determining priorities, the test taker must employ some criteria to use as a guideline. According to Maslow, pain is a priority.
The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication? 1. It is an exogenous source of protease, amylase, and lipase. 2. This enzyme increases the number of bowel movements. 3. This medication breaks down in the stomach to help with digestion. 4. Pancreatic enzymes help break down fat in the small intestine.
ANSWER: 1. 1. Pancreatic enzymes enhance the digestion of starches (carbohydrates) in the gastrointestinal tract by supplying an exogenous (outside) source of the pancreatic enzymes protease, amylase, and lipase. 2. Pancreatic enzymes decrease the number of bowel movements. 3. The enzymes are enteric coated and should not be crushed because the hydrochloric acid in the stomach will destroy the enzymes; these enzymes work in the small intestine. 4. Pancreatic enzymes help break down carbohydrates, and bile breaks down fat. TEST-TAKING HINT: Remember: Enzymes break down other foods and the names end in -ase. The test taker must know the normal function of organs to identify correct answers.
The nurse is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering? 1. Pancreatic enzymes to the client who has finished breakfast. 2. The pain medication, morphine, to the client who has a respiratory rate of 20. 3. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L. 4. The beta blocker to the client who has an apical pulse of 68 bpm.
ANSWER: 1. 1. Pancreatic enzymes must be administered with meals to enhance the digestion of starches and fats in the gastrointestinal (GI) tract. 2. The client's respiratory rate is within normal limits; therefore, the morphine should be administered to the client who is having pain. 3. This is a normal potassium level; therefore, the nurse does not need to question administering this medication. 4. The apical pulse is within normal limits; therefore, the nurse should not question administering this medication. TEST-TAKING HINT: The test taker must determine if the assessment data provided in the option are abnormal, unexpected, or life-threatening to warrant questioning the administration of the medication.
The nurse identifies a concept of hematologic regulation for a client diagnosed with leukemia. Which clinical manifestations support the concept? 1. The client has petechiae on the trunk and extremities. 2. The client complains of pain and swelling in the joints. 3. The client has an Hbg of 9.7 and Hct of 32%. 4. The client complains of a headache and slurred speech.
ANSWER: 1. 1. Petechiae indicate a lack of clotting ability caused by decreased production of platelets. 2. Pain and joint swelling could indicate several different disease processes. 3. The H&H are low but not indicative of leukemia. 4. A headache and slurred speech could indicate a cerebrovascular accident (CVA) or other disease processes. TEST-TAKING HINT: The test taker must be aware of the cause of physiological changes in the body in order to answer this option. Platelets are produced by the bone marrow and a deficient number results in bleeding (small pinpoint areas of bleeding appear on the body).
Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)? 1. Fever, cough, and shortness of breath. 2. Oral thrush, esophagitis, and vaginal candidiasis. 3. Abdominal pain, diarrhea, and weight loss. 4. Painless violet lesions on the face and tip of nose.
ANSWER: 1. 1. Pneumocystis pneumonia (PCP) occurs in approximately 75% to 80% of clients diagnosed with AIDS. Signs/symptoms of it include fever, cough, and shortness of breath. 2. This is an opportunistic infection, but it is not the most common infection. 3. These are signs/symptoms of Mycobacterium avium complex (MAC), which affects up to 25% of client's with AIDS, but it is not the most common opportunistic infection. 4. These are signs/symptoms of Kaposi's sarcoma, which is the most common cancer associated with AIDS; it is not an infectious disease.
The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? 1. Explain it will take up to a month for symptoms of hyperthyroidism to subside. 2. Teach the iodine therapy will have to be tapered slowly over one (1) week. 3. Discuss the client will have to be hospitalized during the radioactive therapy. 4. Inform the client after therapy the client will not have to take any medication.
ANSWER: 1. 1. Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached. 2. A single dose of radioactive iodine therapy is administered; the dosage is based on the client's weight. 3. The colorless, tasteless radioiodine is administered by the radiologist, and the client may have to stay up to two (2) hours after the treatment in the office. 4. If too much of the thyroid gland is destroyed by the radioactive iodine therapy, the client may develop hypothyroidism and have to take thyroid hormone the rest of his or her life. TEST-TAKING HINT: Some questions require the test taker to be knowledgeable of the information, especially medical treatments, and there are no specific hints to help the test taker answer the question
The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement? 1. Keep fresh flowers and raw vegetables out of the client's room. 2. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs. 3. Encourage the client to perform active range of motion. 4. Teach the client about the cardiovascular medications.
ANSWER: 1. 1. Raw fruits and vegetables and fresh flowers can harbor parasites and bacteria and should be kept out of the client's room. 2. This addresses the concept of functional ability, not immunity. 3. This addresses the concept of functional ability, not immunity. 4. This addresses the concept of perfusion, not immunity. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data unexpected for the disease process. Respiratory problems are high priority according to Maslow and often warrant immediate intervention
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body
ANSWER: 1. 1. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time. 2. "Eradicated" means to be completely cured or done away with. HIV cannot be eradicated. 3. The HIV virus originated in the green monkey, in which it is not deadly. HIV in humans replicates readily using the CD4 cells as reservoirs. 4. The HIV virus uses the CD4 cells of the immune system as reservoirs to replicate itself. TEST-TAKING HINT: If the test taker is not aware of the definition of a word, the individual monitoring the test may be able to define the word, but this is not possible on the NCLEX-RN examination. Of the answer options, option "1" has the most important information regarding prognosis and potential spread to noninfected individuals.
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.
ANSWER: 1. 1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions. 2. Muscle spasticity occurs in MS, and bradykinesia occurs in Parkinson's disease. 3. Hirsutism is an overgrowth of hair. Spotty areas of alopecia occur in SLE, and clubbing of the fingers occurs in chronic pulmonary or cardiac diseases. 4. Weight loss and fatigue are experienced by clients diagnosed with SLE. TEST-TAKING HINT: The test taker must know the signs and symptoms of disease processes.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP? 1. Assist the client with abdominal pain to turn to the side and flex the knees. 2. Monitor the Jackson Pratt drainage tube to ensure it is draining properly. 3. Check to see if the client is sleeping after pain medication is administered. 4. Empty the bedside commode of the client who has been having melena.
ANSWER: 1. 1. The UAP can help a client to turn to the side and assume the fetal position, which decreases some abdominal pain. 2. Monitoring a Jackson Pratt drain is a highlevel nursing intervention, which the UAP is not qualified to implement. 3. Evaluation of the effectiveness of a prn medication must be done by the nurse. 4. The nurse should empty the bedside commode to determine if the client is continuing to pass melena (blood in the stool). TEST-TAKING HINT: There are basic rules to delegation. The nurse cannot delegate assessment, teaching, evaluation, medications, unstable clients, or situations requiring nursing judgment.
The client's CBC indicates an RBC 6 (× 10^6 )/mm3 , Hb 14.2 g/dL, Hct 42%, and platelets 69 (× 10^3 )/mm3 . Which intervention should the nurse implement? 1. Teach the client to use a soft-bristle toothbrush. 2. Monitor the client for elevated temperature. 3. Check the client's blood pressure. 4. Hold venipuncture sites for one (1) minute
ANSWER: 1. 1. The client has a low platelet count (thrombocytopenia) and should be on bleeding precautions, such as using a softbristle toothbrush. 2. Monitoring for a fever, a sign of infection, would be an intervention for low WBCs. 3. Assessing the blood pressure is not indicated for any of the blood cell count abnormalities. 4. Holding the venipuncture site would be done for a minimum of five (5) minutes.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
ANSWER: 1. 1. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat. 2. Standard Precautions are used for clients diagnosed with AIDS, the same as for every other client. 3. The nurse should check the orders but not before assessing the client. 4. The client will probably be placed on total parenteral nutrition and will need to be taught these things, but this is not the first action. TEST-TAKING HINT: Assessment is the first step in the nursing process. The nursing process is a good place to start when setting priorities for the nurse's actions.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? 1. Discuss ways to help prevent choking episodes. 2. Explain how to care for a client on a ventilator. 3. Teach how to perform passive range-ofmotion exercises. 4. Demonstrate how to care for the client's feeding tube
ANSWER: 1. 1. The client is at risk for choking; knowing specific measures to help the client helps decrease the client's, as well as the significant other's, anxiety and promotes confidence in managing potential complications. 2. Clients diagnosed with MG may end up on a ventilator at the end stage of the disease, but these clients would not be cared for at home; this would be a very unusual situation. 3. The client should be encouraged to perform active range-of-motion exercises, but the most important intervention is treating choking episodes. 4. The client with MG doesn't necessarily have a feeding tube, and this information is not in the stem. TEST-TAKING HINT: The test taker should only consider the information in the stem of the question, which causes the test taker to eliminate option "4." If the test taker could not decide between options "1" and "3," the test taker should apply Maslow's hierarchy of needs; airway is priority.
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement? 1. Assess for cerebrovascular symptoms. 2. Keep the head of the bed elevated. 3. Order a 2,000-mg sodium diet. 4. Apply antiembolism stockings.
ANSWER: 1. 1. The client is at risk for forming clots, which can lead to cerebrovascular accidents (stroke). 2. There is no reason to keep the HOB elevated. 3. A low-sodium diet is for fluid volume overload, not dehydration. 4. Antiembolism hose are not needed for sickle cell crisis. TEST-TAKING HINT: The test taker must be aware of the cause of physiological changes in the body. The sickling of cells occurs when the client experiences lack of oxygen to the cells or becomes dehydrated. The results of clot formation can lead to strokes and other cerebrovascular accidents.
Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)? 1. Identify specific measures to help avoid fatigue and undue stress. 2. Instruct the client to pad bony prominences, especially the sacral area. 3. Discuss complementary therapies to help manage pain. 4. Explain the possibility of having a splenectomy to help control the symptoms.
ANSWER: 1. 1. The client must use measures to help prevent fatigue, which increases the depletion of acetylcholine and causes muscle weakness. 2. The client with MG is not on strict bedrest, and impaired skin integrity is not an expected complication of this disease process, especially in the early stages. 3. Pain is not an expected complaint of clients diagnosed with MG. 4. A thymectomy, not a splenectomy, may be recommended. Approximately 75% of clients with MG have dysplasia of the thymus gland.
The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level
ANSWER: 1. 1. The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary. 2. Sitting in the waiting area could cause the client to go into a coma and die. 3. A blood transfusion is not an appropriate intervention for this client. 4. Laboratory specimens are not priority and calcium is not a problem in clients with Addison's disease. TEST-TAKING HINT: This client is weak, lethargic, and forgetful, indicating a diminished level of consciousness. The nurse should choose an action addressing the problem
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.
ANSWER: 1. 1. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes insipidus is a totally separate disease process. 2. Serum calcium is not affected by diabetes insipidus. 3. Urine glucose is monitored for diabetes mellitus. 4. White blood cells in the urine indicate the presence of a urinary tract infection. TEST-TAKING HINT: The test taker should not confuse diabetes insipidus and diabetes mellitus.
The client is diagnosed with cancer of the head of the pancreas. Which signs and symptoms should the nurse expect to assess? 1. Clay-colored stools and dark urine. 2. Night sweats and fever. 3. Left lower abdominal cramps and tenesmus. 4. Nausea and coffee-ground emesis.
ANSWER: 1. 1. The client will have jaundice, clay-colored stools, and tea-colored urine resulting from blockage of the bile drainage. 2. Night sweats and fevers are associated with lymphoma. 3. Left lower abdominal cramps are associated with diverticulitis, and tenesmus is straining when defecating. 4. Nausea and coffee-ground emesis are symptoms of gastric ulcers. TEST-TAKING HINT: The test taker should remember anatomical placement of organs. This eliminates options "3" and "4." The pancreas empties pancreatic enzymes into the small bowel in close proximity to where the common bile duct enters the intestine to aid in the digestion of carbohydrates and fats.
The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis? 1. The client's vital signs are: T 99.0, P 110, R 26, and BP 145.80. 2. The client complains of constipation and being constantly cold. 3. The client has an intake of 780 mL and output of 256 mL. 4. The client complains of a headache and has projectile vomiting.
ANSWER: 1. 1. The client with hypothyroidism has slowed body processes so the temperature, pulse, and BP would be brady or lower. 2. All body processes slow as a result of decreased thyroid production. The client will be constipated, cold, have thicker skin, low temperature, and bradycardia. 3. The intake and output would not be affected. 4. Hypothyroidism does not cause headaches or projectile vomiting. TEST-TAKING HINT: The test taker must know basic signs and symptoms. The word "hypo" in the name of the disease would help the test taker eliminate option "1."
The nurse writes a client problem of "activity intolerance" for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Pace activities according to tolerance. 2. Provide supplements high in iron and vitamins. 3. Administer packed red blood cells. 4. Monitor vital signs every four (4) hours
ANSWER: 1. 1. The client's problem is activity intolerance, and pacing of activities directly affects the diagnosis. 2. This is an appropriate intervention for iron or vitamin deficiency, but it is not for activity intolerance. 3. This may be done but not specifically for the diagnosis. 4. This would not help activity intolerance. TEST-TAKING HINT: The test taker should read the stem closely and choose only interventions that directly affect an activity. The word "activity" is in the diagnosis and in the correct answer. When an answer option matches the stem, it is a good choice.
The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on
ANSWER: 1. 1. The exact cause of MS is not known, but there is a theory stating a slow virus is partially responsible. A failure of a part of the immune system may also be at fault. A genetic predisposition involving chromosomes 2, 3, 7, 11, 17, 19, and X may be involved. 2. There is some evidence supporting a genetic component involved in developing MS. 3. A specific gene has not been identified to know if the gene is recessive or dominant. 4. The X chromosome, not the Y chromosome, may be involved. TEST-TAKING HINT: Option "2" has the word "no" in it. Unless the test taker has absolute knowledge this is true, then an absolute word such as "no," "never," "all," or "always" should rule out the option.
The 33-year-old client diagnosed with Stage IV Hodgkin's lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client? 1. Instruct the client to continue scheduled screenings for cancer. 2. Discuss the need for follow-up appointments every five (5) years. 3. Teach the client that the cancer risk is the same as for the general population. 4. Have the client talk with the family about funeral arrangements.
ANSWER: 1. 1. The five (5)-year mark is a time for celebration for clients diagnosed with cancer, but the therapies can cause secondary malignancies and there may be a genetic predisposition for the client to develop cancer. The client should continue to be tested regularly. 2. Follow-up appointments should be at least yearly. 3. The client's risk for developing cancer has increased as a result of the therapies undergone for the lymphoma. 4. This client is in remission, and death is not imminent. TEST-TAKING HINT: The test taker should look at the time frames in the answer options. It would be unusual for a client to be told to have a checkup every five (5) years. Option "4" can be eliminated by the stem, which clearly indicates the client is progressing well at the five (5)-year remission mark.
The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement? 1. Check the posterior neck for bleeding. 2. Assess the client for the Chvostek's sign. 3. Monitor the client's serum calcium level. 4. Change the client's surgical dressing
ANSWER: 1. 1. The incision for a thyroidectomy allows the blood to drain dependently by gravity to the back of the client's neck. Therefore, the nurse should check this area for hemorrhaging, which is a possible complication of any surgery. 2. The Chvostek's sign indicates hypocalcemia, which is too early to assess for in this client. 3. Accidental removal of or damage to the parathyroid glands will not decrease the calcium level for at least 24 hours. 4. Surgeons prefer to change the surgical dressing for the first time.
The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas (ABG) results.
ANSWER: 1. 1. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart. 2. Regular insulin, not intermediate, is the insulin of choice because of its quick onset and peak in two (2) to four (4) hours. 3. Blood glucometer checks are done every one (1) hour or more often in clients with HHNS who are receiving regular insulin drips. 4. Arterial blood gases are not affected in HHNS because there is no breakdown of fat resulting in ketones leading to metabolic acidosis. TEST-TAKING HINT: The test taker should eliminate option "3" based on the word "daily." In the ICU with a client who is very ill, most checks are more often than daily. Remember to look at adjectives; "intermediate" in option "2" is the word eliminating this as a possible correct answer.
The nurse is caring for a client diagnosed with Systemic Inflammatory Response syndrome after an extensive abdominal surgery. Which nursing interventions could prevent the development of Multi Organ Dysfunction Syndrome (MODS)? 1. Place the client on strict intake and output. 2. Administer pain medication via patientcontrolled analgesia. 3. Keep the head of the bed elevated at all times. 4. Practice therapeutic communication.
ANSWER: 1. 1. The intake and output will alert the nurse to potential renal and cardiovascular involvement in the inflammatory response system. 2. Pain control would be under a pain or comfort concept, not immunity. 3. Keeping the head of the bed elevated is to allow for lung expansion, not to decrease an immune system response, and at "all times" is not realistic. 4. Therapeutic communication addresses a psychosocial problem, not a physiological one. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data unexpected for the disease process. The test taker should be very careful about choosing an option with an absolute in the wording. "Every" means there is no exception to the situation that might apply.
The nurse and the licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN? 1. The client newly diagnosed with chronic lymphocytic leukemia. 2. The client who is four (4) hours postprocedure bone marrow biopsy. 3. The client who received two (2) units of (PRBCs) on the previous shift. 4. The client who is receiving multiple intravenous piggyback medications
ANSWER: 1. 1. The newly diagnosed client will need to be taught about the disease and about treatment options. The registered nurse cannot delegate teaching to an LPN. 2. This client is postprocedure and could be cared for by the LPN. 3. This client has already received the blood products; this client requires routine monitoring, which the LPN could perform. 4. The LPN can administer antibiotic medications. TEST-TAKING HINT: The nurse cannot assign assessment, teaching, or evaluation. The clients in options "2," "3," and "4" are stable or have expected situations.
The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules? 1. The nodules indicate a rapidly progressive destruction of the affected tissue. 2. The nodules are small amounts of synovial fluid that have become crystallized. 3. The nodules are lymph nodes which have proliferated to try to fight the disease. 4. The nodules present a favorable prognosis and mean the client is better
ANSWER: 1. 1. The nodules may appear over bony prominences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease. 2. There is a proliferation of the synovial membrane in RA, which leads to the formation of pannus and the destruction of cartilage and bone, but synovial fluid does not crystallize to form the nodules. 3. The nodules are not lymph nodes. Lymph nodes may enlarge in the presence of disease, but they do not proliferate (multiply). 4. The nodes indicate a progression of the disease, not an improving prognosis. TEST-TAKING HINT: The test taker can rule out option "3" with knowledge of anatomy or physiology. Lymph nodes do not multiply; they do form chains throughout the body
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose (IVP). 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level
ANSWER: 1. 1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client. 2. The health-care provider may or may not need to be notified, but this is not the first intervention. 3. The client should be left in the client's room, and 50% dextrose should be administered first. 4. The serum glucose level requires a venipuncture, which will take too long. A blood glucometer reading may be obtained, but the nurse should first treat the client, not the machine. The glucometer only reads "low" after a certain point, and a serum level is needed to confirm exact glucose level. TEST-TAKING HINT: The question is requesting the test taker to select which intervention should be implemented first. All four options could be possible interventions, but only one (1) intervention should be implemented first. The test taker should select the intervention directly treating the client; do not select a diagnostic test.
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have laboratory work done
ANSWER: 1. 1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse. 2. The nurse should notify the charge nurse after flushing the area and trying to get it to bleed. 3. This should be done within four (4) hours of the exposure, not before trying to rid the body of the potential infection. 4. This is done at three (3) months and six (6) months after initial exposure. TEST-TAKING HINT: In questions asking the test taker to select the first action, all the options could be appropriate interventions, but the test taker must decide which has the most immediate need and the most benefit. Directly caring for the wound is of the most benefit.
The client diagnosed with hyperthyroidism is complaining of being hot and cannot sit still. Which should the nurse do based on the assessment? 1. Continue to monitor the client. 2. Have the UAP take the client's vital signs. 3. Request an order for a sedative. 4. Insist the client lie down and rest.
ANSWER: 1. 1. The nurse should continue to monitor the client. The behavior is expected for a client with hyperthyroidism. 2. The client's vital signs are not indicated because of the symptoms. 3. This behavior is expected for a client with hyperthyroidism. A sedative is not needed. 4. The nurse cannot insist the client do anything. TEST-TAKING HINT: The test taker must know expected symptoms for disease processes.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse? 1. Encourage the therapy if it is not contraindicated by the medical regimen. 2. Tell the client only the health-care provider should discuss this with him. 3. Ask how his significant other feels about this deviation from the medical regimen. 4. Suggest the client research an investigational therapy instead.
ANSWER: 1. 1. The nurse should listen without being judgmental about any alternative therapy the client is considering. Alternative therapies, such as massage and relaxation, are frequently beneficial and enhance the medical regimen. 2. The nurse can discuss alternative therapy with the client. 3. This is not addressing the client's concern of using alternative treatment. 4. Investigational therapies are treatments that may have efficacy if proved by scientific methods. It is the health-care provider's responsibility to discuss these therapies with the client. TEST-TAKING HINT: Two options—"3" and "4"—don't address the issue. The answer must address the client's concern.
The client diagnosed with sickle cell disease is experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement? 1. Maintain IV fluids and administer pain medication prn. 2. Encourage frequent ambulation in the hallways. 3. Administer oxygen via nasal cannula at 10 LPM. 4. Monitor the client's red blood cell count every four (4) hours.
ANSWER: 1. 1. The nurse's priority is to treat the cause of the crisis and the pain. 2. During a crisis and the administration of narcotic medication frequent ambulation is not encouraged. 3. The client has the ability to oxygenate the cells; if used then the rate would not be at 10 LPM. 4. The client's RBCs would be monitored but not every four (4) hours. TEST-TAKING HINT: The test taker must be aware of the cause of physiological changes in the body. The nurse must treat a client's discomfort if the cause of the pain is known and no other complications are occurring.
Which area of the body should the nurse assess to identify symptoms to support the early diagnosis of Guillain-Barré syndrome? 1. Face. 2. Chest. 3. Abdomen. 4. Ankle.
ANSWER: 1. 1. The presenting symptom of a client with Guillain-Barré syndrome is ascending paralysis starting in the lower extremities. 2. Abdominal symptoms are not found early in the diagnosis. 3. Chest symptoms are not found early in the diagnosis. 4. Head symptoms are not found early in the diagnosis.
The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale skin, and diaphoresis. Which assessment data warrant immediate intervention? 1. The vital signs are T 98.6° F, P 116, R 28, and BP 88/62. 2. The client is allergic to multiple antibiotic medications. 3. The client has a history of receiving chemotherapy. 4. ABGs are pH 7.35, Pco2 44, Hco3 22, Pao2 92.
ANSWER: 1. 1. The pulse of 116 and BP of 88/62 in addition to the other symptoms indicate the client is in shock. This is an emergency situation. 2. The client is in shock; allergies to medications are not the most important thing. 3. This may be the cause of the anemia, and complications from the chemotherapy may be causing the shock, but the priority intervention is to treat the shock, regardless of the cause. 4. These are normal blood gases, so no immediate intervention regarding arterial blood gases is needed.
The nurse is admitting a 24-year-old African American female client with a diagnosis of ruleout anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 5′5′′; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? 1. Vitamin B12 deficiency. 2. Folic acid deficiency. 3. Iron deficiency. 4. Sickle cell anemia.
ANSWER: 1. 1. The rugae in the stomach produce intrinsic factor, which allows the body to use vitamin B12 from the foods eaten. Gastric bypass surgery reduces the amount of rugae drastically. Clients develop pernicious anemia (vitamin B12 deficiency). Other symptoms of anemia include dizziness and the tachycardia and dyspnea listed in the stem. 2. Folic acid deficiency is usually associated with chronic alcohol intake. 3. Iron deficiency is the result of chronic blood loss or inadequate dietary intake of iron. 4. Sickle cell anemia is associated with African Americans, but the symptoms and history indicate a different anemia. TEST-TAKING HINT: The question did not give a lifetime history of anemia, which would be associated with sickle cell disease. The stem related a history of obesity and surgery. The test taker should look for an answer related to intake of vitamins and minerals. A review of the anatomy of the stomach is the key to the question
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.
ANSWER: 1. 1. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant. 2. This is an appropriate goal for a knowledge deficit nursing diagnosis. Noncompliance is not always the result of knowledge deficit. 3. The nurse is implementing an intervention, and the question asks for a goal which addresses the problem of "high risk for hyperglycemia." 4. The question asks for a short-term goal and this is an example of a long-term goal. TEST-TAKING HINT: Remember, the nursing diagnosis consists of a problem related to an etiology. The goals must address the problem and the interventions must address the etiology. The test taker should always remember a short-term goal is usually a goal met during the hospitalization, and the longterm goal may take weeks, months, or even years.
The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site. 2. Sudden onset of chest pain and frothy sputum. 3. Foul-smelling, concentrated urine. 4. A reddened, inflamed central line catheter site.
ANSWER: 1. 1. The signs/symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues. 2. Chest pain and frothy sputum may indicate a pulmonary embolus. 3. Foul-smelling, concentrated urine may indicate dehydration or urinary tract infection. 4. A reddened, inflamed central line catheter site indicates a possible infection. TEST-TAKING HINT: If the test taker realized that coagulation deals with blood, then the only answer option that addresses any type of bleeding is option "1."
Which laboratory data indicate to the nurse the client's pancreatitis is improving? 1. The amylase and lipase serum levels are decreased. 2. The white blood cell (WBC) count is decreased. 3. The conjugated and unconjugated bilirubin levels are decreased. 4. The blood urea nitrogen (BUN) serum level is decreased.
ANSWER: 1. 1. These laboratory data are used to diagnose and monitor pancreatitis because amylase and lipase are the enzymes produced by the pancreas. 2. Pancreatitis is not an infection of the pancreas resulting from bacteria; such an infection causes an elevation in the WBCs. 3. Bilirubin is used to monitor liver problems. 4. BUN monitors kidney function
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority? 1. Ineffective breathing pattern. 2. Knowledge deficit. 3. Anaphylaxis. 4. Ineffective coping.
ANSWER: 1. 1. This can be an independent or collaborative nursing problem. It is an airway problem and has priority. 2. Knowledge deficit is not a priority over the client with breathing problems. 3. Anaphylaxis is a collaborative problem. The nurse will need to start IVs, administer medications, and possibly place the client on a ventilator if the client is to survive. 4. Ineffective coping is a psychosocial problem; it does not have priority over breathing. TEST-TAKING HINT: The test taker must apply some problem-solving/decision-making standard. In this case Maslow's hierarchy of needs is a good option. Airway has priority.
The charge nurse is reviewing the laboratory values on clients on a medical floor. Which laboratory data should be reported to the health-care provider (HCP) immediately? (Normal values: RBCs (x 10^6): Male 4.7-6.1, Female 4.2-5.4. Hemoglobin: Male 13.5-17.5 g/dL, Female 1.5-15.5 g/dL). Hematocrit: Male 40%-52%, Female 36%-48%). Platelets (x10^3): 150-400. WBC's (x 10^3): 4.5-11) 1. RBCs (x 10^6): 4.7. Hemoglobin: 12.8. Hematocrit: 35. Platelets (x10^3): 39. WBC's (x 10^3): 10.8. 2. RBCs (x 10^6): 4. Hemoglobin: 10.6. Hematocrit: 30.4. Platelets (x10^3): 148. WBC's (x 10^3): 4. 3. RBCs (x 10^6): 7.2. Hemoglobin: 18.9. Hematocrit: 56. Platelets (x10^3): 125. WBC's (x 10^3): 4. RBCs (x 10^6): 5.5. Hemoglobin: 15. Hematocrit: 45. Platelets (x10^3): 45. WBC's (x 10^3): 6.3.
ANSWER: 1. 1. This client has a critically low platelet count, even though the other laboratory values are in a normal or nearnormal range. This client is at risk for hemorrhaging. 2. This client has low values but not dangerously so. The HCP can be shown the results on rounds. 3. This client's laboratory values are high, but not dangerously so; these can be shown to the HCP on rounds. 4. This client has normal laboratory values
The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation? 1. The client with an abdominal peritoneal resection who has a colostomy. 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome. 3. The client with a head injury developing disseminated intravascular coagulation. 4. The client admitted with a gunshot wound who has an H&H of 7 and 22.
ANSWER: 1. 1. This is a major surgery but has a predictable course with no complications identified in the stem, and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this client. 2. Acute respiratory distress syndrome (ARDS) is a potentially life-threatening complication and should be assigned to a more experienced nurse. 3. Disseminated intravascular coagulation (DIC) is life threatening. The client is unstable and should be assigned to a more experienced nurse. 4. This client is experiencing hypovolemia, which means hemorrhaging and potential emergency surgery; therefore, this client should be assigned to a more experienced nurse. TEST-TAKING HINT: The test taker must think about what type of client a new graduate should be assigned. The least critical client is the correct choice
The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises
ANSWER: 1. 1. This medication promotes muscle contraction, which improves muscle strength, which, in turn, allows the client to perform ADLs without assistance. 2. This medication does not affect secretions of the eye. 3. This medication does not help with the digestion of food. 4. This medication does not help with pain; clients with MG do not have muscle pain. TEST-TAKING HINT: The test taker must know about the disease process to be able to answer this question. Remember, when answering pharmacology questions, the effectiveness of the medication is based on what sign/symptom the client is experiencing.
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Administer the medication 30 minutes prior to meals. 2. Instruct the client to take with eight (8) ounces of water. 3. Explain the importance of sitting up for one (1) hour after taking medication. 4. Assess the client's blood pressure prior to administering medication
ANSWER: 1. 1. This medication will increase muscle strength to help enhance swallowing and chewing during meals. 2. There is no need for the client to take this medication with eight (8) ounces of water. 3. The client does not have to sit up after taking this medication. 4. These assessment data would not cause the nurse to question administering this medication. TEST-TAKING HINT: There are very few medications given specifically on time, but this medication is one of them. The blood pressure is checked prior to administering antihypertensive medications
The nurse writes the client problem of "altered sexual functioning" for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented? 1. Encourage the couple to explore alternative ways of maintaining intimacy. 2. Make an appointment with a psychotherapist to counsel the couple. 3. Explain daily exercise will help increase libido and sexual arousal. 4. Discuss the importance of keeping physically calm during sexual intercourse.
ANSWER: 1. 1. This will assist the client and significant other to maintain a close relationship without putting undue pressure on the client. 2. This is a real physical problem, not a psychological one. 3. The problem is impotence, not libido. 4. The problem is not psychosocial. It is a physical problem, and staying calm will not help. TEST-TAKING HINT: The test taker must differentiate physical and psychological problems.
The nurse is teaching the client diagnosed with diabetes. Which should the nurse teach to limit the complications of diabetes? 1. Teach the client to keep the blood glucose under 140 mg/dL. 2. Demonstrate how to test the urine for ketones. 3. Instruct the client to apply petroleum jelly between the toes. 4. Allow the client to eat meals as desired and then take insulin.
ANSWER: 1. 1. To limit the complications of diabetes the client should keep the blood glucose levels under 140 mg/dL. This can be done with medications, diet, and exercise. Self glucose monitoring allows the client to monitor the glucose levels. 2. Testing for urine ketones will not help to keep the blood glucose level controlled. 3. Petroleum jelly is rubbed on the feet but not between the toes. 4. The client should administer sliding-scale insulin when needed but not eat whatever the client wishes. The client should still attempt to control the amount of carbohydrates. TEST-TAKING HINT: The nurse must recommend measures to control or treat disease processes.
The female client recently diagnosed with Hodgkin's lymphoma asks the nurse about her prognosis. Which is the nurse's best response? 1. Survival for Hodgkin's disease is relatively good with standard therapy. 2. Survival depends on becoming involved in an investigational therapy program. 3. Survival is poor, with more than 50% of clients dying within six (6) months. 4. Survival is fine for primary Hodgkin's, but secondary cancers occur within a year.
ANSWER: 1. 1. Up to 90% of clients respond well to standard treatment with chemotherapy and radiation therapy, and those who relapse usually respond to a change of chemotherapy medications. Survival depends on the individual client and the stage of disease at diagnosis. 2. Investigational therapy regimens would not be recommended for clients initially diagnosed with Hodgkin's disease because of the expected prognosis with standard therapy. 3. Clients usually achieve a significantly longer survival rate than six (6) months. Many clients survive to develop long-term secondary complications. 4. Secondary cancers can occur as long as 20 years after a remission of the Hodgkin's disease has occurred. TEST-TAKING HINT: The test taker must have a basic knowledge of the disease process but could rule out option "2" based on the word "investigational."
The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care? 1. The client will maintain vital signs within normal limits during the next 24 hours. 2. The client's urine output will be maintained to achieve output of 600 mL in the next 24 hours. 3. The client will have elevated ALT, AST, and GGT liver enzymes within the next 24 hours. 4. The client's blood glucose reading will be 200 to 240 mg/dL for the next 24 hours.
ANSWER: 1. 1. Vital signs within normal limits indicate the client is stable and is a realistic measurable goal. 2. Six hundred mL of urine in 24 hours averages 25 mL per hour, an inadequate amount of urine to indicate renal perfusion (30 mL per hour). 3. Liver enzymes indicating proper liver function would be to maintain enzymes within normal limits, not elevated. 4. These blood glucose readings are not within normal limits, indicating the need for intervention to bring the glucose down to a normal range with sliding scale. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data expected for the stabilization or improvement of the client. The test taker should work out the math to determine if the client's renal output falls within expected guidelines for adequate renal perfusion.
The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)? 1. The client's CD4 count is 189. 2. The client has an Hgb of 9.4 and Hct of 29.1. 3. The client's chest x-ray show infiltrates. 4. The client complains of a headache unrelieved by Tylenol.
ANSWER: 1. The diagnosis of AIDS is determined by predefined criteria: A CD4 count less than 200; a fungal infection candidiasis of the bronchi, lungs, esophagus or Pneumocystis jiroveci pneumonia (PJP); disseminated extrapulmonary coccidioidomycosis; disseminated extrapulmonary histoplasmosis; a viral issue, cytomegalovirus (CMV) disease other than liver, spleen, or nodes; CMV retinitis herpes simplex virus with chronic ulcers or bronchitis, pneumonia, or esophagitis; progressive multifocal leukoencephalopathy, extrapulmonary Cryptococcus; protozoal toxoplasmosis of the brain, chronic intestinal cryptosporidiosis; bacterial Mycobacterium avium complex (MAC) or Mycobacterium kansasii; or one of the following opportunistic cancers: invasive cervical cancer, Kaposi sarcoma, Burkitt's lymphoma, immunoblastic lymphoma, and primary lymphoma of the brain. TEST-TAKING HINT: This question is asking the test taker to identify the criteria of diagnosing AIDS, which is long and complicated. The test taker should remember any issue that occurs as a result of a failing immune system, opportunistic infections, and cancers.
The client had a total pancreatectomy and splenectomy for cancer of the body of the pancreas. Which discharge instructions should the nurse teach? Select all that apply. 1. Keep a careful record of intake and output. 2. Use a stool softener or bulk laxative regularly. 3. Use correct insulin injection technique. 4. Take the pain medication before the pain gets too bad. 5. Sleep with the head of the bed on blocks.
ANSWER: 2, 3, 4. 1. The client is being discharged. There is no need for the client to continue recording intake and output at home. 2. The client has undergone a radical and extensive surgery and will need narcotic pain medication, and a bowel regimen should be in place to prevent constipation. 3. Removal of the pancreas will create a diabetic state for the client. The client will need insulin and pancreatic enzyme replacement. 4. The client should not allow pain to reach above a "5" before taking pain medication or it will be more difficult to get the pain under control. 5. There is no reason for the client to sleep with the head of the bed elevated. TEST-TAKING HINT: The test taker might choose option "3" by remembering the pancreas secretes insulin. Option "4" is taught to all clients in pain.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client. 3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing the gums.
ANSWER: 2, 3, 4. 1. The client should use an electric razor, which minimizes the opportunity to develop superficial cuts that may result in bleeding. 2. Enemas, rectal thermometers, and intramuscular injections can pose a risk of tissue and vascular trauma that can precipitate bleeding. 3. Even minor trauma can lead to serious bleeding episodes; safer activities such as swimming or golf should be recommended. 4. Direct pressure occludes bleeding vessels. 5. There is no reason why the client can't floss the teeth. TEST-TAKING HINT: This type of question requires the test taker to select all interventions that apply. Bleeding is the priority concern with hemophilia A, so all interventions should be based around activities that can potentially cause bleeding and ways to treat bleeding.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply. 1. The client is pregnant. 2. The client is an intravenous drug abuser. 3. The client has multiple sexual partners. 4. The client does not have available health care. 5. The client does not have adequate bathroom facilities. 6. The client spends her money on nonessential items
ANSWER: 2, 3. 1. Pregnancy is a co-related condition but being pregnant is not an antecedent for having an HIV infection. 2. Intravenous drug use does create a risk for becoming HIV positive. When the drug user shares the needle used to inject the drugs, then body fluids are directly injected into the next person to use the syringe and needle. 3. Unprotected sex involves sharing of body fluids, and even if using a condom, there is no guarantee the condom does not break, resulting in shared fluids. The more partners, the greater the risk. 4. Lack of available health care may delay treatment but is not a risk factor for developing an HIV infection. 5. Adequate bathroom facilities is not an antecedent for HIV infections. The HIV virus dies six (6) minutes outside of a host body or growth environment (petri dish). 6. Many people spend their money on nonessential items; it is not an antecedent for HIV infection. TEST-TAKING HINT: The test taker should answer each option as a true/false question. One option does not eliminate another
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make? 1. "Why are you crying? The medication will help the disease." 2. "You seem upset. I will sit down and we can talk for awhile." 3. "Multiple sclerosis is a disease that has good times and bad times." 4. "I will have the chaplain come and stay with you for a while."
ANSWER: 2. 1. "Why" is requesting an explanation, and the client does not owe the nurse an explanation. 2. This is stating a fact and offering self. Both are therapeutic techniques for conversations. 3. The client did not ask about the nature of MS. The client needs to be able to verbalize feelings. 4. This is "passing the buck." Therapeutic communication is an integral part of nursing. TEST-TAKING HINT: The question is asking for a therapeutic response. Therapeutic responses address feelings.
The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive? 1. Bone marrow transplant. 2. Splenectomy. 3. Frequent blood transfusions. 4. Liver biopsy.
ANSWER: 2. 1. A bone marrow transplant is a treatment option for aplastic anemia and some clients with thalassemia, but not for spherocytosis. 2. Hereditary spherocytosis is a relatively common hemolytic anemia (1:5,000 people) characterized by an abnormal permeability of the red blood cell, which permits it to become spherical in shape. The spheres are then destroyed by the spleen. A splenectomy is the treatment of choice. 3. The client may require blood transfusions, but preventing the destruction of RBCs by the spleen is the better option. 4. A liver biopsy will not affect the client's condition
Which sign/symptom indicates to the nurse the client is experiencing hypoparathyroidism? 1. A negative Trousseau's sign. 2. A positive Chvostek's sign. 3. Nocturnal muscle cramps. 4. Tented skin turgor.
ANSWER: 2. 1. A carpopedal spasm occurs when the blood flow to the arm is decreased for three (3) minutes with a blood pressure cuff; a positive Trousseau's sign indicates hypocalcemia, which is a sign of hypoparathyroid function. A normal Trousseau means the body is functioning as it should. 2. When a sharp tapping over the facial nerve elicits a spasm or twitching of the mouth, nose, or eyes, the client is hypocalcemic, which occurs in clients with hypoparathyroidism. This is known as a positive Chvostek's sign. 3. Muscle cramps makes the nurse suspect hypokalemia (low potassium). 4. Tented skin turgor makes the nurse suspect dehydration, which occurs with hypernatremia.
The client diagnosed with acute pancreatitis has a ruptured pseudocyst. Which procedure should the nurse anticipate the HCP prescribing? 1. Paracentesis. 2. Chest tube insertion. 3. Lumbar puncture. 4. Biopsy of the pancreas.
ANSWER: 2. 1. A paracentesis is used to remove fluid from the abdominal cavity. 2. The pancreas lies immediately below the diaphragm. When the cyst ruptures, alkaline substances in the abdomen cause fluid leaks at the esophageal diaphragmatic opening into the thorax. The fluid must be removed to prevent lung collapse. 3. Lumbar puncture is used to diagnose meningitis. 4. Biopsies are performed to confirm a diagnosis; they are not used for treatment.
Which statement indicates the female client with systemic lupus erythematosus (SLE) understands the discharge instructions? 1. "I should wear sunscreen with at least a 5 SPF." 2. "I am not going to any activities with large crowds." 3. "I should not get pregnant because I have SLE." 4. "I must avoid using hypoallergenic products."
ANSWER: 2. 1. A sunscreen with an SPF of at least 15 should be used by the client with SLE. 2. The client with SLE is at risk for infections and should avoid large crowds. 3. Pregnancy is not contraindicated in most women diagnosed with SLE. 4. The client with SLE should use hypoallergenic products and should not use irritating soaps, shampoos, or chemicals.
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment? 1. The client has a urinary output of 120 mL in two (2) hours. 2. The client has an AP of 110 and a BP of 90/60. 3. The client has clear breath sounds and an RR of 26. 4. The client has hyperactive bowel sounds.
ANSWER: 2. 1. A urinary output of greater than 30 mL/hr is within normal limits and indicates the client is responding to treatment. 2. These vital signs indicate shock, which is a medical emergency and requires immediate intervention. 3. Clear breath sounds indicate response to treatment, and although the RR is increased, this could be the result of anxiety or fear. 4. The client's bowel sounds are not significant data to determine the client's response to treatment
The nurse is assessing a client with complaints of vague upper abdominal pain worse at night but relieved by sitting up and leaning forward. Which assessment question should the nurse ask next? 1. "Have you noticed a yellow haze when you look at things?" 2. "Does the pain get worse when you eat a meal or snack?" 3. "Have you had your amylase and lipase checked recently?" 4. "How much weight have you gained since you saw an HCP?"
ANSWER: 2. 1. A yellow haze is a sign of a toxic level of digoxin, with the client seeing through the yellow haze. Seeing a yellow haze is not the same as the client having jaundice. In jaundice, the skin and sclera are yellow, signs of pancreatic cancer. 2. The abdominal pain is often made worse by eating and lying supine in clients diagnosed with cancer of the pancreas. 3. The client does not know these terms, and the HCP should check these laboratory values. 4. Clients diagnosed with cancer of the pancreas lose weight; they do not gain weight. TEST-TAKING HINT: The test taker could arrive at the correct answer by correlating words in the stem of the question and words in the answer options—the abdomen with eating and pain with pain
Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)? 1. Instill artificial tears four (4) times a day. 2. Apply moisturizers to the skin frequently. 3. Instruct the client on how to apply braces. 4. Encourage the client to decrease smoking.
ANSWER: 2. 1. Artificial tears are appropriate for a client diagnosed with Sjögren's syndrome. 2. Nursing care addresses measures to maintain skin integrity and moisturizers help prevent dryness and cracking; once skin elasticity is lost, it cannot be regained. 3. Braces are not prescribed for the client with scleroderma. 4. The client should stop smoking, not just decrease smoking, because of the vasoconstrictive effect of nicotine and the respiratory effects of the disease.
The nurse is administering morning medications. Which medications should the nurse administer question? 1. The oral carafate to a client who has not eaten breakfast. 2. The subcutaneous insulin to a client refusing blood glucose checks. 3. The levothyroxine PO to a client diagnosed with hypothyroidism. 4. The sliding scale insulin to a client whose blood glucose level is 320 mg/dL.
ANSWER: 2. 1. Carafate is a mucosal barrier agent and should be administered on an empty stomach so the medication can coat the mucosa. The nurse would not question administering this medication. 2. The nurse cannot administer slidingscale insulin without knowing the current blood glucose. The nurse should talk with the client to try and obtain the client's cooperation and, if not, then notify the HCP that the medication cannot be administered. 3. Levothyroxine is an appropriate treatment for hypothyroidism. 4. Sliding scale usually begins at 150 mg/dL; the nurse would not question administering this medication. TEST-TAKING HINT: The test taker must know normal and abnormal diagnostic laboratory values. Medications are administered per sliding scale in response to blood glucose levels. The nurse must also recognize accepted treatments for diseases.
The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple's procedure). Which nursing problem has the highest priority? 1. Anticipatory grieving. 2. Fluid volume imbalance. 3. Alteration in comfort. 4. Altered nutrition.
ANSWER: 2. 1. Clients diagnosed with cancer of the pancreas have a poor prognosis, but this is not the priority problem at this time. 2. This is a major abdominal surgery, and massive fluid volume shifts occur when this type of trauma is experienced by the body. Maintaining the circulatory system without overloading it requires extremely close monitoring. 3. Pain is a priority but not over fluid volume status. 4. Altered nutrition is an appropriate problem but not priority over fluid volume shift. The client will be NPO with a nasogastric tube to suction and will be receiving total parenteral nutrition. TEST-TAKING HINT: The nurse should identify all of the problems, but one—fluid volume imbalance—has the greatest priority because, if not addressed promptly and correctly, it could lead to severe complications.
The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective? 1. "I should decrease my intake of coffee, tea, and cola." 2. "I will eat a low-fat diet and avoid spicy foods." 3. "I will check my amylase and lipase levels daily." 4. "I will return to work tomorrow but take it easy."
ANSWER: 2. 1. Coffee, tea, and cola stimulate gastric and pancreatic secretions and may precipitate pain, so these foods should be avoided, not decreased. 2. High-fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack. 3. Amylase and lipase levels must be checked via venipuncture with laboratory tests, and there are no daily tests the client can monitor at home. 4. The client will be fatigued as a result of decreased metabolic energy production and will need to rest and not return to work immediately. TEST-TAKING HINT: The test taker should be careful with words such as "decrease" because many times the client must avoid certain foods and situations completely, not decrease the intake of them. Only a few blood studies are monitored at home on a daily basis—mainly glucose levels—which should cause the test taker to eliminate option "3."
The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
ANSWER: 2. 1. Cushing's disease is not an autoimmune problem. 2. "Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis. 3. This could be a cause for primary Cushing's syndrome. 4. There is a known reason for the client to have iatrogenic Cushing's syndrome. TEST-TAKING HINT: This question requires the test taker to know basic medical terminology
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client? 1. Determine the client's food preferences. 2. Ask the client if there is an advance directive. 3. Find out about insurance/Medicare reimbursement. 4. Explain the client should eat as much as possible.
ANSWER: 2. 1. Food preferences are important for the caregiver to know because this will be the person preparing meals for the client, but it is not the highest priority. 2. Cancer of the pancreas has a poor prognosis; the nurse should determine if the client has executed an advance directive regarding his or her wishes. 3. This is important because of payment issues, but it is not the highest priority. 4. Clients diagnosed with cancer frequently have anorexia, and explaining the client should eat does not mean the client will eat. TEST-TAKING HINT: The test taker needs to know general information about the disease process to answer this question, but option "2" is a good choice for many terminal diseases. Remember to read the questions carefully. The home health nurse is not arranging meals for the client.
The client is diagnosed with chronic myeloid leukemia and leukocytosis. Which signs/ symptoms would the nurse expect to find when assessing this client? 1. Frothy sputum and jugular vein distention. 2. Dyspnea and slight confusion. 3. Right upper quadrant tenderness and nausea. 4. Increased appetite and weight gain.
ANSWER: 2. 1. Frothy sputum and jugular vein distention are symptoms of heart failure, which could occur as a complication of anemia. 2. Clients with leukocytosis may be short of breath and somewhat confused as a result of decreased capillary perfusion to the lung and brain from excessive amounts of WBCs inhibiting blood flow through the capillaries. 3. The client may have left upper quadrant pain and tenderness from WBC infiltration of the spleen, but the client will not have right upper quadrant tenderness. 4. The client may be anorectic and lose weight.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.
ANSWER: 2. 1. Glucose is elevated in DKA; therefore, the HCP would not be replacing glucose. 2. The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia. 3. Calcium is not affected in the client with DKA. 4. The prescribed IV for DKA—0.9% normal saline—has sodium, but it is not specifically ordered for sodium replacement. This is an isotonic solution. TEST-TAKING HINT: Option "1" should be eliminated because the problem with DKA is elevated glucose, so the HCP would not be replacing it. The test taker should use physiology knowledge and realize potassium is in the cell.
The nurse is completing discharge teaching for the client diagnosed with a sickle cell crisis. The nurse recommends the client getting the flu and pneumonia vaccines. The client asks, "Why should I take those shots? I hate shots." Which statement by the nurse is the best response? 1. "These vaccines promote health in clients with chronic illnesses." 2. "You are susceptible to infections. These shots may help prevent a crisis." 3. "The vaccines will help your blood from sickling secondary to viruses." 4. "The doctor wanted to make sure that I discussed the vaccines with you.
ANSWER: 2. 1. Health promotion is important in clients with chronic illnesses, but the best answer should address the client's specific disease process, not chronic illnesses in general. 2. An individual with SCA has a reduction in splenic activity from infarcts occurring during crises. This situation progresses to the spleen no longer being able to function, and this increases the client's susceptibility to infection. 3. These vaccines do nothing to prevent sickling of the blood cells. 4. Teaching the client is an independent nursing intervention, and the nurse does not need to rely on the HCP to designate what should be taught to the client. TEST-TAKING HINT: Vaccines are recommended to clients with chronic problems to help prevent the flu and pneumonia. The test taker should see if a widely accepted concept could help answer the question and not get caught up in the client's disease process.
The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.
ANSWER: 2. 1. High-fat diets are not recommended for clients diagnosed with diabetes, and food does not have an effect on a CT scan with contrast. 2. Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems. 3. Informed consent is not required for a CT scan. The admission consent covers routine diagnostic procedures. 4. Pancreatic enzymes are administered when the pancreas cannot produce amylase and lipase, not when the beta cells cannot produce insulin. TEST-TAKING HINT: The test taker could eliminate option "1" because high-fat diets are not recommended for any client. Because the stem specifically refers to the biguanide medication and CT contrast, a good choice addresses both of these. Option "2" discusses both the medication and the test.
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.
ANSWER: 2. 1. Hypoglycemia is expected in a client with myxedema; therefore, a 74-mg/dL blood glucose level is expected. 2. A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a Pao2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention. 3. The client with myxedema coma is in an exaggerated hypothyroid state; a low pulse is expected in a client with hypothyroidism. 4. Lethargy is an expected symptom in a client diagnosed with myxedema; therefore, this does not warrant immediate intervention. TEST-TAKING HINT: The words "warrant immediate intervention" means the test taker should select an option that is abnormal for the disease process or a life-threatening symptom.
The nurse writes a diagnosis of "activity intolerance" for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Encourage isometric exercises. 2. Assist the client with activities of daily living (ADLs). 3. Provide a high-protein diet. 4. Refer to the physical therapist
ANSWER: 2. 1. Isometric exercises are bodybuilding exercises; these types of exercises would deplete the client's energy stores. 2. The client with activity intolerance will need assistance to perform activities of daily living. 3. A high-protein diet may be needed, but this does not address activity intolerance. 4. Activity intolerance is not a problem for a physical therapist. The client's blood counts must increase to increase the ability to perform activities.
Which question should the nurse ask when assessing the client for an endocrine dysfunction? 1. "Have you noticed any pain in your legs when walking?" 2. "Have you had any unexplained weight loss?" 3. "Have you noticed any change in your bowel movements?" 4. "Have you experienced any joint pain or discomfort?"
ANSWER: 2. 1. Leg pain when walking indicates intermittent claudication, which occurs with peripheral vascular disease. 2. Weight loss with normal appetite may indicate hyperthyroidism. 3. Changes in bowel movements may indicate colon cancer. 4. Joint pain indicates a musculoskeletal or degenerative joint disease.
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing
ANSWER: 2. 1. Neurological status is monitored every one (1) to two (2) hours. This client's neurological status appears intact. Clients waking up in an intensive care area may not be aware of their surroundings. 2. The output is more than double the intake in a short time. This client could be developing diabetes insipidus, a complication of trauma to the head. 3. These vital signs are within normal limits. 4. A transsphenoidal hypophysectomy is performed by surgical access above the gum line and through the nasal passage. There is no dressing. A drip pad is taped below the nares. TEST-TAKING HINT: Two (2) of the answer options contain normal data and would not warrant immediate intervention. Option "4" does not match the type of surgery.
The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client? 1. Physical therapy. 2. Occupational therapy. 3. Psychiatric counselor. 4. Home health nurse.
ANSWER: 2. 1. Physical therapists work with gait training and muscle strengthening. Generally, the physical therapist works on the lower half of the body. 2. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This is needed for the client with abnormal fingers. 3. A counselor can help the client discuss feelings about body image, loss of function, and role changes, but the best referral is to the occupational therapist. 4. The client may need a home health nurse eventually, but first the client should be assisted to remain as functional as possible. TEST-TAKING HINT: The test taker must be aware of the roles of all the health-care team members. The counselor (option "3") can be ruled out as a possible correct answer because swan-neck fingers are a physical problem.
The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage? 1. Nausea associated with cancer treatment. 2. Shortness of breath and fatigue. 3. Controlling mucositis and diarrhea. 4. The emotional aspects of having cancer
ANSWER: 2. 1. Red blood cell deficiency is anemia. The client should be taught to deal with the effects of anemia, not nausea. 2. Anemia causes the client to experience dyspnea and fatigue. Teaching the client to pace activities and rest often, to eat a balanced diet, and to cope with changes in lifestyle is needed. 3. Mucositis and diarrhea may occur with chemotherapy administration, but this client's problem is anemia. 4. All clients with cancer should be assisted to discuss the impact of cancer on their lives, but this client's problem is anemia.
The client diagnosed with sickle cell anemia asks the nurse, "Should I join the Sickle Cell Foundation? I received some information from the Sickle Cell Foundation. What kind of group is it?" Which statement is the best response by the nurse? 1. "It is a foundation that deals primarily with research for a cure for SCA." 2. "It provides information on the disease and on support groups in this area." 3. "I recommend joining any organization that will help deal with your disease." 4. "The foundation arranges for families that have children with sickle cell to meet."
ANSWER: 2. 1. Research and a search for a cure are not the missions of the Sickle Cell Foundation. 2. The foundation's mission is to provide information about the disease and about support groups in the area. This information helps decrease the client's and significant others' feelings of frustration and helplessness. 3. The nurse should not force personal thoughts on the client. The nurse should provide information and let the client make his or her own decision. This empowers the client. 4. The nurse can arrange for families to meet, but this is not the mission of the foundation. TEST-TAKING HINT: The nurse should know about organizations for specific disease processes in the geographic area, but most organizations provide information on the disease process and support groups
The nurse is explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS? 1. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident. 2. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature. 3. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria. 4. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
ANSWER: 2. 1. SIRS can occur from a burn but it can also occur as a result of any insult that has a great impact on the body systems. 2. This is the definition of SIRS. 3. SIRS can occur from an infection but it can also occur as a result of any insult that has a great impact on the body systems. 4. SIRS can occur from an allergic response but it can also occur as a result of any insult that has a great impact on the body systems. TEST-TAKING HINT: This question is a basic knowledge level definition. The test taker should not refuse to choose an option because it seems too easy.
The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.
ANSWER: 2. 1. SLE can affect any organ system, and these tests are used to determine the possibility of the liver being involved, but they are not used to diagnose SLE. 2. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody. 3. Female clients with SLE develop atherosclerosis at an earlier age, but cholesterol and lipid profile tests are not used to diagnose the disease. 4. These tests may be done to determine SLE infiltration in the kidneys but not to diagnose the disease itself. TEST-TAKING HINT: A complete metabolic panel is ordered for many different diseases; cholesterol and lipid panels are usually ordered for atherosclerosis, and BUN and glomerular filtration tests are specific to the kidneys. Options "1," "3," and "4" could be ruled out because they are specific to other diseases or not specific enough.
The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit.Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.
ANSWER: 2. 1. Serum blood work, although ordered STAT, does not have priority over oxygenation of the client. 2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness. 3. It is extremely important to initiate IV antibiotic therapy to a client diagnosed with an infection as quickly as possible, but this does not have priority over oxygen. 4. Culture specimens should be obtained prior to initiating antibiotic therapy, but oxygen administration is still the first action. TEST-TAKING HINT: Airway, breathing, and providing oxygen to the tissues is the top priority in any nursing situation. If the cells are not oxygenated, they die.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client. 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client. 3. The UAP raises the head of the bed to a high Fowler's position for a client about to eat. 4. The UAP uses a fresh plastic bag to get ice for a client's water pitcher
ANSWER: 2. 1. The UAP should wash the hands before and after client care. 2. The UAP can remove an indwelling catheter with nonsterile gloves. This is a waste of expensive equipment. The nurse is responsible for teaching UAPs appropriate use of equipment and supplies and cost containment. 3. Raising the head of the bed to a 90-degree angle (high Fowler's position) during meals helps to prevent aspiration. 4. Using a clean plastic bag to access the ice machine indicates the assistant is aware of infection control procedures. TEST-TAKING HINT: This is really an "except" question—there will be three (3) options with desire actions and only one (1) needs to change.
The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 × 106 /mm3 , WBC count 150 × 103 /mm3 , platelets 22 × 103 /mm3 , K+ 3.8 mEq/L, and Na+ 139 mEq/L. Based on these results, which intervention should the nurse teach the client? 1. Encourage the client to eat foods high in iron. 2. Instruct the client to use an electric razor when shaving. 3. Discuss the importance of limiting sodium in the diet. 4. Instruct the family to limit visits to once a week.
ANSWER: 2. 1. The anemia that occurs in leukemia is not related to iron deficiency and eating foods high in iron will not help. 2. The platelet count of 22 3 103 /mm3 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count less than 100,000. This client is at risk for bleeding. Bleeding precautions include decreasing the risk by using soft-bristle toothbrushes and electric razors and holding all venipuncture sites for a minimum of five (5) minutes. 3. The sodium level is within normal limits. The client is encouraged to eat whatever he or she wants to eat unless some other disease process limits food choices. 4. The client is at risk for infection, but unless the family or significant others are ill, they should be encouraged to visit whenever possible. TEST-TAKING HINT: The test taker could eliminate option "3" based on a normal laboratory value. The RBC, WBC, and platelet values are all not in normal range. The correct answer option must address one of these values.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on. 2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client
ANSWER: 2. 1. The ascending paralysis has reached the client's respiratory muscles; therefore, the client will not be able to use the hands to write. 2. The client will not be able to use the arms as a result of the paralysis but can blink the eyes as long as the nurse asks simple "yes-or-no" questions. 3. A speech therapist will not be able to help the client communicate while the client is on the ventilator. 4. The ascending paralysis has reached the respiratory muscles; therefore, the client will not be able to use the hands to push the call light. TEST-TAKING HINT: The test taker must realize all the options except option "3" are ways to communicate with a client on the ventilator. Options "1" and "4" both involve use of the hands, which might lead the test taker to eliminate these two options.
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority? 1. Keep the client NPO. 2. Instruct the client to void. 3. Place in the lithotomy position. 4. Assess the client's pedal pulse.
ANSWER: 2. 1. The client does not need to be NPO prior to this procedure. 2. The client should void prior to this procedure to help prevent accidental puncture of the bladder during the procedure. 3. The lithotomy position has the client lying flat with the legs in stirrups, such as when Pap smears are obtained. 4. The pedal pulses should be assessed postprocedure, not prior to the procedure. TEST-TAKING HINT: The adjective "preprocedure" helps rule out option "4" as a possible correct answer; assessing pedal pulse is priority postprocedure. The test taker must know terminology which describes positioning, such as lithotomy, side-lying, supine, Trendelenburg, or prone.
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.
ANSWER: 2. 1. The client has excess fluid and is not dehydrated, and blood glucose levels are not affected. 2. Early signs and symptoms are nausea and vomiting. The client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. In other words, the client is producing a hormone that will not allow the client to urinate. 3. The client experiences dilutional hyponatremia, and the body has too much fluid already. 4. Vasopressin is the name of the antidiuretic hormone. Giving more increases the client's problem. Also, a water challenge test is performed, not a fluid deprivation test. TEST-TAKING HINT: The syndrome's name is confusing, with a double negative— "inappropriate" and "anti." It is helpful to put the situation in the test taker's own words to remember which way the fluids are being shifted in the body.
Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis? 1. Explain the care of a percutaneous endoscopic gastrostomy tube. 2. Discuss the need to take corticosteroids every day. 3. Instruct to wear long-sleeved shirts when exposed to sunlight. 4. Teach the importance of strict hand washing.
ANSWER: 2. 1. The client is at risk for aspiration as a result of muscle weakness, but modifications of dietary needs address this concern. The client does not require a PEG tube. 2. Polymyositis is a systemic connective tissue disorder characterized by inflammation of connective tissues and muscle fibers and is treated with long-term corticosteroid therapy. Adrenal insufficiency may occur if the client quits taking the corticosteroid. 3. Sunlight does not cause an exacerbation or irritation of polymyositis. 4. The client is not at risk for developing an infection, and an infection will not exacerbate the client's medical condition.
The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.
ANSWER: 2. 1. The client is on a special diet and should not have any additional food. 2. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet. 3. The nurse does not need to notify the HCP for an increase in caloric intake. The appropriate referral is to the dietitian. 4. The client is on a special diet. The nurse needs to help the client maintain compliance with the medical treatment and should refer the client to the dietitian. TEST-TAKING HINT: The test taker should select the option attempting to ensure the client maintains compliance. The test taker should remember to work with members of the multidisciplinary health-care team.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? 1. Apply oxygen via nasal cannula. 2. Get a wheelchair for the client. 3. Assess the client's lung fields. 4. Assist the client when ambulating in the hall
ANSWER: 2. 1. The client may need oxygen, but getting the client a wheelchair and getting the client back to bed is priority. 2. The client is experiencing dyspnea on exertion, which is common for clients with anemia. The client needs a wheelchair to limit the exertion. 3. The problem with this client is not a pulmonary one; it is a lack of hemoglobin. 4. Even if the nurse helps the client ambulate, the client still will not have the needed oxygen for the tissues. TEST-TAKING HINT: The test taker should ask, "What is causing the distress and what will alleviate the distress the fastest?" The distress is caused by exertion and it is occurring in the hallway. The most expedient intervention is to have the client stop the activity that is causing the distress; a chair will accomplish this, but the client should be returned to the room, so it needs to be a wheelchair
The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
ANSWER: 2. 1. The client should avoid prescription and over-the-counter drugs containing aspirin because these drugs may have an antiplatelet effect, leading to bleeding. 2. Hemarthrosis is bleeding into the joint. Applying ice to the area can cause vasoconstriction, which can help decrease bleeding. 3. The joint should be immobilized for 24 to 48 hours after the bleeding starts. 4. Dependent position is putting the extremity below the level of the heart; the extremity should be elevated if possible. TEST-TAKING HINT: If the test taker does not know the answer, the test taker could apply medical terminology; in this case, the terminology contains hem-, which refers to "blood." A basic concept with bleeding is that cold causes vasoconstriction; therefore, option "2" would be a good choice to select.
The nurse is caring for a client diagnosed with sickle cell disease. Which should the nurse include in the client's plan of care? 1. Teach the client to limit fluids. 2. Discuss interventions to maintain hydration. 3. Measure the client's calf for swelling. 4. Have the client take narcotic pain medication every four (4) hours.
ANSWER: 2. 1. The client should be encouraged to push fluids to maintain hydration. When the client becomes dehydrated, then sickling of the abnormal red blood cells will occur. 2. The client should maintain hydration status to prevent sickling of the red blood cells. 3. Swelling from sickling cells usually occurs in the joints and into the organs. Measuring the calf would be assessing for deep vein thrombosis. 4. The client should receive pain medication on a prn basis, not routinely around the clock. TEST-TAKING HINT: The test taker must be aware of the cause of physiological changes in the body. The sickling of cells occurs when the client experiences lack of oxygen to the cells or becomes dehydrated.
Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison's disease? 1. Discuss the importance of tapering medications when discontinuing medication. 2. Explain the dose may need to be increased during times of stress or infection. 3. Instruct the client to take medication on an empty stomach with a glass of water. 4. Encourage the client to wear clean white socks when wearing tennis shoes.
ANSWER: 2. 1. The client will have to receive this medication the rest of his or her life, so this should not be discussed with the client. 2. During times of stress, the medication may need to be increased to prevent adrenal insufficiency. 3. The medication should be taken with food to minimize its ulcerogenic effect. 4. Wearing white socks with tennis shoes is not an intervention pertinent to a client diagnosed with Addison's disease.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? 1. Explain the medication loses its efficacy after a few months. 2. Continue to have checkups and laboratory work while taking the medication. 3. Have yearly magnetic resonance imaging to follow the progress. 4. Discuss the drug is taken for three (3) weeks and then stopped for a week.
ANSWER: 2. 1. The drug does not lose efficacy, and clients are removed from the drug when the body cannot tolerate the side effects. 2. The drug requires close monitoring to prevent organ damage. 3. MRI scans are not used to determine the progress of RA. 4. There is no "off" period for the drug. TEST-TAKING HINT: If the test taker is not aware of the medication being discussed, option "2," the correct answer, is information which could be said of most medications.
The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells (WBCs).
ANSWER: 2. 1. The drugs quinidine, digoxin, and hydralazine can interfere with adrenal gland secretions and cause hypofunction. Cushing's syndrome is adrenal gland hyperfunction. 2. The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol. 3. A 24-hour urine specimen for 17-hydroxycorticosterone and 17-ketosteroid may be collected. Metanephrines and catecholamines are urine collections for pheochromocytomas. 4. Spot urinalysis and white blood cell count will not provide information on adrenal gland functions. TEST-TAKING HINT: If the test taker is aware the adrenal gland produces cortisol, then there is only one answer option that refers to cortisol.
The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals. 2. Monitor the client's serum albumin levels. 3. Assess for signs and symptoms of infection. 4. Provide skin care to irradiated areas.
ANSWER: 2. 1. The nurse should administer an antiemetic prior to meals, not an antidiarrheal medication. 2. Serum albumin is a measure of the protein content in the blood that is derived from the foods eaten; albumin monitors nutritional status. 3. Assessment of the nutritional status is indicated for this problem, not assessment of the signs and symptoms of infections. 4. This addresses an altered skin integrity problem. TEST-TAKING HINT: The stem of the question asks for interventions for "altered nutrition." Assessment is the first step of the nursing process, but option "3" is not assessing nutrition
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which task should the nurse delegate to the UAP? 1. Check on the bowel movements of a client diagnosed with melena. 2. Take the vital signs of a client who received blood the day before. 3. Evaluate the dietary intake of a client who has been noncompliant with eating. 4. Shave the client diagnosed with severe hemolytic anemia.
ANSWER: 2. 1. The nurse should evaluate the stools of a client diagnosed with melena (dark, tarry stools indicate blood) as part of the ongoing assessment. 2. The UAP can take the vital signs of a client who is stable; this client received the blood the day before. 3. Evaluation is the nurse's responsibility; the nurse should know exactly what the client is eating. 4. A client with severe hemolytic anemia would have pancytopenia and is at risk for bleeding. TEST-TAKING HINT: Melena indicates a problem with the bowel movements and would indicate a need for nursing judgment. A nurse cannot delegate judgment decisions.
Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time. 2. A low fibrinogen level. 3. An increased platelet count. 4. An increased white blood cell count.
ANSWER: 2. 1. The prothrombin time (PT), along with the partial thromboplastin time (PTT) and thrombin time, are prolonged or increased in a client with DIC. 2. The fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases. 3. The platelet count is decreased in DIC. The platelets are used up because clotting and bleeding are occurring simultaneously. 4. White blood cell counts increase as a result of infection, not from DIC. TEST-TAKING HINT: An understanding of bleeding may help the test taker rule out options "3" and "4" because platelets are needed for clotting, so an increased platelet count would not cause bleeding, and WBCs are associated with infection. If the test taker thinks about oral anticoagulant therapy and remembers that PT is prolonged with bleeding, it might lead to eliminating option "1" as a possible correct answer.
The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client? 1. "What time of year do the symptoms occur?" 2. "Which over-the-counter medications have you tried?" 3. "Do other members of your family have allergies to animals?" 4. "Why do you think you have allergies?"
ANSWER: 2. 1. The symptoms are occurring at this time, so asking what time of the year the symptoms occur is not an appropriate question. 2. There are many over-the-counter remedies available. Therefore, the nurse should assess which medications the client has tried and what medications the client is currently taking. 3. The client being allergic to animals was not in the stem. Many clients diagnosed with allergic rhinitis are allergic to seasonal environmental allergens such as pollen and mold. 4. The client probably does not have any explanation for developing allergies. TEST-TAKING HINT: The test taker should not read into a question. Because animals were not mentioned in the stem, option "3" can be eliminated. Many over-the-counter medications and herbal remedies are available to clients, and it is important for the nurse to determine what the client has been taking.
The nurse is transcribing the HCP's order for an iron supplement on the MAR. At which time should the nurse schedule the daily dose? 1. 0900. 2. 1000. 3. 1200. 4. 1630.
ANSWER: 2. 1. The usual medication dosing time for daily medications is 0900, but this is only an hour after the breakfast meal. Iron absorption is reduced when taken with food. 2. This is approximately two (2) hours after breakfast and is the correct dosing time for iron to achieve the best effects. Iron preparations should be administered one (1) hour before a meal or two (2) hours after a meal. Iron can cause gastrointestinal upset, but if administered with a meal, absorption can be diminished by as much as 50%. 3. This is the usual time health-care facilities serve lunch. 4. This time would be very close to the evening meal and would decrease the absorption of the iron. TEST-TAKING HINT: The test taker could eliminate options "3" and "4" if the test taker realized both of these times are very close to mealtimes, so, with this in common, food must pose a problem for the medication
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.
ANSWER: 2. 1. These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation. 2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism. 3. Decreased blood pressure and slow heart rate are signs of myxedema coma. 4. These are signs/symptoms of myxedema coma. TEST-TAKING HINT: If the test taker does not have the knowledge to answer the question, the test taker should look at the options closely. Options "1," "3," and "4" all have signs/symptoms of "decrease"—hypoactive, hypotension, and hypoxia. The test taker should select the option that does not match.
The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? 1. The UAP is helping the client to sit on the bedside chair. 2. The UAP is wearing sterile gloves when bathing the client. 3. The UAP is helping the client shave and brush the teeth. 4. The UAP is providing a back massage to the client.
ANSWER: 2. 1. This action is appropriate and does not require any intervention by the nurse. 2. The UAP should wear nonsterile gloves, not sterile gloves. Wearing sterile gloves is not cost effective. 3. The client has dementia, so helping the client with activities of daily living is appropriate to enable the client to maintain as much independence as possible. 4. This is an excellent intervention to help prevent skin breakdown; it is relaxing for the client and does not require intervention from the nurse.
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antisepticbased mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.
ANSWER: 2. 1. This client probably has oral candidiasis, a fungal infection of the mouth and esophagus. Brushing the teeth and patchy areas will not remove the lesions and will cause considerable pain. 2. This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition. 3. Antiseptic-based mouthwashes usually contain alcohol, which is painful, for the client. 4. The foods the client has eaten did not cause this condition. TEST-TAKING HINT: The client is complaining of a "sore mouth." The test taker must notice all the important information in the stem before attempting to choose an answer. How are brushing the area, an antiseptic mouthwash, or the foods eaten going to alleviate the pain?
The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test? 1. The client will have wires attached to the scalp and lights will flash off and on. 2. The machine will be loud and the client must not move the head during the test. 3. The client will drink a contrast medium 30 minutes to one (1) hour before the test. 4. The test will be repeated at intervals during a five (5)- to six (6)-hour period
ANSWER: 2. 1. This describes an evoked potential electroencephalogram (EEG). 2. MRI scans require the client to lie still and not move the body; the client should be warned about the loud noise. 3. The client does not drink any contrast medium. If contrast is used, it will be given IVP for a CT scan. 4. The test is performed at one time. TEST-TAKING HINT: The test taker must be knowledgeable about different tests and procedures and be able to teach about them to the client. There are no test-taking hints to help remember protocols for procedures and tests.
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, Paco2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.
ANSWER: 2. 1. This indicates the client is dehydrated, which does not indicate the client is getting better. 2. The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment. 3. These ABGs indicate metabolic acidosis; therefore, the client is not responding to treatment. 4. This potassium level is low and indicates hypokalemia, which shows the client is not responding to medical treatment. TEST-TAKING HINT: The phrase "responding to medical treatment" is asking the test taker to determine which data indicate the client is getting better. The correct answer will be normal data, and the other three (3) options will be signs/symptoms of the disease process or condition.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.
ANSWER: 2. 1. This is an appropriate long-term goal for the client problem "impaired skin integrity." 2. The client with Guillain-Barré syndrome will not be able to move the extremities; therefore, preventing muscle atrophy is an appropriate long-term goal. 3. The client will not be able to move the extremities. Therefore, the nurse will have to do passive range-of-motion exercises; this is an intervention, not a goal. 4. This is a nursing intervention, not a goal, and the client should be turned while sleeping unless the client is on a special immobility bed. TEST-TAKING HINT: The adjective "long-term" should make the test taker eliminate option "4" because the words "two (2) hours" are in the goal. The word "perform" is an intervention, which is not a goal; therefore option "3" could be eliminated as the correct answer.
The nurse at a freestanding health-care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.
ANSWER: 2. 1. This is an example of interviewing the client; it is not an example of client advocacy. 2. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices. 3. Adult Protective Services is an organization investigating any actual or potential abuse in adults. This client is not being abused by anyone. 4. The client needs the insulin to control the diabetes, and talking to the HCP about taking him off a needed medication is not an example of advocacy. TEST-TAKING HINT: Remember, the test taker must understand what the question is asking and the definition of the terms.
The client diagnosed with cancer of the pancreas is being discharged to start chemotherapy in the HCP's office. Which statement made by the client indicates the client understands the discharge instructions? 1. "I will have to see the HCP every day for six (6) weeks for my treatments." 2. "I should write down all my questions so I can ask them when I see the HCP." 3. "I am sure this is not going to be a serious problem for me to deal with." 4. "The nurse will give me an injection in my leg and I will get to go home."
ANSWER: 2. 1. This is routine for radiation therapy, but chemotherapy is given one (1) to three (3) or four (4) days in a row and then a period of three (3) to four (4) weeks will elapse before the next treatment. This is called intermittent pulse therapy. 2. The most important person in the treatment of the cancer is the client. Research has proved the more involved a client becomes in his or her care, the better the prognosis. Clients should have a chance to ask questions. 3. Cancer of any kind is a serious problem. 4. Most antineoplastic medications are administered intravenously. Many of the medications can cause severe complications if administered intramuscularly. TEST-TAKING HINT: The test taker can eliminate option "3" based on this statement being denial of the problem
The client's nephew has just been diagnosed with sickle cell anemia (SCA). The client asks the nurse, "How did my nephew get this disease?" Which statement would be the best response by the nurse? 1. "Sickle cell anemia is an inherited autosomal recessive disease." 2. "He was born with it and both his parents were carriers of the disease." 3. "At this time, the cause of sickle cell anemia is unknown." 4. "Your sister was exposed to a virus while she was pregnant."
ANSWER: 2. 1. This is the etiology for sickle cell anemia (SCA), but a layperson would not understand this explanation. 2. This explains the etiology in terms that a layperson could understand. When both parents are carriers of the disease, each pregnancy has a 25% chance of producing a child who has sickle cell anemia. 3. The cause of SCA is known, and genetic counseling can explain it to the prospective parent. 4. A virus does not cause sickle cell anemia. TEST-TAKING HINT: When discussing disease processes with laypersons, the nurse should explain the facts in terms that the person can understand. Would a layperson know what "autosomal recessive" means? The test taker should consider terminology when selecting an answer
The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells immediately (STAT). 2. Initiate an IV with an 18-gauge needle and hang normal saline. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client's admission.
ANSWER: 2. 1. This should be done, but the client requires the IV first. This client is at risk for shock. 2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible. 3. The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority. 4. This is the last thing on this list in order of priority. TEST-TAKING HINT: The question requires the test taker to decide which of the actions comes first. Only one of the options actually has the nurse treating the client. The test taker must not read into a question—for example, that consent is needed to send a client to surgery to correct the problem, so that could be first. Only one answer option has the potential to stabilize the client
The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least five (5) minutes. 2. Limit fresh fruits and flowers. 3. Place all clients in reverse isolation. 4. Have the clients use a soft-bristle toothbrush.
ANSWER: 2. 1. This would be done for thrombocytopenia (low platelets), not neutropenia (low white blood cells). 2. Fresh fruits and flowers may carry bacteria or insects on the skin of the fruit or dirt on the flowers and leaves, so they are restricted around clients with low white blood cell counts. 3. Clients with severe neutropenia may be placed in reverse isolation, but not all clients with neutropenia will be placed in reverse isolation. Clients are at a greater risk for infecting themselves from endogenous fungi and bacteria than from being exposed to noninfectious individuals. 4. This is an intervention for thrombocytopenia. TEST-TAKING HINT: The test taker must match the problem with the answer option. Options "1" and "4" would probably be implemented for the client with a bleeding disorder. Option "3" has the word "all" in it, which would make the test taker not select this option
An 18-year-old female client, 5′4″ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.
ANSWER: 2. 1. Type 1 diabetes usually occurs in young clients who are underweight. In this disease, there is no production of insulin from the beta cells in the pancreas. People with type 1 diabetes are insulin dependent with a rapid onset of symptoms, including polyuria, polydipsia, and polyphagia. 2. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short. 3. Gestational diabetes occurs during pregnancy. 4. Acanthosis nigricans (AN), dark pigmentation and skin creases in the neck, is a sign of hyperinsulinemia. The pancreas is secreting excess amounts of insulin as a result of excessive caloric intake. It is identified in young children and is a precursor to the development of type 2 diabetes. TEST-TAKING HINT: The test taker must be aware of kilograms and pounds. The stem is asking about a disease process and acanthosis nigricans is a clinical manifestation of a disease, not a disease itself. Therefore, the test taker should not select this as a correct answer.
Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."
ANSWER: 2. 1. Visiting a foreign country is not a risk factor for contracting this syndrome. 2. This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits. 3. This syndrome is not a contagious or a communicable disease. 4. Taking herbs is not a risk factor for developing Guillain-Barré syndrome. TEST-TAKING HINT: There are some questions requiring the test taker to be knowledgeable of the disease process. Herbs may aggravate a disease process, but as a rule they do not cause disease processes, so option "4" can be eliminated.
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client? 1. Discuss obtaining a motorized wheelchair for the client. 2. Teach the client to stand with the feet slightly apart. 3. Encourage the client to narrow his or her base of support. 4. Explain the need to balance activity with rest.
ANSWER: 2. 1. Walkers or canes may be weighted to provide support and balance for the client; a wheelchair should be used as a last resort. 2. Standing with the feet slightly apart widens the client's base of support and helps decrease balance problems. 3. The client should widen his or her base of support by standing with the feet slightly apart. Narrowing the base of support does not help. 4. This intervention addresses fatigue, which does not cause balance problems.
The client is diagnosed with Hodgkin's disease. Which data are diagnostic for Hodgkin's disease? 1. Night sweats and low-grade fever. 2. Cavitation noted on the chest x-ray. 3. Reed-Sternberg cells found on biopsy. 4. Weight loss and palpable inguinal lymph nodes.
ANSWER: 3, 4. 1. Night sweats and low-grade fever do occur in Hodgkin's disease but also occur in diseases associated with an HIV infection. 2. Cavitation occurs with tuberculosis. 3. Reed-Sternberg cells found on biopsy are diagnostic for Hodgkin's disease. 4. Weight loss and palpable lymph nodes shuld be investigated but are not definitive in the diagnosis of Hodgkin's disease. TEST-TAKING HINT: The test taker must be aware of the cause of physiological changes in the body. The test taker should read every word; "diagnostic" means not just signs and symptoms, which could be attributed to several different diseases, but something that is only attributed to the disease in question.
The client is diagnosed with sickle cell crisis. The nurse is calculating the client's intake and output (I&O) for the shift. The client had 20 ounces of water, eight (8) ounces of apple juice, three (3) cartons of milk with four (4) ounces each, 1,800 mL of IV fluids for the last 12 hours, and a urinary output of 1,200. What is the client's total intake for this shift? _____________
ANSWER: 3,000 mL. The key is knowing that 1 ounce is equal to 30 mL. Then, 20 ounces (20 × 30) = 600 mL, 8 ounces (8 × 30) = 240 mL, and 4 ounces (4 × 30) = 120 × 3 cartons = 360 mL for a total of 600 + 240 + 360 = 1,200 mL of oral fluids. That, plus 1,800 mL of IV fluids, makes the total intake for this shift 3,000 mL. TEST-TAKING HINT: The test taker must memorize equivalents such as how many milliliters are in an ounce. This is the only way that the test taker can convert the client's intake to be able to assess the balance between intake and output.
The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"
ANSWER: 3. 1. A client with type 2 diabetes usually is prescribed oral hypoglycemic medications, not insulin. 2. The client could not eat enough food to cause a 680-mg/dL blood glucose level; therefore, this question does not need to be asked. 3. The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to two (2) weeks. 4. This does not help determine the cause of this client's HHNS. TEST-TAKING HINT: If the test taker does not know the answer to this question, the test taker could possibly relate to the phrase "acute complication" and realize a medical problem might cause this and select infection, option "3."
The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma? 1. A history of skin cancer. 2. A history of high blood pressure. 3. A family history of adrenal tumors. 4. A family history of migraine headaches.
ANSWER: 3. 1. A history of skin cancer is not a risk factor for pheochromocytoma. 2. A history of high blood pressure is a sign of this disease, not a risk factor for developing it. 3. There is a high incidence of pheochromocytomas in family members with adrenal tumors, and the von Hippel-Lindau gene is thought to be a primary cause. 4. Headaches are a symptom of this disease but not a risk factor for it
The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for? 1. Decreased pulmonary functioning. 2. Impaired muscle functioning. 3. Congestive heart failure. 4. Altered gastric secretions
ANSWER: 3. 1. A low hemoglobin level will not decrease pulmonary functioning. In fact, the lungs will try to compensate for the anemia by speeding up respirations to oxygenate the red blood cells and provide oxygen to the tissues. 2. The client may have difficulty with activity intolerance, but this will be from lack of oxygen, not lack of ability of the muscles to function. 3. General complications of severe anemia include heart failure, paresthesias, and confusion. The heart tries to compensate for the lack of oxygen in the tissues by becoming tachycardic. The heart will be able to maintain this compensatory mechanism for only so long and then will show evidence of failure. 4. The gastric secretions will not be altered. The blood supply to the stomach may be shunted to the more vital organs, leaving the acidic stomach to deal with the production of acid, and this could cause the client to develop a gastric ulcer.
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.
ANSWER: 3. 1. A moon face, buffalo hump, and hyperglycemia result from Cushing's syndrome, hyperfunction of the adrenal gland. 2. Hirsutism is hair growth where it normally does not occur, such as facial hair on women. Fever and irritability, along with hirsutism, are clinical manifestations of Cushing's syndrome. 3. Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease. 4. Tachycardia, bulging eyes, and goiter are clinical manifestations occurring with thyroid disorders. TEST-TAKING HINT: This question contains answer options referring to opposite diseases, Addison's disease and Cushing's syndrome. If two options—in this case, options "1" and "2"—are appropriate for one of the diseases, then these two can be ruled out as the correct answer.
The nurse is caring for the following clients. Which client should the nurse assess first? 1. The client whose partial thromboplastin time (PTT) is 38 seconds. 2. The client whose hemoglobin is 14 g/dL and hematocrit is 45%. 3. The client whose platelet count is 75,000 per cubic millimeter of blood. 4. The client whose red blood cell count is 4.8 × 106 /mm3 .
ANSWER: 3. 1. A range for the normal PTT is 32 to 39 seconds. 2. These are normal hemoglobin/hematocrit levels for either a male or female client. 3. A platelet count of less than 100,000 per cubic millimeter of blood indicates thrombocytopenia. 4. This is a normal red blood cell count. TEST-TAKING HINT: The test taker must be knowledgeable of normal laboratory values. The test taker should write these normal values on a 3 × 5 card, carry it with him or her, and memorize the values.
The nurse is teaching the client diagnosed with type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching? 1. A submarine sandwich, potato chips, and diet cola. 2. Four (4) slices of a supreme thin-crust pizza and milk. 3. Smoked turkey sandwich, celery sticks, and unsweetened tea. 4. A roast beef sandwich, fried onion rings, and a cola.
ANSWER: 3. 1. A submarine sandwich is on a bun-type bread and is usually six (6) to 12 inches long, and potato chips add fat and more carbohydrates to the meal. 2. Four (4) slices of pizza contain excessive numbers of carbohydrates, plus cheese and meats, and whole milk is high in fat. 3. Turkey is a low-fat meat. A sandwich usually means normal slices of bread, and the client needs at least 50% carbohydrates in each meal. Celery sticks are not counted as carbohydrates. 4. The roast beef sandwich is high in carbohydrates, fried onion rings are high in fat, and a regular cola is high in carbohydrates.
The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours
ANSWER: 3. 1. A unilateral adrenalectomy results in one adrenal gland still functioning. No hormone replacement will be required. 2. The client can still have normal physiological functioning, including sexual functioning, with the remaining gland. 3. Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge. 4. Turning and coughing is taught prior to surgery, not at discharge. TEST-TAKING HINT: The test taker must notice the adjectives; "discharge" tells the reader a time frame for the instructions. This rules out option "4."
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse? 1. The client with congestive heart failure with an apical pulse of 64 who received 0.125 mg digoxin, a cardiac glycoside. 2. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/80. 3. The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late. 4. The client with AIDS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a CD4 cell count of less than 200.
ANSWER: 3. 1. An apical heart rate of less than 60 warrants intervention if the primary nurse gave the medication. 2. A blood pressure of less than 90/60 warrants intervention if the primary nurse gave the medication. 3. These medications must be administered exactly on time so increased strength can occur during activity such as eating or grooming. There are very few medications administered exactly on time, but this is one of them. 4. The client with AIDS receives prophylactic treatment for Pneumocystis pneumonia (PCP) when the CD4 count is less than 200 to 300.
Which client history is most significant in the development of symptoms for a client who has iatrogenic Cushing's disease? 1. Long-term use of anabolic steroids. 2. Extended use of inhaled steroids for asthma. 3. History of long-term glucocorticoid use. 4. Family history of increased cortisol production
ANSWER: 3. 1. Anabolic steroids are used by individuals to build muscle mass. Long-term use can lead to psychosis or heart attacks. 2. Inhaled steroids do not have systemic effects, which is described by iatrogenic Cushing's disease. 3. Iatrogenic Cushing's disease is Cushing's disease caused by medical treatment—in this case, by taking excessive steroids resulting in the symptoms of moon face, buffalo hump, and other associated symptoms. 4. Family history does not cause iatrogenic problems.
The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse? 1. Administer methotrexate, an antineoplastic medication, IV. 2. Assess the lung sounds of a client with RA who is coughing. 3. Demonstrate how to use clothing equipped with Velcro fasteners. 4. Discuss methods of birth control compatible with treatment medications.
ANSWER: 3. 1. Antineoplastic medications can be administered only by a registered nurse who has been trained in the administration and disposal of these medications. 2. Assessment cannot be assigned to a licensed practical nurse. 3. The licensed practical nurse (LPN) can demonstrate how to use adaptive clothing. 4. This is teaching requiring knowledge of medications and interactions and should not be assigned to an LPN. TEST-TAKING HINT: The nurse cannot assign assessment, evaluation, or teaching or any medication requiring specialized knowledge or skills to administer safely.
The male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse he has been having a lot of "gas," along with frothy and very foul-smelling stools. Which intervention should the nurse implement? 1. Explain this is common for chronic pancreatitis. 2. Ask the client to bring in a stool specimen to the clinic. 3. Arrange an appointment with the HCP for today. 4. Discuss the need to decrease fat in the diet so this won't happen.
ANSWER: 3. 1. Any change in the client's stool should be a cause for concern to the clinic nurse. 2. This is not necessary because the nurse knows changes in stool occur as a complication of pancreatitis, and the client needs to see the HCP. 3. Steatorrhea (fatty, frothy, foul-smelling stool) is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of the pancreatitis. The client should see the HCP. 4. Decreasing fat in the diet will not help stop this type of stool. TEST-TAKING HINT: This question requires the test taker to have knowledge of the disease process, but if the test taker knows the exocrine function of the pancreas is part of the gastrointestinal system, the test taker might think altered stool is a cause for concern
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with iron-deficiency anemia who is prescribed iron supplements. 2. The client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly. 3. The client diagnosed with aplastic anemia who has developed pancytopenia. 4. The client diagnosed with renal disease who has a deficiency of erythropoietin.
ANSWER: 3. 1. Any nurse should be able to administer iron supplements, which are oral iron preparations. 2. Any nurse should be able to give an intramuscular medication. 3. Pancytopenia is a situation that develops in clients diagnosed with aplastic anemia because the bone marrow is not able to produce cells of any kind. The client has anemia, thrombocytopenia, and leukopenia. This client could develop an infection or hemorrhage, go into congestive heart failure, or have a number of other complications develop. This client needs the most experienced nurse. 4. A deficiency of erythropoietin is common in clients diagnosed with renal disease. The current treatment for this is to administer erythropoietin, a biologic response modifier, subcutaneously or, if the anemia is severe enough, a blood transfusion. TEST-TAKING HINT: The test taker could eliminate options "1" and "2" because of the words "most experienced nurse" in the stem
Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic. 2. Morphine, a narcotic analgesic. 3. Epogen, a biologic response modifier. 4. Gleevec, a genetic blocking agent.
ANSWER: 3. 1. Because of the ineffective or nonexistent WBCs (segmented neutrophils) characteristic of leukemia, the body cannot fight infections, and antibiotics are given to treat infections. 2. Leukemic infiltrations into the organs or the central nervous system cause pain. Morphine is the drug of choice for most clients with cancer. 3. Epogen is a biologic response modifier that stimulates the bone marrow to produce red blood cells. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth. 4. Gleevec is a drug that specifically works in leukemic cells to block the expression of the BCR-ABL protein, preventing the cells from growing and dividing. TEST-TAKING HINT: If the test taker were not familiar with the drug mentioned in option "4," then this option would not be a good choice. Options "1" and "2" are common drugs and should not be chosen as the answer unless the test taker knows for sure they are contraindicated.
The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.
ANSWER: 3. 1. Blood glucose levels do not address the problem of altered body image. 2. Head-to-toe assessments are performed to detect a physiological problem, not a psychosocial one. 3. Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face. 4. Bowel sounds and temperature are physical symptoms. TEST-TAKING HINT: The intervention must match the problem.
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse? 1. The client is able to mark the correct site for the surgery. 2. The client can only tell the nurse about the surgery in lay terms. 3. The client is allergic to iodine and does not have an allergy bracelet. 4. The client has signed a consent form for surgery and anesthesia.
ANSWER: 3. 1. By the Joint Commission standards, clients must mark any surgical site to make sure the operation is not done on the incorrect site, such as the right arm instead of the left arm. 2. The client should understand the surgery in his or her own terms. 3. Iodine is the basic ingredient in Betadine (povidone-iodine), which is a common skin prep used for surgeries. Therefore, the nurse should notify the surgeon if the client has an allergy to iodine. 4. The client should have a signed consent for the surgery and the anesthesia prior to surgery. TEST-TAKING HINT: The options involve basic concepts for surgical preparation, and allergies must be identified on the client as well as in the client's chart
Which is a potential complication that occurs specifically to a male client diagnosed with sickle cell anemia during a sickle cell crisis? 1. Chest syndrome. 2. Compartment syndrome. 3. Priapism. 4. Hypertensive crisis.
ANSWER: 3. 1. Chest syndrome refers to chest pain, fever, and a dry, hacking cough with or without preexisting pneumonia and is not a fatal complication. It can occur in either gender. 2. Compartment syndrome is a complication of a cast that has been applied too tightly or a fracture in which there is edema in a muscle compartment. 3. This is a term that means painful and constant penile erection that can occur in male clients with SCA during a sickle cell crisis. 4. A hypertensive crisis is potentially fatal, but it is not a complication of SCA. The client with sickle cell anemia usually has cardiomegaly or systolic murmurs; both genders have this. TEST-TAKING HINT: This is a knowledgebased question, but if the test taker realized that priapism could only occur in males, this might help the test taker select option "3" as a correct answer. Whenever there is a gender for the client, it usually has something to do with the correct answer.
The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
ANSWER: 3. 1. Clients with SIADH have a problem with retaining fluid. This is expected. 2. This client's intake and output are relatively the same. 3. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize. 4. The client has to get up all night to urinate, so the client feeling tired is expected. TEST-TAKING HINT: All of the answer options contain expected information except option "3."
The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.
ANSWER: 3. 1. Crumbling toenails indicate tinea unguium, which is a fungus infection of the toenail. 2. Athlete's foot is a non-life-threatening fungal infection. 3. A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection. 4. Big, thick toenails are fungal infections and do not require immediate intervention by the nurse. TEST-TAKING HINT: The test taker should select the option indicating this is possibly a life-threatening complication or some type of assessment data the health-care provider should be informed of immediately. Remember "warrants immediate intervention."
The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.
ANSWER: 3. 1. Discussing the information with others is not allowing the client to decide what is best for himself. 2. This could be an example of beneficence (to do good) if the nurse did this so the client has information on which to base a decision on whether to continue the fluid restriction. 3. This is an example of autonomy (the client has the right to decide for himself). 4. This is an example of dishonesty and should never be tolerated in a health-care setting. TEST-TAKING HINT: The stem asks the test taker about autonomy. Even if the test taker did not know the ethical principle, autonomy means the right of self-governance. Only one of the answer options could fit the definition of autonomy
The client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse implement? 1. Assess for rectal bleeding. 2. Increase fluid intake. 3. Assess gag reflex. 4. Keep in supine position.
ANSWER: 3. 1. During this procedure, a scope is placed down the client's mouth; therefore, assessing for rectal bleeding is not an intervention. 2. The client's throat has been anesthetized to insert the scope; therefore, fluid and food are withheld until the gag reflex has returned. 3. The gag reflex will be suppressed as a result of the local anesthesia applied to the throat to insert the endoscope into the esophagus; therefore, the gag reflex must be assessed prior to allowing the client to resume eating or drinking. 4. The client should be in a semi-Fowler's or side-lying position to prevent aspiration. TEST-TAKING HINT: The test taker should apply the nursing process and select an option that addresses assessment—either "1" or "3." The medical prefix endo- should help the test taker select option "3" as the correct answer.
Which clinical manifestation of Stage I nonHodgkin's lymphoma would the nurse expect to find when assessing the client? 1. Enlarged lymph tissue anywhere in the body. 2. Tender left upper quadrant. 3. No symptom in this stage. 4. Elevated B-cell lymphocytes on the CBC.
ANSWER: 3. 1. Enlarged lymph tissue would occur in Stage III or IV Hodgkin's lymphoma. 2. A tender left upper quadrant would indicate spleen infiltration and occurs at a later stage. 3. Stage I lymphoma presents with no symptoms; for this reason, clients are usually not diagnosed until the later stages of lymphoma. 4. B-cell lymphocytes are the usual lymphocytes involved in the development of lymphoma, but a serum blood test must be done specifically to detect B cells. They are not tested on a CBC. TEST-TAKING HINT: Most cancers are staged from 0 to IV. Stage 0 is microinvasive and Stage I is minimally invasive, progressing to Stage IV, which is large tumor load or distant disease. If the test taker noted the "Stage I," then choosing the option that presented with the least amount of known disease— option "3"—would be a good choice.
Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis. 3. Administer frozen plasma. 4. Calculate the intake and output.
ANSWER: 3. 1. Heparin, a parenteral anticoagulant, is administered to interfere with the clotting cascade and may prevent further clotting factor consumption as a result of uncontrolled bleeding, but its use is controversial. Oral anticoagulants are not administered. 2. Plasmapheresis involves the removal of plasma from withdrawn blood by centrifugation, reconstituting it in an isotonic solution, and then reinfusing the solution back into the body, but it is not a treatment for DIC. 3. Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets. 4. Calculating the intake and output is adding up how much oral and intravenous fluids went into the client and how much fluid came out of the client. It does not require an HCP's order and thus is not a collaborative treatment. TEST-TAKING HINT: "Collaborative" means another health-care discipline must order or perform the intervention. A test-taking hint that may help with unit examinations, but not with the NCLEX-RN, is that, if the test taker has studied the assigned content and has never heard of one of the words in the answer options, the test taker should not select that answer—in this case, perhaps the word "plasmapheresis."
The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.
ANSWER: 3. 1. Kussmaul's respirations occur with diabetic ketoacidosis (DKA) as a result of the breakdown of fat, resulting in ketones. 2. Diarrhea and epigastric pain are not associated with HHNS. 3. Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA. 4. This occurs with DKA as a result of the breakdown of fat, resulting in ketones. TEST-TAKING HINT: The test taker must be able to differentiate between HHNS (type 2 diabetes) and DKA (type 1 diabetes), which primarily is the result of the breakdown of fat and results in an increase in ketones causing a decrease in pH, resulting in metabolic acidosis.
Which client is at the highest risk for developing a lymphoma? 1. The client diagnosed with chronic lung disease who is taking a steroid. 2. The client diagnosed with breast cancer who has extensive lymph involvement. 3. The client who received a kidney transplant several years ago. 4. The client who has had ureteral stent placements for a neurogenic bladder
ANSWER: 3. 1. Long-term steroid use suppresses the immune system and has many side effects, but it is not the highest risk for the development of lymphoma. 2. This client would be considered to be in late-stage breast cancer. Cancers are described by the original cancerous tissue. This client has breast cancer that has metastasized to the lymph system. 3. Clients who have received a transplant must take immunosuppressive medications to prevent rejection of the organ. This immunosuppression blocks the immune system from protecting the body against cancers and other diseases. There is a high incidence of lymphoma among transplant recipients. 4. A neurogenic bladder is a benign disease; stent placement would not put a client at risk for cancer. TEST-TAKING HINT: To answer this question, the test taker must be aware of the function of the immune system in the body and of the treatments of the disease processes.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? 1. Recommend lying in the prone position with legs extended. 2. Maintain a tripod position over the bedside table. 3. Place in side-lying position with knees flexed. 4. Encourage a supine position with a pillow under the knees
ANSWER: 3. 1. Lying on the stomach will not help to decrease the client's pain. 2. This is a position used by clients with chronic obstructive pulmonary disease to help lung expansion. 3. This fetal position decreases pain caused by the stretching of the peritoneum as a result of edema. 4. Laying supine causes the peritoneum to stretch, which increases the pain. TEST-TAKING HINT: The test taker should think about where the pancreas is located in the abdomen to help identify the correct answer. Prone or supine causes the abdomen to be stretched, which increases pain.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question? 1. Cefazolin sodium IVPB every six (6) hours. 2. Furosemide by mouth twice daily. 3. Metoprolol IVP every four (4) hours and prn. 4. Acetaminophen by mouth every four (4) hours prn.
ANSWER: 3. 1. MODS is frequently a result of sepsis; the nurse would not question an antibiotic. 2. MODS can involve development of capillary permeability that allows fluids to "leak" from the capillaries into the interstitial space; the nurse would not question a medication that encourages the fluid to return to the circulatory system for excretion by the kidneys. 3. MODS's effect on the circulatory system includes a decreased blood pressure. The nurse would question administering a medication that decreases the blood pressure. 4. This is not a high dose of acetaminophen and could be administered for mild pain. The nurse would not question this medication.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"
ANSWER: 3. 1. MS does not affect the menstrual cycle. 2. A rash across the bridge of the nose suggests systemic lupus erythematosus. 3. These are clinical manifestations of MS and can go undiagnosed for years because of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS. 4. Taking birth control medications should not produce these symptoms or the pattern of occurrence. TEST-TAKING HINT: This stem is somewhat involved. The test taker must be sure to understand the important parts, which are the client's age, complaints, and occurrence of complaints. This should cause the test taker to think about what these have in common.
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? 1. Use astringent lotion on the face and skin. 2. Inspect the skin weekly for open areas or rashes. 3. Dry the skin thoroughly by patting. 4. Apply anti-itch medication between the toes.
ANSWER: 3. 1. Moisturizing lotions, not astringents, are applied. Astringent lotions have an alcohol base, which is drying to the client's skin. 2. The skin should be inspected daily for any breakdown or rashes. 3. The skin should be washed with mild soap, rinsed, and patted dry. Rubbing can cause abrasions and skin breakdown. 4. The stem does not tell the test taker the client is itching, and SLE does not have itching as a symptom. Lotions are not usually applied between the toes because this fosters the development of a fungal infection between the toes. TEST-TAKING HINT: If the test taker did not know what "astringent" meant, then the test taker should skip this option and continue looking for a correct answer. In option "2," the time frame of weekly makes this option wrong.
The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse discuss as an example of a primary nursing intervention? 1. Monitor for elevated blood glucose at random intervals. 2. Inspect the skin and sclera of the eyes for a yellow tint. 3. Limit meat in the diet and eat a diet low in fat. 4. Instruct the client with hyperglycemia about insulin injections.
ANSWER: 3. 1. Monitoring the blood glucose at random intervals, as done at a health fair, could identify possible diabetes mellitus or the presence of a pancreatic tumor, but detecting a disease at an early stage is secondary screening, not primary prevention. 2. Inspecting the skin for jaundice is a secondary nursing intervention. 3. Limiting the intake of meat and fats in the diet is an example of primary interventions. Risk factors for the development of cancer of the pancreas are cigarette smoking and eating a high-fat diet. By changing these behaviors, the client could possibly prevent the development of cancer of the pancreas. Other risk factors include genetic predisposition and exposure to industrial chemicals 4. Instructing a client with hyperglycemia (diabetes mellitus) is an example of tertiary nursing care. TEST-TAKING HINT: Even if the test taker were not sure of the definition of primary, secondary, or tertiary nursing interventions, "primary" means first. Only one answer option is preventive, and preventing something comes before treating it.
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago. 2. The nursing student who received a measles immunization two (2) months ago. 3. The mother with a six (6)-week-old newborn. 4. The client who developed an allergy to aspirin in childhood.
ANSWER: 3. 1. Oral surgeries are associated with transient bacteremia, and the client cannot donate for 72 hours after an oral surgery. 2. The client cannot donate blood for one (1) month following rubella immunization. 3. The client cannot donate blood for six (6) months after a pregnancy because of the nutritional demands on the mother. 4. Recent allergic reactions prevent donation because passive transference of hypersensitivity can occur. This client has an allergy developed during childhood. TEST-TAKING HINT: All of the answer options have a given time period, and these time frames make each option correct or incorrect. The test taker must pay particular attention whenever an option contains time frames. Is it long enough or not frequent enough?
Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance.
ANSWER: 3. 1. Performing the head-to-toe assessment is a nursing consideration, not a client consideration. This is a physiological intervention, not a psychosocial one. 2. Maintaining body weight is physical. 3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS. 4. Activity tolerance is a physical problem. TEST-TAKING HINT: All of the options except one (1) focus on the physical care of the client. The stem asked the test taker to consider a psychosocial need.
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of bodyimage changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.
ANSWER: 3. 1. SLE is frequently diagnosed in young women and reproduction is a concern for these clients, but it is not the most important goal. 2. The client's body image is important, but this is not the most important. 3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment. 4. Measures are taken to prevent breakdown, but skin breakdown is not life threatening. TEST-TAKING HINT: When the question asks for "priority," the test taker should determine if one of the options has lifethreatening information or could result in a serious complication for the client.
Which sign/symptom will the nurse expect to assess in the client diagnosed with a vaso-occlusive sickle cell crisis? 1. Lordosis. 2. Epistaxis. 3. Hematuria. 4. Petechiae
ANSWER: 3. 1. Skeletal deformities, such as lordosis or kyphosis, are common. They are secondary to chronic vaso-occlusive crisis, not an acute crisis. 2. A bloody nose is not an expected finding in a client diagnosed with an acute vaso-occlusive crisis. 3. Vaso-occlusive crisis, the most frequent crisis, is characterized by organ infarction, which will result in bloody urine secondary to kidney infarction. 4. Petechiae are small pinpoint blood spots on the skin, but they are not signs/symptoms of a vaso-occlusive crisis. TEST-TAKING HINT: Understanding medical terminology of assessment data is an important part of being able to answer NCLEX-RN questions. These terms can help eliminate or select an answer option.
The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach? 1. Sleep with the HOB elevated to prevent increased intracranial pressure. 2. Take an analgesic medication for pain only when the pain becomes severe. 3. Explain radiation therapy to the head may result in permanent hair loss. 4. Discuss end-of-life decisions prior to cognitive deterioration.
ANSWER: 3. 1. Sleeping with the head of the bed elevated might relieve some intracranial pressure, but it will not prevent increased intracranial pressure from occurring. 2. Analgesic medications for clients with cancer are given on a scheduled basis with a fast-acting analgesic administered prn for breakthrough pain. 3. Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. Radiation therapy has longer lasting side effects than chemotherapy. If the radiation therapy destroys the hair follicles, the hair will not grow back. 4. Cognitive deterioration does not usually occur. TEST-TAKING HINT: The test taker must be aware of the treatments used for the disease processes to answer this question but might eliminate option "2" because it violates basic principles of pain management.
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently. 4. Provide supplemental dietary sodium with the client's meals.
ANSWER: 3. 1. Steroid medications increase gastric acid; therefore, a proton pump inhibitor is an appropriate medication for the client. 2. Cultures are ordered prior to administering antibiotics, not steroids. 3. Steroids interfere with glucose metabolism by blocking the action of insulin; therefore, the blood glucose levels should be monitored. 4. Steroid medications cause the client to retain sodium; therefore, a low-sodium diet should be encouraged. TEST-TAKING HINT: Steroid medications are some of the most common medications administered by nurses. They are also among the most dangerous; therefore, the test taker must know about steroids, their actions, side effects, and adverse effects.
The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So the thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication
ANSWER: 3. 1. Steroids are not addicting. 2. The adrenal gland, not the thyroid gland, produces the glucocorticoid cortisol. 3. Tapering steroids is important because the adrenal gland stops producing cortisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure. 4. Tapering the dose is standard medical practice, not a whim of the HCP. TEST-TAKING HINT: Basic knowledge of anatomy and physiology eliminates option "2." Tapering steroid medication is basic knowledge for the nurse administering a steroid
The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter (OTC) medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.
ANSWER: 3. 1. The American Diabetes Association is an excellent referral, but the nurse should discuss specific ways to prevent DKA. 2. The client should be careful with OTC medications, but this intervention does not help prevent the development of DKA. 3. Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice. 4. Vaccines are important to help prevent illness, but regardless of whether the client gets these vaccines, the client can still develop diabetic ketoacidosis. TEST-TAKING HINT: The words "most important" in the stem of the question indicate one (1) or more options may be appropriate instructions but only one (1) is the priority intervention
The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first? 1. Assess the eyes using an ophthalmoscope. 2. Tell the client to keep the eyes closed. 3. Notify the health-care provider (HCP). 4. Call the Rapid Response Team (RRT).
ANSWER: 3. 1. The HCP and not the nurse should perform this assessment. The nurse has an unusual and potentially life-changing issue identified. 2. Keeping the eyes closed will not change the outcome of retinal detachment. This is an ophthalmological emergency. 3. This is an emergency; this indicates retinal detachment. The nurse should notify the HCP. 4. The RRT will help to prevent a cardiac or respiratory arrest. The HCP should be notified to arrange for an ophthalmologist consult. TEST-TAKING HINT: The test taker should recognize life-changing or life-threatening complications of a disease process. Failure to immediately intervene can result in a "failure to rescue" situation.
The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse implement? 1. Call the HCP to question the order because blood must infuse within four (4) hours. 2. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. 3. Notify the laboratory to split each unit into half-units and infuse each half for four (4) hours. 4. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.
ANSWER: 3. 1. The HCP has written an appropriate order for this client, who has heart failure, and does not need to be called to verify the order before the nurse implements it. 2. Blood or blood components have a specified amount of infusion time, and this is not eight (8) hours. The time constraints are for the protection of the client. 3. The correct procedure for administering a unit of blood over eight (8) hours is to have the unit split into halves. Each halfunit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume. 4. This rate has already been determined by the HCP to be unsafe for this client. TEST-TAKING HINT: The key to this question is the time frame of eight (8) hours and the client's diagnosis of heart failure. Basic knowledge of heart failure allows the test taker to realize that fluid volume is the problem. Only one option addresses administering a smaller volume at a time.
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.
ANSWER: 3. 1. The blood glucose level should be obtained, but it is not the first intervention. 2. If it is determined the client is having a hypoglycemic reaction, orange juice is appropriate. 3. Regular insulin peaks in two (2) to four (4) hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable. 4. Dextrose 50% is only administered if the client is unconscious and the nurse suspects hypoglycemia. TEST-TAKING HINT: When answering a question requiring the nurse to decide which intervention to implement first, all four options are plausible for the situation but only one answer should be implemented first. The test taker must apply the nursing process; assessment is the first step of the nursing process
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention? 1. Type and crossmatch for a transfusion. 2. Assess for petechiae and purpura. 3. Perform phlebotomy of 500 mL of blood. 4. Monitor for low hemoglobin and hematocrit
ANSWER: 3. 1. The client has too many red blood cells and does not need more. 2. Petechiae and purpura occur when a client does not have adequate platelets. 3. The client has too many red blood cells, which can cause as much damage as too few. The treatment for this disease is to remove the excess blood; 500 mL at a time is removed. 4. The client's hemoglobin and hematocrit are high, not low.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first? 1. The client diagnosed with RA complaining of pain at a "3" on a 1-to-10 scale. 2. The client diagnosed with SLE who has a rash across the bridge of the nose. 3. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV. 4. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
ANSWER: 3. 1. The client in pain should receive medication as soon as possible to keep the pain from becoming worse, but the client is not at risk for a serious complication. 2. A butterfly rash across the bridge of the nose occurs in approximately 50% of the clients diagnosed with SLE. 3. Antineoplastic drugs can be caustic to tissues; therefore, the client's IV site should be assessed. The client should be assessed for any untoward reactions to the medications first. 4. Scleroderma is a disease characterized by waxlike skin covering the entire body. This is expected for this client. TEST-TAKING HINT: Pain is a priority, but the test taker must determine if there is another client who could experience complications if not seen immediately.
The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client? 1. Diabetes insipidus (DI). 2. Crohn's disease. 3. Narcotic addiction. 4. Peritonitis.
ANSWER: 3. 1. The client is at risk for diabetes mellitus (destruction of beta cells), not diabetes insipidus, a disorder of the pituitary gland. 2. Crohn's disease is an inflammatory disorder of the lining of the gastrointestinal system, especially of the terminal ileum. 3. Narcotic addiction is related to the frequent, severe pain episodes often occurring with chronic pancreatitis, which require narcotics for relief. 4. Peritonitis, an inflammation of the lining of the abdomen, is not a common complication of chronic pancreatitis. TEST-TAKING HINT: The test taker may be able to delete options based on normal anatomical and physiological data. Diabetes insipidus is a complication of the pituitary gland; Crohn's disease is a disease of the GI tract; and the peritoneum is the lining of the abdomen. Therefore, options "1," "2," and "4" can be eliminated.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours. 3. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
ANSWER: 3. 1. The client is not allowed to drink during the test. 2. This test does not require any medications to be administered, and vasopressin will treat the DI, not help diagnose it. 3. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated. 4. No fluid is allowed and a sonogram is not involved. TEST-TAKING HINT: The name of the test is a fluid deprivation test. Two (2) of the options require the administration of some type of fluid
The HCP has ordered one (1) unit of packed RBCs for the client who is right-handed. Which area would be the best place to insert the intravenous catheter? 1. Right hand. 2. Left antecubital region. 3. Left forearm. 4. Left hand.
ANSWER: 3. 1. The client is right-handed; therefore, the nurse should attempt to place the IV catheter in the nondominant arm. 2. The antecubital area should not be used as an IV site because the movement of the elbow will crimp the cannula and it is uncomfortable for the client to keep the arm straight all the time. 3. The left forearm is the best site to start the IV because it has larger veins that will accommodate an 18-gauge catheter, which should be used when administering blood. This area is less likely to have extravasation because there is no joint movement, and this site is on the client's nondominant side. 4. The hand area usually has smaller veins that do not accommodate a larger gauge catheter, and hand movement can cause extravasation more readily than forearm movement.
The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.
ANSWER: 3. 1. The client may be in the primary infection stage when the body has not had time to develop antibodies to the HIV virus. 2. Repeated exposure to HIV increases the risk of infection, but it only takes one exposure to develop an infection. 3. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV. 4. The client may or may not have a different virus, but this is not the reason the test is negative. TEST-TAKING HINT: Answer options "1" and "4" assume the client is negative for the HIV virus. Therefore, these options should be eliminated as correct answers unless the test taker is completely sure the statement is correct.
The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I&O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.
ANSWER: 3. 1. The client should have the water pitcher filled, but this is not the first action. 2. This should be done but not before assessing the problem. 3. The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma. 4. This could be done, but it will not give the nurse information about DI. TEST-TAKING HINT: The nurse must apply a systematic approach to answering priority questions. Maslow's hierarchy of needs should be applied if it is a physiological problem and the nursing process if it is a question of this nature. Assessment is the first step in the nursing process.
The client is diagnosed with hemophilia. Which safety precaution should the nurse encourage? 1. Wear helmets and pads during contact sports. 2. Take antibiotics prior to any dental work. 3. Keep clotting factor VIII on hand at all times. 4. Use ibuprofen, an NSAID, for mild pain.
ANSWER: 3. 1. The client should not participate in contact sports because even minimal injury can cause massive bleeding. 2. The client should have factor VIII on hand for any dental procedure to make sure that he or she clots, but antibiotics are not needed. 3. The client must have the clotting factor on hand in case of injury to prevent massive bleeding. 4. NSAIDs prolong bleeding and should be avoided.
The nurse is discussing the endocrine system with the client. Which endocrine gland secretes epinephrine and norepinephrine? 1. The pancreas. 2. The adrenal cortex. 3. The adrenal medulla. 4. The anterior pituitary gland.
ANSWER: 3. 1. The endocrine function of the pancreas is the secretion of insulin and amylin. 2. The adrenal cortex secretes mineralocorticoids, glucocorticoids, and gonadotrophins. 3. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. 4. The anterior pituitary gland secretes the growth hormone
The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two-thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn's disease who is complaining of perineal discomfort.
ANSWER: 3. 1. The likelihood of a client who has already received more than half of the blood product having a transfusion reaction is slim. The first 15 minutes have passed and to this point the client is tolerating the blood. 2. Clients diagnosed with leukemia have a cancer involving blood cell production. These are expected findings in a client diagnosed with leukemia. 3. This client has a potential for hemorrhage and is reporting blood in the vomitus. This client should be assessed first. 4. Crohn's disease involves frequent diarrhea stools, leading to perineal irritation and skin excoriation. This is expected and not life threatening. Clients "1," "2," and "3" should be seen before this client. TEST-TAKING HINT: In a prioritizing question, the test taker should be able to rank in order which client to see first, second, third, and fourth. Expected but not immediately lifethreatening situations are seen after a situation in which the client has a life-threatening problem.
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis.
ANSWER: 3. 1. The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state. 2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective. 3. The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective. 4. Diaphoresis (sweating) occurs with hyperthyroidism, not hypothyroidism. TEST-TAKING HINT: One way of determining the effectiveness of medication is to determine if the signs/symptoms of the disease are no longer noticeable.
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2. Do not use gloves when starting an IV or performing a procedure. 3. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4. Wear white cotton gloves at all times to protect the hands.
ANSWER: 3. 1. The nurse should use nonlatex gloves because of the latex allergy, but the gloves do not have to be sterile. 2. The nurse must use gloves during procedures and starting an IV. Not using gloves is a violation of Occupational Safety and Health Administration standards and places the nurse at risk for developing illnesses. 3. The nurse should be prepared to care for a client at all times and should not place himself or herself at risk because the facility does not keep nonlatex gloves available in the rooms. The nurse should carry the needed equipment (nonlatex gloves) with him or her. 4. White cotton gloves are made of cloth and do not provide the barrier against wet substances. TEST-TAKING HINT: The test taker must be aware of adjectives such as "sterile" in option "1." Basic concepts such as Standard Precautions should cause the test taker to eliminate option "2." Option "4" has the word "all" in it and could be eliminated as an answer because this is an absolute.
The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.4, Pao2 88, Paco2 35, and Hco3 24.
ANSWER: 3. 1. The rate of ventilation is usually 12 to 15 breaths per minute in adults who are on ventilators, so this rate does not require immediate intervention. 2. A manual resuscitation (Ambu) bag must be at the client's bedside in case the ventilator malfunctions; the nurse must bag the client. 3. A pulse oximeter reading of less than 93% warrants immediate intervention; a 90% peripheral oxygen saturation indicates a Pao2 of about 60 (normal, 80 to 100). When the client is placed on the ventilator, this should cause the client's oxygen level to improve. 4. These ABGs are within normal limits and do not warrant immediate intervention. TEST-TAKING HINT: The test taker must know specific norms for frequently performed tests for the client. Even if the test taker were not knowledgeable of the ventilator-based decisions based on norms, the test taker could ask, "Is a client with respiratory rate of 14 in respiratory failure or compromise?" Equipment at the bedside probably does not warrant immediate intervention.
The nurse is preparing to administer the following medications. Which medication should the nurse question administering? 1. The thyroid hormone to the client who does not have a T3, T4 level. 2. The regular insulin to the client with a blood glucose level of 210 mg/dL. 3. The loop diuretic to the client with a potassium level of 3.3 mEq/L. 4. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.
ANSWER: 3. 1. The thyroid hormone must be administered daily, and thyroid levels are drawn every six (6) months or so. 2. A blood glucose level of 210 mg/dL requires insulin administration; therefore, the nurse should not question administering this medication. 3. This potassium level is below normal, which is 3.5 to 5.5 mEq/L. Therefore, the nurse should question administering this medication because loop diuretics cause potassium loss in the urine. 4. The digoxin level is within therapeutic range—0.8 to 2 mg/dL; therefore, the nurse should administer this medication. TEST-TAKING HINT: When administering medication, the nurse must know when to question the medication, how to know it is effective, and what must be taught to keep the client safe while taking the medication. The test taker may want to turn the question around and say, "I should give this medication."
Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.
ANSWER: 3. 1. There is a surgical option available. 2. This surgery is performed in clients with pituitary tumors and is accomplished by going through the client's upper lip though the nasal passage. 3. In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies, triggering an autoimmune response in MG. After a thymectomy, the production of autoantibodies is reduced or eliminated, and this may resolve the signs/symptoms of MG. 4. An adrenalectomy is the surgery for a client diagnosed with Cushing's disease, a disease in which there is an increased secretion of glucocorticoids and mineralocorticoids. TEST-TAKING HINT: This is a knowledge-based question, but the test taker may be able to eliminate options "2" and "4" if the test taker has a basic understanding of anatomy and physiology and knows surgery involving the pituitary or adrenal glands does not help prevent signs and symptoms of a muscular disorder.
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, Pao2 88, Paco2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
ANSWER: 3. 1. This client could be cared for by any nurse qualified to work in an intensive care unit. 2. These blood gases are within normal limits. 3. This client has a low blood pressure and tachycardia. This client may be experiencing an addisonian crisis, a potentially life-threatening condition. The most experienced nurse should care for this client. 4. A negative Trousseau's sign is normal for this client. TEST-TAKING HINT: The answer options "1," "2," and "4" have expected or normal data. Only one option has abnormal data. Even if the test taker is unaware of addisonian crisis, these are vital signs indicating potential shock.
The client diagnosed with Multi Organ Dysfunction Syndrome (MODS) has renal, cardiovascular, and pulmonary dysfunction issues. Which statement by the nurse indicates an understanding of the client's prognosis? 1. "As long as the client is maintained on a ventilator, then the prognosis can be up to 60% recovery." 2. "The client will have less than a 2% potential for recovery from the MODS." 3. "When three or more body systems fail, the mortality rate can be 70% to 80%." 4. "More than one body system in failure reduces the recovery rate to 80% to 90%."
ANSWER: 3. 1. This client is at high risk for a negative outcome, including death. 2. This client has a 20% to 30% chance for survival. 3. The prognosis for clients with MODS is poor with mortality rates between 70% and 80% if three or more systems fail. 4. The rate of recovery is reduced to 20% to 30%. TEST-TAKING HINT: This question is asking the test taker to identify data describing the potential outcomes for a client. In order to answer this question the test taker must have a working knowledge of the disease process; however, if the test taker is not aware of the information, reading "Multiorgan" could help to eliminate option "1" because ventilators do maintain life; but the longer a client remains on a ventilator, the worse the prognosis. Hospital-acquired infections frequently occur with ventilator clients.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? 1. Assign a different nurse every shift to the client. 2. Ask the HCP to tell the client not to yell at the staff. 3. Call a team meeting and discuss options with the staff. 4. Tell one (1) staff member to care for the client a week at a time.
ANSWER: 3. 1. This does not provide continuity of care for the client. It does recognize the nurse's position, but it is not the best care for the client. 2. The HCP should be asked to attend the care plan meeting to assist in deciding how to work with the client, but asking the HCP to "tell" the client to behave is not the best way to handle the situation. The client can always refuse to behave as requested. 3. The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client. 4. Telling a staff member to care for the client for a week could result in a buildup of animosity and make the situation worse. TEST-TAKING HINT: The test taker is being asked for the most appropriate method. Option "4" can be discarded because of the word "tell." Option "3" gives the option for multiple individuals to work together toward an outcome.
The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy
ANSWER: 3. 1. This intervention should be implemented, but it is not the first action. 2. This does address oxygenation but will take time to accomplish, so this intervention is not the first action. 3. The client is cyanotic with dyspnea and wheezing. The nurse should administer oxygen first. 4. The client may be allergic to iodine, a component of many shellfish, but the first need of the client is oxygenation. TEST-TAKING HINT: The test taker must apply some decision-making standard to determine what to do first. Maslow's hierarchy of needs ranks oxygen as first. Of the two (2) options addressing oxygen, option "3" immediately attempts to provide oxygen to the client.
The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach? 1. Take the prescribed iron until it is completely gone. 2. Monitor pulse and blood pressure at a local pharmacy weekly. 3. Have a complete blood count checked at the HCP's office. 4. Perform isometric exercise three (3) times a week.
ANSWER: 3. 1. This is an instruction for antibiotics, not iron. The client will take iron for an indefinite period. 2. Pulse is indirectly affected by anemia when the body attempts to compensate for the lack of oxygen supply, but this is an indirect measure, and blood pressure is not monitored for anemia. 3. The client should have a complete blood count regularly to determine the status of the anemia. 4. Isometric exercises are bodybuilding exercises, and the client should not be exerting himself or herself in this manner. TEST-TAKING HINT: The test taker could eliminate option "1" because this applies to antibiotics and option "4" because it is isometric exercise.
The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach? 1. Tell the client never to scratch the rash. 2. Instruct the client in administering IM Benadryl. 3. Explain how to take a steroid dose pack. 4. Have the client wear shirts with long sleeves and high necks
ANSWER: 3. 1. This is an unrealistic expectation for a client diagnosed with poison ivy. The pruritus is intense. 2. The client should be instructed on how to use the EpiPen, not IM Benadryl. 3. Clients with poison ivy are frequently prescribed a steroid dose pack. The dose pack has the steroid provided in descending doses to help prevent adrenal insufficiency. 4. This may cause the client to be warm, which increases the likelihood of itching. TEST-TAKING HINT: Option "1" has the word "never," which is an absolute word and can be eliminated on this basis. Very few conditions require the nurse to teach the client to take intramuscular (IM) injections; therefore, option "2" could be eliminated as a possible answer.
The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse? 1. The nurse explains the IVP diuretic will make the client urinate. 2. The nurse dons nonsterile gloves to remove the client's dressing. 3. The nurse administers a medication without checking for allergies. 4. The nurse asks the UAP for help moving a client up in bed.
ANSWER: 3. 1. This is appropriate anytime the nurse is administering a diuretic medication. 2. A nurse uses nonsterile gloves to remove old dressings, then washes the hands and sets up the sterile field before donning sterile gloves to reapply the dressing. 3. Checking for allergies is one (1) of the five (5) rights of medication. Is it the right drug? Even if the drug is the one the HCP ordered, it is not the right drug if the client is allergic to it. The nurse should always assess a client's allergies prior to administering any medication. 4. The nurse should ask for assistance in moving a client in bed to prevent on-the-job injuries. TEST-TAKING HINT: The stem asks the test taker to determine which is an incorrect action. This is an "except" question. Three (3) answers are actions the nurse should take.
The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? 1. Perform joint x-rays to determine progression of the disease. 2. Send blood to the laboratory for an erythrocyte sedimentation rate. 3. Recommend the flu and pneumonia vaccines. 4. Assess the client for increasing joint involvement.
ANSWER: 3. 1. This is done, but it will not prevent any disease from occurring. 2. This will follow the progression of the disease of RA, but it is not preventive. 3. RA is a disease with many immunological abnormalities. The clients have increased susceptibility to infectious disease, such as the flu or pneumonia, and, therefore, vaccines, which are preventive, should be recommended. 4. Assessing the client does not address preventive care. TEST-TAKING HINT: The stem requires the test taker to determine what action is preventive care for the client with RA. Only option "3" addresses preventive care.
The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.
ANSWER: 3. 1. This issue is not a priority concern of a newly diagnosed client with MS. 2. This is not priority over a potential suicide statement. 3. A potential suicide statement is priority for the nurse when caring for the client with MS. 4. Flu and pneumonia vaccines are not priority. TEST-TAKING HINT: When the test taker is prioritizing, a systematic approach must be used. Safety is priority, and a threat to a client's life is priority.
The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home? 1. Assess the client's social support network. 2. Identify the client's usual coping methods. 3. Have consistent uninterrupted time with the client. 4. Discuss and complete an advance directive.
ANSWER: 3. 1. This will help identify people who can help support the client, but it is not the highest priority. 2. This will help the nurse identify methods which worked previously in stressful situations and may help the client deal with this disease. 3. Developing a therapeutic relationship with the client is priority because the client probably has less than six (6) months to live. All the other interventions can be implemented, but establishing a therapeutic relationship will allow the nurse to discuss and implement additional interventions. 4. An advance directive is important, and unless the client is declared legally incompetent in a court of law, the client can complete an advance directive, but establishing a therapeutic relationship with the client is priority.
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? 1. Thyroid hormones. 2. Oxygen. 3. Sedatives. 4. Laxatives.
ANSWER: 3. 1. Thyroid hormones are the treatment of choice for the client diagnosed with hypothyroidism; therefore, the nurse should not question this medication. 2. In untreated hypothyroidism, the medical management is aimed at supporting vital functions, so administering oxygen is an appropriate medication. 3. Untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication. 4. Clients with hypothyroidism become constipated as a result of decreased metabolism, so laxatives should not be questioned by the nurse. TEST-TAKING HINT: When a question asks which order the nurse should question, three of the options are medications the nurse expects to administer to the client. Sometimes saying, "The nurse administers this medication," may help the test taker select the correct answer.
The nurse is caring for the female client recovering from a sickle cell crisis. The client tells the nurse her family is planning a trip this summer to Yellowstone National Park. Which response would be best for the nurse? 1. "That sounds like a wonderful trip to take this summer." 2. "Have you talked to your doctor about taking the trip?" 3. "You really should not take a trip to areas with high altitudes." 4. "Why do you want to go to Yellowstone National Park?"
ANSWER: 3. 1. Whenever an opportunity presents itself, the nurse should teach the client about his or her condition. This client should not go to areas that have decreased oxygen, such as Yellowstone National Park, which is at high altitude. 2. This is passing the buck. The nurse can respond to this comment. 3. High altitudes have decreased oxygen, which could lead to a sickle cell crisis. 4. It is none of the nurse's business why the client wants to go to Yellowstone National Park. The client's safety comes first, and the nurse needs to teach the client. TEST-TAKING HINT: Even if the test taker did not know the answer to this question, the only answer option that does any teaching is option "3," which would be the best choice. Yellowstone National Park, because of its altitude, has something to do with the answer
The client is diagnosed with congestive heart failure and anemia. The HCP ordered a transfusion of two (2) units of packed red blood cells. The unit has 250 mL of red blood cells plus 45 mL of additive. At what rate should the nurse set the IV pump to infuse each unit of packed red blood cells? ____________
ANSWER: 30. 74 mL/hr. Pumps are set at an hourly rate. The client in congestive heart failure should receive blood at the slowest possible rate to prevent the client from further complications of fluid volume overload. Each unit of blood must be infused within four (4) hours of initiation of the infusion. 250 mL + 45 mL = 295 mL 295 mL ÷ 4 = 73 ¾ mL/hr, which rounded is 74 mL/hr. TEST-TAKING HINT: The test taker must think about the disease process and the normal requirement for administering blood to arrive at the correct answer
The male client with sickle cell anemia comes to the emergency department with a temperature of 101.4°F and tells the nurse that he is having a sickle cell crisis. Which diagnostic test should the nurse anticipate the emergency department doctor ordering for the client? 1. Spinal tap. 2. Hemoglobin electrophoresis. 3. Sickle-turbidity test (Sickledex). 4. Blood cultures.
ANSWER: 4. 1. A spinal tap is a test used to diagnose meningitis. 2. Hemoglobin electrophoresis is a test used to help diagnose sickle cell anemia; it is the "fingerprinting" of the protein, which detects homozygous and heterozygous forms of the disease. 3. The Sickledex test is a screening test commonly used to screen for sickle cell anemia. It is performed by a finger stick with results in three (3) minutes. 4. The elevated temperature is the first sign of bacteremia. Bacteremia leads to a sickle cell crisis. Therefore, the bacteria must be identified so the appropriate antibiotics can be prescribed to treat the infection. Blood cultures assist in determining the type and source of infection so that it can be treated appropriately. TEST-TAKING HINT: The client's temperature in the stem is the key to selecting blood cultures as the correct answer
The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client? 1. Prednisone, a glucocorticoid. 2. Zithromax, an antibiotic. 3. Ativan, a tranquilizer. 4. Epogen, a biologic response modifier.
ANSWER: 4. 1. A steroid could delay healing time after the surgery and has no effect on the production of red blood cells. 2. An antibiotic does not increase the production of red blood cells. Orthopedic surgeries frequently involve blood loss. The client is wishing to donate blood to himself or herself (autologous). 3. Tranquilizers do not affect the production of red blood cells. 4. Epogen and Procrit are forms of erythropoietin, the substance in the body that stimulates the bone marrow to produce red blood cells. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at six (6) weeks prior to surgery. No phlebotomy will be done within 72 hours of surgery. TEST-TAKING HINT: The test taker should examine the key words "autologous" and "transfusion." If the test taker did not know the meaning of the word "autologous," "auto-" as a prefix refers to "self," such as an autobiography is one's own story. Pairing "self" with "transfusion" then should make the test taker look for an option that would directly affect the production of blood cells.
The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness? 1. CLL is not serious, and clients die from other causes first. 2. There are no symptoms with this form of leukemia. 3. This is a childhood illness and is self-limiting. 4. In early stages of CLL, the client may be asymptomatic.
ANSWER: 4. 1. All types of leukemia are serious and can cause death. The chronic types of leukemia are more insidious in the onset of symptoms and can have a slower progression of the disease. Chronic types of leukemia are more common in the adult population. 2. The symptoms may have a slower onset, but anemia causing fatigue and weakness and thrombocytopenia causing bleeding can be present (usually in the later stages of the disease). Organ enlargement from infiltration may be present. Secondary symptoms of fever, night sweats, and weight loss may also be present. 3. This disease is usually found in adults. 4. In this form of leukemia, the cells seem to escape apoptosis (programmed cell death), which results in many thousands of mature cells clogging the body. Because the cells are mature, the client may be asymptomatic in the early stages. TEST-TAKING HINT: The test taker can eliminate option "1" based on the words "not serious"; common sense lets the test taker know this is not true.
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.
ANSWER: 4. 1. Altered body image is a psychosocial problem, which is not a priority over a potentially lethal physical complication, and physical changes occur over an extended period. 2. Activity intolerance will occur with adrenal gland hypofunction, but this is not a priority over dehydration. 3. Impaired coping can occur in clients with adrenal gland disorders, but it is not a priority over dehydration. 4. Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia. TEST-TAKING HINT: Assuming all of the problems listed apply to the client diagnosed with Addison's disease, two are psychosocial problems and two are physiological. Applying Maslow's hierarchy of needs, the two psychological problems can be ruled out as the highest priority. Of the two options remaining, activity intolerance is not life altering or threatening.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury
ANSWER: 4. 1. Altered nutrition may be a priority for a client with malnutrition, but HIV encephalopathy is a cognitive deficit. 2. The client might grieve if the client still has enough cognitive ability to understand the loss is occurring, but this is not the most important consideration. 3. A client diagnosed with encephalopathy may not have the ability to understand instructions. The nurse should teach the significant others. 4. Safety is always an issue with a client with diminished mental capacity. TEST-TAKING HINT: The test taker must have a basis for deciding priority. Maslow's hierarchy of needs lists safety as a high priority
Which test is considered diagnostic for Hodgkin's lymphoma? 1. A magnetic resonance image (MRI) of the chest. 2. A computed tomography (CT) scan of the cervical area. 3. An erythrocyte sedimentation rate (ESR). 4. A biopsy of the cervical lymph nodes.
ANSWER: 4. 1. An MRI of the chest area will determine numerous disease entities, but it cannot determine the specific morphology of Reed-Sternberg cells, which are diagnostic for Hodgkin's disease. 2. A CT scan will show tumor masses in the area, but it is not capable of pathological diagnosis. 3. ESR laboratory tests are sometimes used to monitor the progress of the treatment of Hodgkin's disease, but ESR levels can be elevated in several disease processes. 4. Cancers of all types are definitively diagnosed through biopsy procedures. The pathologist must identify ReedSternberg cells for a diagnosis of Hodgkin's disease. TEST-TAKING HINT: The test taker can eliminate the first three (3) answer options based on these tests giving general information on multiple diseases. A biopsy procedure of the involved tissues is the only procedure that provides a definitive diagnosis
The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain? 1. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic. 2. Motrin (ibuprofen), a nonsteroidal antiinflammatory drug (NSAID), prn. 3. Demerol (meperidine), a narcotic analgesic, every four (4) hours. 4. Morphine, a narcotic analgesic, every two (2) to three (3) hours prn.
ANSWER: 4. 1. Aspirin is an option for mild pain, but it would not be strong enough during a crisis. 2. NSAIDs are helpful because they relieve pain and decrease inflammation, but they are not used during a crisis because they are not strong enough. 3. Demerol breaks down in the body into normeperidine, which can cause seizures in large doses. 4. Morphine is the drug of choice for a crisis; it does not have a ceiling effect and can be given in large amounts and frequent doses.
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse? 1. "I always take the aspirin with food." 2. "If I have dark stools, I will call my HCP." 3. "Aspirin will not cure my arthritis." 4. "I am having some ringing in my ears."
ANSWER: 4. 1. Aspirin should be taken with food to prevent gastrointestinal upset. 2. Daily aspirin is used as an anticoagulant; therefore, abnormal bleeding should be reported to the HCP. 3. Aspirin is used to reduce the inflammatory process and manage the signs and symptoms, but it does not stop the disease process. 4. Tinnitus (ringing in the ears) is a sign of aspirin toxicity, and the client should be instructed to decrease the aspirin dosage or stop taking aspirin altogether. The client should be instructed to contact the health-care provider
The client is three (3) days postoperative unilateral adrenalectomy. Which discharge instructions should the nurse teach? 1. Discuss the need for lifelong steroid replacement. 2. Instruct the client on administration of vasopressin. 3. Teach the client to care for the suprapubic Foley catheter. 4. Tell the client to notify the HCP if the incision is inflamed.
ANSWER: 4. 1. Because the client has one adrenal gland remaining, the client may not need lifelong supplemental steroids. 2. Vasopressin is administered to clients with diabetes insipidus. 3. The client does not have a suprapubic catheter during this procedure. 4. Any inflammation of the incision indicates an infection and the client will need to receive antibiotics, so the HCP must be notified.
The client is diagnosed with acute pancreatitis. Which health-care provider's admitting order should the nurse question? 1. Bedrest with bathroom privileges. 2. Initiate IV therapy of D5W at 125 mL/hr. 3. Weigh the client daily. 4. Low-fat, low-carbohydrate diet.
ANSWER: 4. 1. Bedrest will decrease metabolic rate, gastrointestinal secretion, pancreatic secretions, and pain; therefore, this HCP's order should not be questioned. 2. The client will be NPO; therefore, initiating IV therapy is an appropriate order. 3. Short-term weight gain changes reflect fluid balance because the client will be NPO and receiving IV fluids. Daily weight is an appropriate HCP's order. 4. The client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain. TEST-TAKING HINT: The test taker must determine which HCP's order is not expected for the diagnosis. Sometimes, if the test taker asks which order is expected, it is easier to identify the unexpected or abnormal HCP order.
The client asks the nurse, "They say I have cancer. How can they tell if I have Hodgkin's disease from a biopsy?" The nurse's answer is based on which scientific rationale? 1. Biopsies are nuclear medicine scans that can detect cancer. 2. A biopsy is a laboratory test that detects cancer cells. 3. It determines which kind of cancer the client has. 4. The HCP takes a small piece out of the tumor and looks at the cells.
ANSWER: 4. 1. Biopsies are surgical procedures requiring needle aspiration or excision of the area; they are not nuclear medicine scans. 2. The biopsy specimen is sent to the pathology laboratory for the pathologist to determine the type of cell. "Laboratory test" refers to tests of body fluids performed by a laboratory technician. 3. A biopsy is used to determine if the client has cancer and, if so, what kind. However, this response does not answer the client's question. 4. A biopsy is the removal of cells from a mass and examination of the tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg cells are diagnostic for Hodgkin's disease. If these cells are not found in the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed sample or, depending on involvement of the tissue, diagnose a non-Hodgkin's lymphoma. TEST-TAKING HINT: Option "1" can be eliminated if the test taker knows what the word "biopsy" means. Option "3" does not answer the question and can be eliminated for this reason
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV
ANSWER: 4. 1. Birth control pills provide protection against unwanted pregnancy but they do not protect females from getting sexually transmitted diseases. In fact, because of the reduced chance of becoming pregnant, some women may find it easier to become involved with multiple partners, increasing the chance of contracting a sexually transmitted disease. 2. There is no vaccine or cure for the HIV virus. 3. Adolescents are among the fastest-growing population to be newly diagnosed with HIV and AIDS. 4. Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship. TEST-TAKING HINT: Answer option "1" is a form of an absolute, which could cause the test taker to eliminate this option. Option "4" is also an absolute—"only"—but it is a true statement. There are some absolutes in the health-care profession.
The client is diagnosed with leukemia and has leukocytosis. Which laboratory value would the nurse expect to assess? 1. An elevated hemoglobin. 2. A decreased sedimentation rate. 3. A decreased red cell distribution width. 4. An elevated white blood cell count.
ANSWER: 4. 1. Clients with leukemia are usually anemic because of the bone marrow's inability to produce cells or, in this case, the bone marrow, stuck in high gear, producing immature white blood cells that are unable to function normally. 2. Sedimentation rates increase in some diseases, such as rheumatoid arthritis, but there will be no change in leukemia. 3. The red cell distribution width (RDW), shown in the CBC report, reports on the size of the red blood cells. 4. An elevated white blood cell count is what is being described in the term "leukocytosis"—leuko- means "white" and cyto- refers to "cell." Leukocytosis is the opposite of leukopenia.
Which interrelated psychological concept is priority for the nurse caring for a client diagnosed with leukemia? 1. Comfort. 2. Stress. 3. Grieving. 4. Coping.
ANSWER: 4. 1. Comfort is appropriate for the disease but is not the priority concept. Pain alerts the client that a problem is occurring but is not life threatening. 2. Stress could be a concept but coping problems are priority. 3. Grieving is an interrelated concept but is limited in the scope of the client's needs. 4. Coping includes dealing with stress, anxiety, and grief. The nurse can help the client most by assisting in identifying the client's coping mechanisms. TEST-TAKING HINT: The test taker must be aware of concepts that are interrelated. Coping encompasses stress and grieving. The word "psychological" can rule out option "1" because comfort is pain
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? 1. Contact Precautions. 2. Airborne Precautions 3. Droplet Precautions. 4. Standard Precautions.
ANSWER: 4. 1. Contact Precautions are a form of transmission-based precautions used when the infectious organism is known to be spread by contact with a substance. 2. Airborne Precautions are used for bacteria, which are very small molecules carried at some distance from the client on air currents. The bacterium which causes tuberculosis is an example of such bacteria. A special isolation mask is required to enter the client's negative air pressure room. 3. Droplet Precautions are used for organisms causing flu or some pneumonias. The organisms have a larger molecule and "drop" within three (3) to four (4) feet. A normal isolation mask is used with this client. 4. Standard Precautions are used for all contact with blood and body secretions. TEST-TAKING HINT: Isolation procedures are basic nursing knowledge, and the test taker must know, understand, and be able to comply with all of the procedures.
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client? 1. Take a corticosteroid dose pack when stung by a bee. 2. Take antihistamines prior to outdoor activities. 3. Use a cromolyn sodium (Intal) inhaler prophylactically. 4. Carry a bee sting kit, especially when going outside.
ANSWER: 4. 1. Corticosteroids may be used in both systemic and topical forms for many types of hypersensitivity responses but must be ordered by a health-care provider and are not automatically taken after a bee sting. 2. Antihistamines are the major class of drugs used to treat hypersensitivity responses, but they are not taken prophylactically. They are used when a reaction occurs. 3. This drug treats allergic rhinitis and asthma prophylactically. It does not help bee stings or insect bites. 4. The kit usually includes a prefilled syringe of epinephrine and an epinephrine nebulizer, which allows prompt self-treatment for any future exposures to insect venom or other potential allergen exposure.
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35-year-old pregnant client with placenta previa. 2. A 42-year-old client with a pulmonary embolus. 3. A 60-year-old client receiving hemodialysis three (3) days a week. 4. A 78-year-old client diagnosed with septicemia.
ANSWER: 4. 1. DIC is a complication in many obstetric problems, including septic abortion, abruptio placentae, amniotic fluid embolus, and retained dead fetus, but it is not a complication of placenta previa. 2. A client with a fat embolus is at risk for DIC, but a client with a pulmonary embolus is not. 3. Hemodialysis is not a risk factor for developing DIC. 4. DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC. TEST-TAKING HINT: The test taker could eliminate option "3" if the test taker knew that DIC is a complication of another disorder. Age is not a risk factor for developing DIC.
The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.
ANSWER: 4. 1. Diabetes insipidus is not diabetes mellitus; sliding-scale insulin is not administered to the client. 2. There is no caffeine restriction for DI. 3. Checking urine ketones is not indicated. 4. The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently. TEST-TAKING HINT: Two (2) of the answer options are appropriate for diabetes mellitus, not diabetes insipidus, and can be eliminated based on this alone
Which client would the nurse identify as being at risk for developing diabetes? 1. The client who eats mostly candy and potatoes. 2. The 22-year-old client who has been taking birth control pills. 3. The client who has a cousin who has had diabetes for two (2) years. 4. The 38-year-old female who delivered a 10-pound infant.
ANSWER: 4. 1. Eating sweets and high-carbohydrate foods can lead to obesity, but eating candy does not cause diabetes. 2. Birth control pills do not increase the risk of developing diabetes. 3. Type 2 diabetes can be more prevalent in families, but one cousin does not increase the risk of diabetes for the client. 4. Research shows that women who delivered a large infant have a greater risk for developing diabetes. TEST-TAKING HINT: The test taker must know antecedents of developing disease processes.
The nurse writes the problem of "grieving" for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care? 1. Encourage the client to talk about feelings of loss. 2. Arrange for the family to plan a memorable outing. 3. Refer the client to the American Cancer Society's Dialogue group. 4. Have the chaplain visit with the client.
ANSWER: 4. 1. Encouraging the client to talk about his or her feelings is an independent nursing intervention. 2. Discussing activities that will make pleasant memories and planning a family outing improve the client's quality of life and assist the family in the grieving process after the client dies, but this is an independent nursing intervention. 3. Nurses can and do refer clients diagnosed with cancer to the American Cancer Society- sponsored groups independently. Dialogue is a group support meeting that focuses on dealing with the feelings associated with a cancer diagnosis. 4. Collaborative interventions involve other departments of the health-care facility. A chaplain is a referral that can be made, and the two disciplines should work together to provide the needed interventions. TEST-TAKING HINT: The stem of the question asks for a collaborative intervention, which means that another health-care discipline must be involved. Options "1," "2," and "3" are all interventions the nurse can do without another discipline being involved.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? 1. Administer parenteral epinephrine, an adrenergic agonist. 2. Prepare for immediate endotracheal intubation. 3. Provide a calm assurance when caring for the client. 4. Establish and maintain a patent airway
ANSWER: 4. 1. Epinephrine is the drug of choice for an anaphylactic reaction. It is a potent vasoconstrictor and bronchodilator counteracting the effects of histamine, but this is not the priority intervention. 2. This is an important intervention, but it is not the priority intervention. 3. Decreasing the client's anxiety is important, but it is not the priority intervention. 4. Establishing a patent airway is priority because facial angioedema, bronchospasm, and laryngeal edema occur with an anaphylactic reaction. Inserting a nasopharyngeal or oropharyngeal airway is the priority intervention to save the client's life.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day
ANSWER: 4. 1. Fiber should be increased in the client diagnosed with hypothyroidism because the client experiences constipation secondary to decreased metabolism. 2. The client with hyperthyroidism should have a high-calorie, high-protein diet. 3. The client's fluid intake should be increased to replace fluids lost through diarrhea and excessive sweating. 4. The client with hyperthyroidism has an increased appetite; therefore, well-balanced meals served several times throughout the day will help with the client's constant hunger. TEST-TAKING HINT: If the test taker knows the metabolism is increased with hyperthyroidism, then increasing the food intake is the most appropriate choice
The client diagnosed with menorrhagia complains to the nurse of feeling listless and tired all the time. Which scientific rationale would explain why these symptoms occur? 1. The pain associated with the menorrhagia does not allow the client to rest. 2. The client's symptoms are unrelated to the diagnosis of menorrhagia. 3. The client probably has been exposed to a virus that causes chronic fatigue. 4. Menorrhagia has caused the client to have decreased levels of hemoglobin.
ANSWER: 4. 1. Menorrhagia (excessive blood loss during menses) does not cause pain. Fibroids or other factors that cause the menorrhagia may cause pain, but lack of rest or sleep is not responsible for the listlessness or fatigue. 2. The symptoms are the direct result of the excessive blood loss. 3. Some viruses do cause a chronic fatigue syndrome, but there is a direct cause and effect from the menorrhagia. 4. Menorrhagia is excessive blood loss during menses. If the blood loss is severe, then the client will not have the blood's oxygencarrying capacity needed for daily activities. The most frequent symptom and complication of anemia is fatigue. It frequently has the greatest impact on the client's ability to function and quality of life. TEST-TAKING HINT: Three (3) of the answer options have the word "menorrhagia" in them, but option "3" detours from the subject to talk about viruses; this could eliminate it as a consideration. This question requires the test taker to understand medical terminology—in this case, what menorrhagia means—and then decide what results from that process in the body
The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching? 1. "This medication may cause drowsiness so I need to be careful." 2. "I should not drink any type of alcohol or take any antihistamines." 3. "I will increase the fiber in my diet and increase fluid intake." 4. "I stopped taking the medication because I can't afford it."
ANSWER: 4. 1. Muscle relaxants have sedative effects, so appropriate safety measures should be taken. 2. The client should avoid central nervous system depressants because they can increase the sedative effects of the medication. 3. This will help prevent constipation, which is a side effect of this medication. 4. This medication must be tapered over one (1) to two (2) weeks when discontinuing because sudden withdrawal may cause _seizures and paranoid ideation.
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is increased amplitude of electrical stimulation in the muscle. 3. The circulating acetylcholine receptor antibodies are decreased. 4. The client shows a marked improvement of muscle strength.
ANSWER: 4. 1. No change in the client's muscles strength indicates it is not MG. 2. There is reduced amplitude in an electromyogram (EMG) in a client with MG. 3. The serum assay of circulating acetylcholine receptor antibodies is increased, not decreased, in MG, and this test is only 80% to 90% accurate in diagnosing MG. 4. Clients with MG show a significant improvement of muscle strength lasting approximately five (5) minutes when Tensilon (edrophonium chloride) is injected. TEST-TAKING HINT: There are some knowledge-based questions, such as diagnostic tests.
The student nurse asks the nurse, "What is sickle cell anemia?" Which statement by the nurse would be the best answer to the student's question? 1. "There is some written material at the desk that will explain the disease." 2. "It is a congenital disease of the blood in which the blood does not clot." 3. "The client has decreased synovial fluid that causes joint pain." 4. "The blood becomes thick when the client is deprived of oxygen."
ANSWER: 4. 1. Offering the nursing student written material is appropriate, but the nurse's best statement would be to answer the student's question. 2. The problem in sickle cell anemia is the blood clots inappropriately when there is a decrease in oxygenation. 3. This is a true statement, but it is not the best response because it is not answering the nursing student's question. 4. Sickle cell anemia is a disorder of the red blood cells characterized by abnormally shaped red cells that sickle or clump together, leading to oxygen deprivation and resulting in crisis and severe pain. TEST-TAKING HINT: When answering a question, the test taker should really close the eyes and answer the question exactly how he or she would answer in the clinical setting. Most nurses would answer the student's question and not offer written material.
The concepts of nutrition and metabolism have been identified for the client. Which referral should the nurse include in the plan of care? 1. Physical therapy. 2. Social work. 3. Speech therapy. 4. Dietary
ANSWER: 4. 1. Physical therapy is not indicated. 2. Social work is not indicated. 3. Speech therapy is not indicated. 4. Metabolism involves the intake and utilization of nutrients; the dietitian should be consulted. TEST-TAKING HINT: As a coordinator of care, the nurse must be aware of each discipline and how it affects the client's care.
The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate? 1. Protamine sulfate, an anticoagulant antidote. 2. Heparin sodium, an anticoagulant. 3. Lovenox, a low molecular weight anticoagulant. 4. Vitamin K, an anticoagulant agonist
ANSWER: 4. 1. Protamine sulfate is the antidote for a heparin overdose, not for warfarin toxicity. 2. Administering heparin would increase the client's risk of bleeding. 3. Lovenox is a low molecular weight heparin and would increase the client's risk of bleeding. 4. The antidote for warfarin (Coumadin) is vitamin K, an anticoagulant agonist.
Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis? 1. Encourage the client to ventilate feelings about the disease process. 2. Discuss the effects of disease on the client's career and other life roles. 3. Instruct the client to perform most important activities in the morning. 4. Teach the client the proper use of hot and cold therapy to provide pain relief
ANSWER: 4. 1. Rheumatoid arthritis is a chronic illness, and verbalization of feelings is helpful in dealing with disease processes, but it is not the highest priority intervention. 2. This helps the client accept the disease process and body changes and helps the client to begin to identify strategies for coping with them, but it is not the highest priority intervention. 3. Helping the client prioritize activities helps the client maintain independence as long as possible. 4. Pain is priority over psychological problems and activity; remember Maslow's hierarchy of needs.
The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client? 1. The client's clot formations will resolve in two (2) days. 2. The saturation of the client's dressings will be documented. 3. The client will use lemon-glycerin swabs for oral care. 4. The client's urine output will be greater than 30 mL per hour.
ANSWER: 4. 1. The body dissolves clots over a period of several days to a week or more. The problem in DIC is that the body is bleeding and clotting simultaneously. 2. This is a nursing goal, not a client goal. 3. Lemon-glycerin swabs are drying to the mucosa and should be avoided because they will increase bleeding from the mucosa. 4. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.
The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented? 1. Plan a strenuous exercise program. 2. Order a mechanical soft diet. 3. Maintain a keep-open IV. 4. Obtain an order for a sedative.
ANSWER: 4. 1. The client diagnosed with RA is generally fatigued, and strenuous exercise increases the fatigue, places increased pressure on the joints, and increases pain. 2. The client should be on a balanced diet high in protein, vitamins, and iron for tissue building and repair and should not require a mechanically altered diet. 3. There is no specific reason for the client to be ordered a keep-open IV; the client can swallow needed medications. 4. Sleep deprivation resulting from pain is common in clients diagnosed with RA. A mild sedative can increase the client's ability to sleep, promote rest, and increase the client's tolerance of pain. TEST-TAKING HINT: The test taker should be aware of adjectives leading to an option being eliminated—for example, the word "strenuous" in option "1."
The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warm-up and cool-down exercises
ANSWER: 4. 1. The client diagnosed with type 2 diabetes who is not taking insulin or oral agents does not need extra food before exercise. 2. The client with diabetes who is at risk for hypoglycemia when exercising should carry a simple carbohydrate, but this client is not at risk for hypoglycemia. 3. Clients with diabetes controlled by diet and exercise must exercise daily at the same time and in the same amount to control the glucose level. 4. All clients who exercise should perform warm-up and cool-down exercises to help prevent muscle strain and injury. TEST-TAKING HINT: Options "1" and "2" apply directly to clients diagnosed with diabetes, and options "3" and "4" do not directly address clients diagnosed with diabetes. The reader could narrow the choices by either eliminating or including the two similar options.
Which client problem is the nurse's priority concern for the client diagnosed with acute pancreatitis? 1. Impaired nutrition. 2. Skin integrity. 3. Anxiety. 4. Pain relief.
ANSWER: 4. 1. The client is NPO and can live without food for a number of days as long as he or she receives fluids. 2. The client is not on strict bedrest and can move about in the bed; therefore, skin integrity is not a priority problem. In pancreatitis, the tissue damage is internal. 3. The client may be anxious, but psychosocial problems are not priority. 4. The client with pancreatitis is in excruciating pain because the enzymes are autodigesting the pancreas; severe abdominal pain is the hallmark symptom of pancreatitis.
The client diagnosed with end-stage renal disease (ESRD) has developed anemia. Which would the nurse anticipate the HCP prescribing for this client? 1. Place the client in reverse isolation. 2. Discontinue treatments until blood count improves. 3. Monitor CBC daily to assess for bleeding. 4. Give client erythropoietin, a biologic response modifier.
ANSWER: 4. 1. The client is anemic, not neutropenic, so reverse isolation is not needed. 2. This client will be receiving a form of dialysis to maintain life. Discontinuing treatments until the counts improve would be resigning the client to death. 3. The red blood cell count would not appreciably improve from one day to the next unless a transfusion had been given. 4. Erythropoietin is a biologic response modifier produced by the kidneys in response to a low red blood cell count in the body. It stimulates the body to produce more RBCs
The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of "risk for altered skin integrity related to pruritus." Which intervention should the nurse implement? 1. Assess tissue turgor. 2. Apply antifungal creams. 3. Monitor bony prominences for breakdown. 4. Have the client keep the fingernails short.
ANSWER: 4. 1. The client is at risk for poor nutrition and malabsorption syndrome for which tissue turgor assessment is appropriate, but the client problem is pruritus, or itching. 2. The itching is associated with the cancer and not a fungus. 3. The client should be monitored for skin breakdown, but pruritus is itching and an intervention is needed to prevent skin problems as a result of scratching. 4. Keeping the fingernails short will reduce the chance of breaks in the skin from scratching. TEST-TAKING HINT: The problem is "risk for skin breakdown." The etiology is "pruritus." Interventions address the etiology. Goals address the problem.
The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.
ANSWER: 4. 1. The kidneys filter wastes, not antibodies, from the blood. 2. The problem is an overactive immune system, not damage to the endocrine system. There is no research supporting a virus as an initiating factor. 3. SLE is an autoimmune disease characterized by exacerbations and remission. There is empirical evidence indicating hormones may cause the development of the disease, and some drugs can initiate the process. 4. There is evidence for familial and hormonal components to the development SLE. SLE is an autoimmune disease process in which there is an exaggerated production of autoantibodies. TEST-TAKING HINT: The test taker could eliminate options "1" and "2" by referring to basic anatomy and physiology and the function of the kidneys and endocrine system.
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should not be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bedrest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.
ANSWER: 4. 1. The licensed practical nurse (LPN) can administer a muscle relaxant. 2. The licensed practical nurse can talk with a health-care provider about medication the LPN can give. 3. The LPN can draw blood. 4. The nurse should not assign assessing, teaching, or evaluation to the LPN. Evaluating the client's ability to perform selfcatheterization should not be assigned to the LPN. TEST-TAKING HINT: When deciding on assigning tasks, the test taker must be aware of the capabilities of each classification of staff by licensure.
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis? 1. Occupational therapist. 2. Recreational therapist. 3. Vocational therapist. 4. Speech therapist.
ANSWER: 4. 1. The occupational therapist assists the client with ADLs, but with MG the client has no problems with performing them if the client takes the medication correctly (30 minutes prior to performing ADLs). 2. A recreational therapist is usually in a psychiatric unit or rehabilitation unit. 3. A vocational therapist or counselor helps with the client finding a job which accommodates the disease process; clients with MG are usually not able to work in the late stages. 4. Speech therapists address swallowing problems, and clients with MG are dysphagic and at risk for aspiration. The speech therapist can help match food consistency to the client's ability to swallow, which enhances client safety. TEST-TAKING HINT: The test taker must be aware of the responsibilities of the other health-care team members. "Collaborative" means working with another health-care team discipline.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented first? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-oflife care.
ANSWER: 4. 1. The problem is grieving R/T loss of functioning. Assistive devices will not prevent loss of functioning and do not address grieving. 2. A legal power of attorney is for personal property and control of financial issues, which is not the focus of the nurse's care. A legal power of attorney for health care may be appropriate. 3. The nurse should and must discuss end-of-life issues with the client and does not need to contact the hospital chaplain. If or when the client reveals spiritual needs, then the nurse could contact the chaplain. 4. The client should make personal choices about end-of-life issues while it is possible to do so. This client is progressing toward immobility and all the complications related to it. TEST-TAKING HINT: This is a psychological problem requiring a psychological answer. Option "1" is a physical intervention and therefore should be eliminated as a correct answer. The test taker should remember adjectives ("legal") are important when answering questions. Option "3" is "passing the buck"; the test taker should be careful if thinking of selecting this type of option.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Collect urine for analysis. 2. Notify the laboratory of the reaction. 3. Administer diphenhydramine, an antihistamine. 4. Stop the transfusion at the hub.
ANSWER: 4. 1. The question asks for a first action; urine will be collected for analysis, but this is not the first intervention. 2. The question asks for a first action. The laboratory should be notified, but this is not the first action to take. 3. Administering an antihistamine may be done, but it is more important to stop the transfusion causing the reaction. 4. Anytime the nurse suspects the client is having a reaction to blood or blood products, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client's body
The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/ dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.
ANSWER: 4. 1. The regular intravenous insulin is continued because ketosis is not present, as with DKA. 2. The client diagnosed with type 2 diabetes does not excrete ketones in HHNS because there is enough insulin to prevent fat breakdown but not enough to lower blood glucose. 3. The client may or may not feel like eating, but it is not the appropriate intervention when the blood glucose level is reduced to 300 mg/dL. 4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale. TEST-TAKING HINT: When two (2) options are the opposite of each other, they can either be eliminated or can help eliminate the other two options as incorrect answers. Options "2" and "3" do not have insulin in the answer; therefore, they should be eliminated as possible answers.
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.
ANSWER: 4. 1. The temperature is not affected by aldosteronism. 2. The pulse is not affected by this disorder. 3. The respirations are not affected by this disorder. 4. Blood pressure is affected by aldosteronism, with hypertension being the most prominent and universal sign of aldosteronism.
The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response? 1. "It is because of the screening techniques used in the United States." 2. "It is a genetic predisposition rare in North Americans." 3. "The medications available in the United States decrease goiters." 4. "Iodized salt helps prevent the development of goiters in the United States."
ANSWER: 4. 1. There is no screening for thyroid disorders, just serum thyroid levels. 2. This is not a true statement. 3. Medications do not decrease the development of goiters. 4. Almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, which is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the United States has iodine added. TEST-TAKING HINT: The nurse must know about disease processes. There is no testtaking hint to help with knowledge.
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia
ANSWER: 4. 1. These are clinical manifestations of multiple sclerosis and are expected. 2. These are expected clinical manifestations of multiple sclerosis. 3. These are expected clinical manifestations of multiple sclerosis. 4. Dysphagia is a common problem of clients diagnosed with multiple sclerosis, and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia. TEST-TAKING HINT: This question is asking the test taker to identify the assessment data unexpected for the disease process. Respiratory problems are high priority according to Maslow and often warrant immediate intervention
Which laboratory data would the nurse identify when discussing a client with uncontrolled diabetes mellitus type 2? (Note: Reference values: Glucose 70-110 mg/dL; hemoglobin A1c4-6). 1) Glucose 89, HbA1C 5.6. 2) Glucose 134, HbA1C 7.1. 3) Glucose 112, HbA1C 8.2. 4) Glucose 439, HbA1C 9.3.
ANSWER: 4. 1. These results are both WNL; they do not indicate type 2 diabetes. 2. These results are both slightly above normal but they do not indicate type 2 diabetes. 3. These results are both slightly above normal but they do not indicate type 2 diabetes. 4. Both laboratory values are above the normal range. The A1c indicates a lengthy time (at least two [2] to three [3] months) that the blood glucose has been high. This would be supportive of uncontrolled type 2 diabetes. TEST-TAKING HINT: The test taker must know normal and abnormal diagnostic laboratory values. Laboratory values vary depending on which laboratory performs the test.
Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, Pao2 99, Paco2 48, HCO3 24. 2. pH 7.38, Pao2 95, Paco2 40, HCO3 22. 3. pH 7.46, Pao2 85, Paco2 30, HCO3 26. 4. pH 7.30, Pao2 90, Paco2 30, HCO3 18.
ANSWER: 4. 1. This ABG indicates respiratory acidosis, which is not expected. 2. This ABG is normal, which is not expected. 3. This ABG indicates respiratory alkalosis, which is not expected. 4. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis. TEST-TAKING HINT: The test taker must know normal ABGs to be able to correctly answer this question. Normal ABGs are pH 7.35 to 7.45; Pao2 80 to 100; Paco2 35 to 45; HCO3 22 to 26.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement? 1. Tell the wife she must stop crying. 2. Escort the wife out of the room. 3. Medicate the client immediately. 4. Acknowledge the wife's fears.
ANSWER: 4. 1. This action does not address the wife's fears, and telling her to stop crying will not help the situation. 2. Making the wife leave the room will further upset the client and the client's wife. 3. Medicating the client will not help the wife, but if the nurse can calm the wife, then it is hoped the client will calm down. 4. It is scary for a wife to see her loved one with a tube down his mouth and all the machines around him. The nurse should help the wife by acknowledging her fears. TEST-TAKING HINT: The test taker should select the option addressing the wife's needs first. By addressing the wife's needs, the client will calm down. The test taker should not automatically select the option which medicates the client.
Which client should be assigned to the experienced medical-surgical nurse who is in the first week of orientation to the oncology floor? 1. The client diagnosed with non-Hodgkin's lymphoma who is having daily radiation treatments. 2. The client diagnosed with Hodgkin's disease who is receiving combination chemotherapy. 3. The client diagnosed with leukemia who has petechiae covering both anterior and posterior body surfaces. 4. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units of packed red blood cells.
ANSWER: 4. 1. This client is receiving treatments that can have life-threatening side effects; the nurse is not experienced with this type of client. 2. Chemotherapy is administered only by nurses who have received training in chemotherapy medications and their effects on the body and are aware of necessary safety precautions; this nurse is in the first week of orientation. 3. This is expected in a client with leukemia, but it indicates a severely low platelet count; a nurse with more experience should care for this client. 4. This client is receiving blood. The nurse with experience on a medical-surgical floor should be able to administer blood and blood products. TEST-TAKING HINT: The key to this question is the fact, although the nurse is an experienced medical-surgical nurse, the nurse is not experienced in oncology. The client who could receive a treatment on a medical-surgical floor should be assigned to the nurse.
The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after IV fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.
ANSWER: 4. 1. This is a diagnostic test done to diagnose MG. 2. These assessment data indicate the client is experiencing a myasthenic crisis, which is the result of undermedication, missed doses of medication, or the development of an infection. 3. The vital signs do not indicate if the client is experiencing a cholinergic crisis. 4. The injection of edrophonium chloride (Tensilon test) not only diagnoses MG but helps to determine which type of crisis the client is experiencing. In a myasthenic crisis, the test is positive (the client's muscle strength improves), but in cholinergic crisis, the test is negative (there is no improvement in muscle strength), or the client will actually get worse and emergency equipment must be available. TEST-TAKING HINT: This question requires the test taker to be knowledgeable of the disease process, but this is an important concept the test taker must understand about myasthenia gravis.
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response? 1. SIRS is a localized response to major trauma that has occurred within the last three (3) months. 2. SIRS is a syndrome of potential responses to illness that has an optimum prognosis. 3. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia. 4. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
ANSWER: 4. 1. This is a systemic problem, not a localized response. 2. SIRS untreated or unresponsive to treatment progresses to Multi Organ Dysfunction Syndrome (MODS). 3. SIRS is not limited to myocardial or pulmonary issues. 4. This is the definition of SIRS. TEST-TAKING HINT: This question is asking the test taker to know the definition of a disease process. The test taker may be able to answer the question by identifying words in the name that describe what is occurring in the body, Localized versus the name "systemic" could eliminate option "1."
The unlicensed assistive personnel (UAP) asks the primary nurse, "How does someone get hemophilia A?" Which statement would be the primary nurse's best response? 1. "It is an inherited X-linked recessive disorder." 2. "There is a deficiency of the clotting factor VIII." 3. "The person is born with hemophilia A." 4. "The mother carries the gene and gives it to the son."
ANSWER: 4. 1. This is a true statement, but it is medical jargon explaining how someone gets hemophilia A and so is not the best response. 2. This is a true statement, but it refers to the pathophysiology of hemophilia A and does not explain how someone gets the disease. 3. This is a true statement, but it does not answer the question of how someone gets it. 4. This is a true statement and explains exactly how someone gets hemophilia A: The mother passes it to the son. TEST-TAKING HINT: When the stem has the word "best" in it, then all four answer options could be correct and, in this case, statements that the nurse could reply, but only one answer option is best. The test taker needs to evaluate the stem and identify terms that may help select the best option; in this case, a UAP is asking the question and a direct answer without using medical jargon should be given.
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse? 1. Discuss the Myasthenia Foundation with the client's wife. 2. Refer the client to a local myasthenia gravis support group. 3. Ask the client's wife if she would like to talk to a counselor. 4. Sit down and allow the wife to ventilate her feelings to the nurse.
ANSWER: 4. 1. This is an appropriate action by the nurse, but it is not the best action. 2. Support groups are helpful to the client's significant others, but in this situation, it is not the best action for the nurse. 3. A counselor is an appropriate intervention, but it is not the best action. 4. Directly addressing the wife's feelings is the best action for the nurse in this situation. All the other options can be done, but the best action is to address the wife's feelings. TEST-TAKING HINT: The test taker should select the option directly addressing and helping the client or significant other. Remember, if the word "best," "most important," or "first" is in the stem, then all four (4) options could be possible interventions, but only one is the highest priority.
The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal antiinflammatory drugs (NSAIDs)? 1. Take with an over-the-counter medication for the stomach. 2. Drink a full glass of water with each pill. 3. If a dose is missed, double the medication at the next dosing time. 4. Avoid taking the NSAID on an empty stomach.
ANSWER: 4. 1. This is prescribing, and the nurse is not licensed to do this unless the nurse has become a nurse practitioner. 2. NSAIDs do not require a specific amount of water to be effective, unlike bulk laxatives. 3. The medication should be taken in the usual dose when the client realizes a dose has been missed. 4. NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food. TEST-TAKING HINT: Knowledge of medication administration is a priority for every nurse. It is especially important for the nurse to be familiar with commonly used medications such as NSAIDs, which can be purchased over the counter and may be taken by the client in addition to prescription medications.
The nurse is teaching a community class to people with type 2 diabetes mellitus. Which explanation explains the development of type 2 diabetes? 1. The islet cells in the pancreas stop producing insulin. 2. The client eats too many foods high in sugar. 3. The pituitary gland does not produce vasopressin. 4. The cells become resistant to the circulating insulin.
ANSWER: 4. 1. This is the cause of type 1 diabetes mellitus. 2. This may be a reason for obesity, which may lead to type 2 diabetes, but eating too much sugar does not cause diabetes. 3. This is the explanation for diabetes insipidus, which should not be confused with diabetes mellitus. 4. Normally insulin binds to special receptors sites on the cell and initiates a series of reactions involved in metabolism. In type 2 diabetes, these reactions are diminished primarily as a result of obesity and aging.
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome? 1. Decreasing deep tendon reflexes. 2. Drooping of the eyelids has resolved. 3. A positive Babinski's reflex. 4. Descending increase in muscle strength.
ANSWER: 4. 1. This occurs in the acute stage of GuillainBarré syndrome. 2. This indicates the client diagnosed with myasthenia gravis is getting better. 3. A positive Babinski's reflex in an adult client is abnormal and indicates neurological deficits. 4. The recovery stage may take from several months to two (2) years, and muscle strength and function return in a descending order
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.
ANSWER: 4. 1. This should be done but after preventing any more of the PRBCs from infusing. 2. Benadryl may be administered to reduce the severity of the transfusion reaction, but it is not first priority. 3. The nurse should assess the client, but in this case the nurse has all the assessment data needed to stop the transfusion. 4. The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client's bloodstream. TEST-TAKING HINT: In a question that requires the test taker to determine a priority action, the test taker must decide what will have the most impact on the client. Option "4" does this. All the options are interventions that should be taken, but only one will be first.
The client asks the nurse, "Which time of the year is allergic rhinitis least likely to occur?" Which statement is the nurse's best response? 1. "It is least likely to occur during the springtime." 2. "Allergic rhinitis is not likely to occur during the summer." 3. "It is least likely to occur in the early fall." 4. "Allergic rhinitis is least likely to occur in early winter."
ANSWER: 4. 1. Tree pollen is abundant in early spring. 2. Rose and grass pollen are prevalent in early summer. 3. Ragweed and other pollens are prevalent in early fall. 4. Early winter is the beginning of deciduous plants becoming dormant. Therefore, allergic rhinitis is least prevalent during this time of year. TEST-TAKING HINT: The test taker could eliminate the three (3) options based on the plant growing season if the test taker realized allergic rhinitis can be caused by environmental plant pollens and molds.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP? 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received 10 units of platelets in brushing the teeth.
ANSWER: 4. 1. UAPs cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion. The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. 4. The UAP can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding gums should be given prior to delegating the procedure. TEST-TAKING HINT: The test taker must be aware of delegation guidelines. The nurse cannot delegate assessment or any intervention requiring nursing judgment. Options "1," "2," and "3" require judgment and cannot be delegated to a UAP.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. "I see you are crying. We can talk if you would like."
ANSWER: 4. 1. Unless the nurse has SLE and has been through the exact same type of tissue involvement, then the nurse should not tell a client "I know." This does not address the client's feelings. 2. The nurse should never ask the client "why." The client does not owe the nurse an explanation of his or her feelings. 3. Support groups should be recommended, but this is not the best response when the client is crying. 4. The nurse stated a fact, "You are crying," and then offered self by saying "Would you like to talk?" This addresses the nonverbal cue, crying, and is a therapeutic response. TEST-TAKING HINT: The question asks for a therapeutic response, which means a feeling must be addressed. Therapeutic responses do not ask "why," so the test taker could rule out option "2."
The client admitted with rule-out GuillainBarré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure? 1. Monitor the client for hypotension. 2. Apply pressure to the puncture site. 3. Test the client's cerebrospinal fluid. 4. Increase the client's fluid intake.
ANSWER: 4. 1. Very little cerebrospinal fluid is removed from the client. Therefore, hypotension is not a potential complication of this procedure. 2. A bandage is placed over the puncture site, and pressure does not need to be applied to the site. 3. The laboratory staff, not the nurse, complete tests on the cerebrospinal fluid; the nurse could label the specimens and take them to the laboratory. 4. Increased fluid intake will help prevent a postprocedure headache, which may occur after a lumbar puncture. TEST-TAKING HINT: The test taker could eliminate option "3" because nurses usually do not perform tests on bodily fluids at the bedside. A basic concept in many procedures is, if fluid is removed, it usually must be replaced, which might cause the test taker to select option "4."
The client diagnosed with leukemia has received a bone marrow transplant. The nurse monitors the client's absolute neutrophil count (ANC). What is the client's neutrophil count if the WBCs are 2.2 (× 103 )/mm3 , neutrophils are 25%, and bands are 5%? ____________
ANSWER: 660 ANC. To determine the absolute neutrophil count, first the WBC count must be determined: 2.2 multiplied by 1,000 (103 ) = 2,200. Multiply that by 30 (25% neutrophils + 5% bands) to obtain 66,000 and divide that by 100 to determine the ANC of 660. The ANC is used to determine a client's risk of developing an infection.
The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500-mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record? ____________
ANSWER: 886 mL of fluid has infused. 250 mL + 63 mL = 313 mL per unit 313 + 313 = 626 mL 500 mL of saline - 240 mL remaining = 260 mL infused. 626 mL + 260 mL = 886 mL of fluid infused. TEST-TAKING HINT: This problem has several steps but only requires basic addition and subtraction. The test taker should use the drop-down calculator on the computer to check or double-check the answer to make sure that simple mistakes are not made.
The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance. 1. Start the transfusion slowly. 2. Have the client sign a permit. 3. Assess the IV site for size and patency. 4. Check the blood with another nurse at the bedside. 5. Obtain the blood from the laboratory
ANSWER: In order of performance: 2, 3, 5, 4, 1. 2. The client must give consent prior to receiving blood; therefore, this is the first intervention. 3. Blood products should be administered within 30 minutes of obtaining the blood from the laboratory; therefore, the nurse should determine the IV is patent and the catheter is large enough to administer blood, preferably an 18-gauge catheter, before obtaining the blood. 5. The nurse must then obtain the blood from the laboratory. 4. Blood must be checked by two (2) registered nurses at the bedside to check the client's crossmatch bracelet with the unit of blood. 1. After all of the previous steps are completed, then the nurse should start the infusion of the blood slowly for the first 15 minutes to determine if the client is going to have a reaction.
The client diagnosed with type 1 diabetes mellitus received regular insulin two (2) hours ago. The client is complaining of being jittery and nervous. Which interventions should the nurse implement? List in order of priority. 1. Call the laboratory to confirm blood glucose level. 2. Administer a quick-acting carbohydrate. 3. Have the client eat a bologna sandwich. 4. Check the client's blood glucose level at the bedside. 5. Determine if the client has had anything to eat.
ANSWER: In order of performance: 5, 2, 4, 1, 3. 5. Regular insulin peaks in two (2) to four (4) hours; therefore, the nurse should suspect a hypoglycemic reaction if the client has not eaten anything. 2. The antidote for insulin is glucose; therefore, the nurse should give the client some type of quick-acting food source. 4. The nurse should obtain the client's blood glucose level as soon as possible; this can be done with a glucometer at the bedside. 1. Most hospitals require a confirmatory serum blood glucose level. Do not wait for results to give food. 3. A source of long-acting carbohydrate and protein should be given to prevent a reoccurrence of hypoglycemia.
The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority. 1. Establish a patent airway. 2. Administer epinephrine, an adrenergic agonist, IVP. 3. Start an IV with 0.9% saline. 4. Teach the client to carry an EpiPen when outside. 5. Administer diphenhydramine (Benadryl), an antihistamine, IVP.
ANSWER: In order of priority: 1, 3, 2, 5, 4. 1. Airway is always the first priority for any process in which the airway might be compromised. 3. The nurse should start an IV so medications can be administered to treat the anaphylactic reaction. 2. Epinephrine is the drug of choice for the treatment of anaphylaxis. The medication is administered every 10 to 15 minutes until the reaction has subsided. Epinephrine is given for its vasoconstrictive action. 5. Benadryl, an antihistamine, is given to block histamine release, reducing capillary permeability. 4. Teaching is important to prevent or treat further reactions, but this will be done after the crisis is over
The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive? ________
ANSWER: The client has received 8,650 mL of intravenous fluid. TEST-TAKING HINT: This is a basic addition problem. If the test taker has difficulty with this problem, then a math review course would be in order
The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: 251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
ANSWER: Three (3) units. The client's result is 189, which is between 151 and 200, so the nurse should administer three (3) units of Humalog insulin subcutaneously. TEST-TAKING HINT: The test taker must be aware of the way HCPs write medication orders. HCPs order insulin on a sliding scale according to a range of blood glucose levels.
Which assessment data should make the nurse suspect the client has chronic allergies? 1. Jaundiced sclera and jaundiced palms of hands. 2. Pale, boggy, edematous nasal mucosa. 3. Lacy white plaques on the oral mucosa. 4. Purple or blue patches on the face.
ANSWER:2. 1. This may indicate a hemolytic reaction. 2. Pale, boggy, edematous nasal mucosa indicates chronic allergies. 3. This may indicate hemolysis or immune deficiency. 4. This may indicate Kaposi's sarcoma.
_____: Resistance to infection that occurs when the body responds to an invading antigen by making specific antibodies against the antigen. Immunity lasts for years and is natural by infection or artificial by stimulation (e.g., vaccine) of the body's immune defenses.
Active immunity
_____: A clinical sign of some abnormal condition related to a reduction in one of the following: number of red blood cells, amount of hemoglobin, or hematocrit (percentage of packed red blood cells per deciliter of blood).
Anemia
_____: An abnormal karyotype with more or fewer than 23 pairs of chromosomes.
Aneuploid (aneuploidy
The nurse is performing an assessment on a client with anemia. What are the typical clinical manifestations of anemia? A) Pallor. B) Fatigue. C) Tachycardia. D) Dyspnea on exertion. E) Elevated temperature. F) Decreased breath sounds.
Answer: A, B, C, D. The typical clinical manifestations of anemia are: pallor, fatigue, tachycardia, and dyspnea on exertion. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Fatigue is a classic symptom of anemia because lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body.Respiratory problems with anemia do not include changes in breath sounds. Skin is cool to the touch, and an intolerance to cold is noted. Elevated temperature would signify something additional, such as infection.
What are the risk factors for the development of leukemia? (Select all that apply). A) Down syndrome. B) Chemical exposure. C) Ionizing radiation. D) Prematurity at birth. E) Bone marrow hypoplasia. F) Multiple blood transfusions
Answer: A, B, C, E. Risk factors related to the development of leukemia include: Down syndrome, chemical exposure, ionizing radiation, and bone marrow hypoplasia. Certain genetic factors contribute to the development of leukemia. Down syndrome is one such condition. Exposure to chemicals through medical need or by environmental events can also contribute. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes. Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia.Although some genetic factors may influence the incidence of leukemia, prematurity at birth is not one of them. There is no indication that multiple blood transfusions are connected to clients who have leukemia.
A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? A) Brain. B) Bone. C) Lymph nodes. D) Kidneys. E) Liver
Answer: A, B, C, E. Typical sites of metastasis of lung cancer include the brain, bone, lymph nodes, liver, and pancreas.Kidneys are not a typical site of lung cancer metastasis.
Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? (Select all that apply). A) Change the decorations in the home according to the season. B) Put the bed close to the window. C) Write out detailed instructions, and have the client read them over before performing a task. D) Ask the client what time he or she prefers to shower or bathe. E) Mark off the days of the calendar, leaving open the current date.
Answer: A, B, D, E. Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule.Directions to the client need to be short and uncomplicated, and not detailed.
A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? (Select all that apply). A) Fluid retention. B) Gastric distress. C) Hypotension. D) Infection. E) Osteoporosis.
Answer: A, B, D, E. Prednisone is a corticosteroid that may cause fluid and sodium retention. It can cause gastric distress and irritation and usually is taken with food or an antacid. Prednisone decreases the immune response, increasing the susceptibility for infection. It can also cause osteoporosis.Hypertension (not hypotension) is an adverse effect of prednisone.
The nurse includes which factors in teaching regarding the typical warning signs of cancer? (Select all that apply): A) Persistent constipation. B) Scab present for 6 months. C) Curdlike vaginal discharge. D) Axillary swelling. E) Headache.
Answer: A, B, D. Change in bowel habits, a sore that does not heal, and a lump or thickening in the breast or elsewhere are all potential warning signs of cancer.Curd like vaginal discharge represents a yeast infection. Headache is not a warning sign, but may be present with multiple medical problems.
An 82-year-oldclient with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? A) Hypotension. B) Hypertension. C) Decreased pallor. D) Rapid, bounding pulse. E) Flattened superficial veins. F) Capillary refill less than 3 seconds.
Answer: A, B, D. The assessment findings that are unsafe for the nurse to continue the blood transfusion for the client are: hypotension, hypertension, and rapid, bounding pulse. In an older adult receiving a transfusion, low blood pressure is a sign of a transfusion reaction, hypertension is a sign of overload, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic.Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem.
The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? (Select all that apply). A) Calcium gluconate. B) Emergency tracheotomy kit. C) Furosemide (Lasix). D) Hypertonic saline. E) Oxygen. F) Suction.
Answer: A, B, E, F. Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client's bedside because of the risk for increased secretions.Furosemide is a diuretic used to treat hypercalcemia associated with hyperparathyroidism. However, hypocalcemia from inadvertent parathyroid removal during thyroidectomy is the greater concern. Hypertonic saline is not necessary for this client. This client is not expected to have hyponatremia after surgery.
When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? Episodes of confusion Pulse 88 and regular Weakness, tremors Na: 115 mEq/L (115 mmol/L) K: 4.2 mEq/L (4.2 mmol/L) Creatinine: 0.8 mg/dL (70.8 mcmol/L) Medications: Ondansetron (Zofran); Cyclophosphamide (Cytoxan) (Select all that apply). A) Hyponatremia. B) Mental status changes. C) Azotemia. D) Bradycardia. E) Weakness.
Answer: A, B, E. Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia (low sodium level) results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia.Azotemia refers to a buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.
A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply). A) "Ask her how she is feeling." B) "Ask her if she needs anything." C) "Tell her to be brave and to not cry." D) "Tell her what you know about leukemia." E) "Talk to her as you normally would when you haven't seen her for a long time."
Answer: A, B, E. The nurse suggests some comments a family member of a recently diagnosed client with leukemia might say to the client. The first statement may be, "ask her how she is feeling." This is a broad general opening and would be nonthreatening to the client. Or "ask her if she needs anything" Asking if she needs anything is a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member would talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option.Telling her to be brave and not to cry is callous and unfeeling. If the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia would be the client's prerogative.
The nurse is teaching a client with newly diagnosed anemia about conserving energy. Which instructions would the nurse give to the client? (Select all). A) "Provide yourself with four to six small, easy-to-eat meals daily." B) "Perform your care activities in groups to conserve your energy." C) "Stop activity when shortness of breath or palpitations is present." D) "Allow others to perform your care during periods of extreme fatigue." E) "Drink small quantities of protein shakes and nutritional supplements daily." F) "Perform a complete bath daily to reduce your chance of getting an infection."
Answer: A, C, D, E. Having four to six small meals daily is preferred over three large meals. This practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status.A complete bath needs to be performed only every other day. On days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities would be spaced every hour or so rather than in groups to conserve energy. Care activities need to be avoided just before and after meals.
When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? A) Bruises. B) Fever. C) Petechiae. D) Epistaxis. E) Pallor.
Answer: A, C, D. Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count (thrombocytopenia).Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.
The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? (Select all that apply). A) Arthralgia. B) Blurred vision. C) Lymphadenopathy. D) Malaise. E) Ptosis.
Answer: A, C, D. Serum sickness is a group of symptoms that occur after receiving serum or certain drugs. Symptoms include arthralgia (achy joints), lymphadenopathy (enlarged lymph nodes), fever, rash, malaise, and possibly polyarthritis and nephritis.Blurred vision and ptosis are not symptoms of serum sickness.
A client at the medical clinic is being evaluated for hypothyroidism. For which of these symptoms consistent with hypothyroidism does the nurse assess? (Select all that apply). A) Pulse rate below 60 beats per minute. B) Agitation and inability to sleep. C) Increasing thermostat settings in the home. D) Increase in appetite over the last year E) Bizarre or manic behavior
Answer: A, C. The nurse assesses the client with hypothyroidism for bradycardia (heart rate below 60). Blood pressure and heart rate and rhythm must be monitored as well as any indications of shock (e.g., hypotension, decreased urine output, changes in mental status). Intolerance to cold is also noted and increasing thermostat settings in the home or additional clothing may be necessary for comfort.Hypothyroidism does not cause agitation and inability to sleep; those symptoms are consistent with hyperthyroidism. Hypothyroidism can cause lethargy, apathy, drowsiness, decreased attention span, and memory. The client often reports an increase in time spent sleeping, sometimes up to 14 to 16 hours daily. The appetite decreases rather than increases and constipation frequently ensues. Bizarre or manic behaviors do not occur with hypothyroidism. Mood swings may occur with hyperthyroidism along with laughing and crying without cause.
Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease? (Select all that apply). A) Use long-handled devices such as a reacher. B) When getting out o f bed, use fingers to push off. C) Sit in a low back chair. D) Bend at the waist while keeping the back straight. E) Use adaptive devices such as Velcro closures. F) Turn a doorknob clockwise.
Answer: A, E. For clients with a connective tissue disease, the use of long-handled devices such as a reacher and other adaptive devices, such as Velcro closures, helps to protect the joints. When getting out of bed, the client should not push off with fingers, but use the entire palm of both hands. Clients with connective tissue disease should sit in a chair that has a high, straight back, and not a low chair, and should bend at the knees, not the waist, while keeping the back straight. Doorknobs should be turned counterclockwise, not clockwise, to avoid twisting the arm and promoting ulnar deviation.
The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? A) "My mother and grandmother had breast cancer, so I am at risk." B) "I get a mammogram every 2 years since I turned 30." C) "A clinical breast examination is performed every month since I turned 40." D) "A computed tomography (CT) scan will be done every year after I turn 50."
Answer: A. A strong family history of breast cancer indicates a risk for breast cancer.Annual rather than biannual screening may be indicated for a strong family history. An annual mammogram is performed after age 40 or in younger clients with a strong family history. The client may perform a self-breast examination monthly, but a clinical examination by a health care provider is indicated annually. Annual CT breast scans after age 50 are not a current recommendation.
A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) "I will apply lotion to the dry areas of my feet, but not between my toes." B) "I will buy over-the-counter medicine to treat the calluses on my feet." C) "I will let my feet air dry after washing." D) "I will wear sandals to allow air to circulate around my feet."
Answer: A. A) Lotion can be used for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth. B) Topical over-the-counter medications can impair skin integrity and lead to further injury. C) The client should dry her feet thoroughly after washing to prevent bacterial growth between the toes. D) The client should wear closed-toe shoes to prevent injury to her feet.
A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? A) pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L. B) pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L. C) pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L. D) pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L.
Answer: A. A) Metabolic acidosis is a common manifestation of DKA, with pH characteristically low, carbon dioxide within the expected reference range, and bicarbonate low. B) Clients who have DKA have an acidic pH, not a pH within the expected reference range. C) Clients who have DKA have an acidic pH, not a pH within the expected reference range. D) Clients who have DKA have an acidic pH, not an alkaline pH.
A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? A) Reduction of the effects of thyroid hormone on the heart. B) Increase in the heart's sensitivity to thyroid hormone. C) Blockage of the release of thyroid hormone from the thyroid gland. D) Increase in the uptake of thyroid hormone by the thyroid gland.
Answer: A. A) Propranolol is a beta2-adrenergic blocking agent that decreases the rapid heart rate that excessive thyroid stimulation causes. B) Propranolol does not increase the heart's sensitivity to thyroid hormone; instead, it helps prevent dysrhythmias. C) Propranolol does not affect thyroid hormone release; instead, it helps lower the client's heart rate. D) Propranolol does not affect the uptake of thyroid hormone by the thyroid gland; instead, it helps lower the client's blood pressure.
A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information about hyperacute rejection should the nurse include in the teaching? A) The organ will need to be removed if hyperacute rejection occurs. B) Hyperacute rejection can occur during the first few weeks after the transplant. C) Immunosuppressive therapy is given to reverse hyperacute rejection. D) If hyperacute rejection occurs, the kidney can become enlarged.
Answer: A. A) Removing the transplanted organ is the only treatment for hyperacute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant kidney. B) Hyperacute rejection occurs immediately following transplantation. Acute rejection occurs during the first few weeks following the client's transplant. C) Immunosuppressive therapy is not used to reverse hyperacute rejection, but it can prevent chronic rejection of the transplant kidney. D) Enlargement of the transplant kidney due to an inflammatory response is consistent with an acute rejection.
To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about the test, which of the following instructions should the nurse include? A) "Restrict coffee intake 2 to 3 days prior to the test." B) "Take low-dose aspirin for pain during the testing period." C) "Start fasting at midnight prior to the day of the test." D) "Begin the 24-hour urine collection with the first morning urination."
Answer: A. A) The client should avoid coffee and tea (even if they are decaffeinated), bananas, chocolate, and vanilla for 2 to 3 days prior to the test. B) The client should avoid aspirin because it can affect test results. C) The client does not have to fast prior to the test, but there are foods the client should avoid, such as bananas and citrus fruits. D) The client should discard the first morning urine, and then collect all urine after that for 24 hr.
A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? A) Erythema at the IV insertion site. B) Mucositis of the oral cavity. C) Loss of body hair. D) Report of anorexia.
Answer: A. A) The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding. B) Sores in the mouth is an expected adverse effect of chemotherapy C) Loss of body hair is an expected adverse effect of chemotherapy D) Weight loss is an expected adverse effect of chemotherapy.
A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse xpect? A) Reed-Sternberg cells. B) Overproduction of blast phase cells. C) Overgrowth of B-lymphocyte plasma cells. D) Epstein-Barr virus.
Answer: A. A) The nurse should expect to find Reed-Sternberg cells, which are cancer cells specific to a client who has Hodgkin's lymphoma, in the client's lymph nodes. B) The nurse should expect a client who has leukemia to have an overproduction of blast phase cells. C) The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte plasma cells. D) The nurse should recognize that the Epstein-Barr virus is associated with the development of Burkitt's lymphoma and Hodgkin's lymphoma; however, it is not a diagnostic finding after the disease has occurred.
A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease? A) "If you develop pain and stiffness in your joints, you should see your doctor." B) "If bitten by a tick, you should be tested immediately." C) "You should wear dark-colored clothing to deter ticks from biting." D) "If you have a tick embedded in your skin, apply a lit match to remove it."
Answer: A. A) The nurse should inform the group that manifestations of stage I Lyme disease include influenza-like symptoms, a "bull's-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider. B) The nurse should instruct the group to be tested for Lyme disease 4 to 6 weeks after being bitten by a tick because earlier testing is not reliable. C) The nurse should instruct the group to wear light colors so ticks on the body can be seen easily. D) The nurse should instruct the group not to use a lit match to remove a tick because this action can increase the risk of spreading an infection. The nurse should instruct the group to gently remove ticks with tweezers.
A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make? A) "Ask a friend or a family member to help with household chores." B) "Use pillows to support your joints while in bed." C) "Exercise every other day." D) "Take a cool bath in the evening."
Answer: A. A) The nurse should instruct the client to allow others to assist with household chores to reduce the risk for joint injury and to give the client the opportunity to rest. B) The nurse should instruct the client to use only one small pillow, placed behind the head, while in bed to prevent flexion contractures. C) The nurse should instruct the client to exercise daily but to balance activity with rest. D) The nurse should instruct the client to take a warm shower instead of a tub bath due to the difficulty the client can experience getting in and out of the tub. A warm shower can also relax muscles and reduce pain.
A nurse is providing teaching to a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? A) Avoid direct sun exposure to the skin. B) Rub the skin with a towel when drying. C) Use an antibacterial soap to cleanse the skin. D) Wash the ink marking off when showering.
Answer: A. A) The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation. B) The nurse should instruct the client to pat, rather than rub, the skin dry to avoid damage to the skin. C) The nurse should instruct the client to cleanse his skin with mild soap and water because the client's skin is fragile due to the external radiation. The client should avoid antibacterial soaps because they can irritate the skin. D) The nurse should instruct the client not to remove the ink or dye markings because they identify the location of the site that is being radiated.
A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? A) Fasting blood glucose 96 mg/dL B) Casual blood glucose 210 mg/dL C) Postprandial blood glucose 195 mg/dL D) Preprandial blood glucose 60 mg/dL
Answer: A. A) This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective. B) A casual blood glucose level of 210 mg/dL is above the expected reference range. C) A postprandial blood glucose level of 195 mg/dL is above the expected reference range. D) A preprandial blood glucose level of 60 mg/dL is below the expected reference range.
A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? A) Left shift in WBC differential. B) Crackles heard on auscultation. C) Negative blood culture. D) Oxygen saturation 93%.
Answer: A. A) When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be a manifestation of sepsis, and the nurse should report this finding to the provider. B) Crackles heard on auscultation is nonurgent because it is an expected finding for a client who has pneumonia. Therefore, the nurse should report another finding first. C) A negative blood culture is nonurgent because it indicates that the client does not have a systemic infection caused by the pneumonia. Therefore, the nurse should report another finding first. D) An oxygen saturation of 93% is nonurgent because it is an expected finding for a client who has pneumonia. Tissues are adequately provided with oxygen when a client has an oxygen saturation of 92% to 100%. Therefore, the nurse should report another finding first.
A nurse is counseling a 60-year-old African-American male client about risk factors for lung cancer. Teaching should focus most on what risk factor? A) Tobacco use. B) Ethnicity. C) Gender. D) Increased age.
Answer: A. Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can modify and change.Ethnicity, gender, and increasing age are associated with lung cancer, but they are not modifiable risk factors that the client can change.
Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? A) Antibiotics have been given to clients for conditions that do not require antibiotics. B) Microorganisms are more susceptible to antibiotics today than when they were given years ago. C) Additional precautions are taken, along with Standard Precautions, to prevent infection. D) Most antibiotics are effective for infection.
Answer: A. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics.Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection.
Which information does the nurse include when teaching a client about antibiotic therapy for infection? A) Take all antibiotics as prescribed, unless side effects develop. B) Take antibiotics until symptoms subside, and then stop taking the drugs. C) Take antibiotics when symptoms of infection develop. D) Share antibiotics with family members who develop the same infection.
Answer: A. Antibiotics should be taken as prescribed until they are gone. Teach the client about possible side effects and allergic manifestations. The provider must be contacted immediately if any side effects develop.Antibiotics must be taken until they are gone, even if the client feels better or when symptoms of infection appear. They should be taken only by the person for whom they are prescribed and not shared with anyone else.
A client with iatrogenic Cushing's disease is a resident in a long-term care facility. Which nursing action included in the plan of care is most appropriate to delegate to unlicensed assistive personnel (UAP)? A) Assist with personal hygiene and skin care. B) Develop a plan of care to minimize risk for infection. C) Instruct the client on the reasons to avoid overeating. D) Monitor for signs and symptoms of fluid retention.
Answer: A. Assisting a client with bathing and skin care is included in UAP scope of practice.It is not within the UAP's scope of practice to develop a plan of care, although they will play a very important role in following the plan of care as delegated by a professional nurse. Client teaching requires professional knowledge and education and would not be delegated to UAP. Monitoring for signs and symptoms of fluid retention is part of client assessment, and is not within the UAP's skill set. This monitoring requires a higher level of education and clinical judgment possessed by a professional nurse.
The nurse is mentoring a recent graduate registered nurse (RN) about administering blood and blood products. What action does the nurse perform before starting the transfusion? A) Verify with another RN all of the data on blood products. B) Use a 22-gauge needle to obtain venous access when starting the infusion. C) Remain with the client who is receiving the blood for the first 5 minutes of the infusion. D) Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion.
Answer: A. Before administering blood and blood products, the nurse must verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities when administering blood and blood products.A 20-gauge needle (or a central line catheter) is used. The 22-gauge needle is too small. Initial VS must be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen.
The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A) Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8%. B) Potassium level of 2.9 mEq/L (2.9 mmol/L) and diarrhea. C) 250,000 platelets/mm3 (250 × 109/L). D) 5000 white blood cells/mm3 (5 × 109/L).
Answer: A. Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% has anemia demonstrated by low hemoglobin and hematocrit levels.The client with diarrhea and a potassium level of 2.9 mEq/L (2.9 mmol/L) has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 (250 × 109/L) and the client with 5000 white blood cells/mm3 (5 × 109/L) demonstrate normal values.
The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A) Monitor weight. B) Trend red blood cells and hemoglobin and hematocrit. C) Monitor platelets. D) Observe for motor deficits.
Answer: A. Cachexia results in extreme body wasting, malnutrition, and severe weight loss.Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.
While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A) Wear a gown and gloves to prevent contact with the client or client-contaminated items. B) Assign the client to a private room with a negative airflow. C) Wear a mask when working within 3 feet (91 cm) of the client. D) Have the client wear a surgical mask when being transported out of the room.
Answer: A. Caregivers should wear a gown and gloves to prevent contact with the client or contaminated items when caring for a client with this infection. This is the best way to prevent the spread of infection. Gloves should also be worn when entering the room.A private room is preferred for this client. If a private room is not available, the client may be cohorted with another client with the same active infection and with the same microorganisms if no other infection is present. The client does not require respiratory isolation and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection.
The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? A) Dry eyes. B) Abdominal bloating after eating. C) Excessive production of saliva in the mouth. D) Intermittent episodes of diarrhea.
Answer: A. Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis sicca). Abdominal bloating, excessive saliva production, and diarrhea are not common conditions in clients with Sjögren's syndrome; however, dry mouth is commonly described.
The nurse is teaching a client about proper nutrition to prevent an endocrine disorder. Which food does the nurse suggest adding to the diet when the client indicates a dislike of fish? A) Iodized salt. B) Red meat. C) Soy products. D) Salt substitute.
Answer: A. Dietary deficiencies in iodide-containing foods may be a cause of certain endocrine disorders. For clients who do not eat saltwater fish on a regular basis, the nurse teaches them to use iodized salt in food preparation.The client would eat a well-balanced diet that includes less animal fat. Eating soy products contributes to a healthier diet, but does not prevent an endocrine disorder. Using a salt substitute does not prevent an endocrine disorder. In fact, salt substitutes may contain high levels of potassium, which may lead to electrolyte imbalances.
The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? A) "I will gently remove the tick with tissue and then burn it to prevent the spread of the disease." B) "It is best to walk in the center of an outside trail." C) "I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease." D) "I'll wear light-colored clothes with long sleeves, long pants, closed shoes, and a hat when I am walking in the woods."
Answer: A. Further instruction is needed if an audience member states that, "I will gently remove the tick with tissue and then burn it to prevent the spread of the disease." Burning a Lyme disease-carrying tick could spread infection, so flushing it down the toilet is the recommended disposal method. Walking in the center of the trail is a protective measure against Lyme disease. If bitten, testing is not reliable until 4 to 6 weeks later. Wearing light-colored clothes, long pants, long sleeves, closed shoes, and hat are appropriate skin protection measures against Lyme disease.
The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? A) "I can break in my shoes by wearing them all day." B) "I need to monitor my feet daily for blisters or skin breaks." C) "I will never go barefoot." D) "I need to quit smoking."
Answer: A. Further teaching about injury prevention is needed when the client with diabetic peripheral neuropathy says that "I can break in my shoes by wearing them all day." Shoes need to be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated because if the client has diabetic neuropathy, stepping on something sharp or harmful would not be felt. Tobacco use further decreases peripheral circulation increasing the risk for vascular complications.
The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A) "I will begin exercising for at least an hour a day." B) "I will monitor my diet and avoid empty calories." C) "If I lose weight, I may not need to use the insulin anymore." D) "Weight loss can be a sign of diabetic ketoacidosis."
Answer: A. Further teaching is needed when the client says that "I will begin exercising for at least an hour a day." The goal of weight control for Type 2 diabetes is to change sedentary behavior to active behavior. This is begun by starting low-intensity activities in short sessions (less than 10 minutes). The client may increase sessions to moderate or vigorous aerobic physical activity to lose and or sustain weight loss.Monitoring the diet and avoiding empty calories is essential to managing type 2 diabetes. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis due to osmotic diuresis.
A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? A) "With this treatment, I probably cannot spread this virus to others." B) "This treatment does not kill the virus." C) "This medication prevents the virus from replicating in my body." D) "Research has shown the effectiveness of this therapy if I do not forget to take any doses."
Answer: A. HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids.HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.
The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? A) Infection with hepatitis B virus. B) Consuming a diet high in animal fat. C) Exposure to radon. D) Familial polyposis.
Answer: A. Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer.Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer. Familial polyposis is a risk factor for colorectal cancer.
The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? A) "Please report any increased redness, swelling, warmth, or pain to your health care provider." B) "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." C) "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." D) "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."
Answer: A. Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important.Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. Positioning is important but is not the priority here.
A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. The client has a prescription for Desmopressin (DDAVP). Which outcome indicates a positive response to treatment? A) Urine output of 60-80 mL/hour B) Blood glucose level of 110 mg/dL (6.1 mmol/L) C) Ability to sit quietly and read a magazine D) Potassium level within expected range
Answer: A. Lithium may cause drug-related diabetes insipidus causing the kidneys to be unable to respond to ADHl, causing profound diuresis. Desmopressin acetate (DDAVP), a synthetic form of vasopressin (ADH), is the drug of choice to stop fluid loss.A blood glucose result of 110 mg/dL (6.1 mmol/L) is within the range of normal blood glucose levels. The ability to sit quietly and read a magazine is not an expected outcome after the administration of desmopressin; this is potentially and outcome for clients receiving lithium therapy for bipolar disorder. Hypokalemia may result from the ongoing diuresis of DI, but this does not evaluate the outcome of treatment.
Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50 x 109/L). What action is most important for the nurse to take? A) Notify the health care provider of the platelet count. B) Administer the prescribed LMWH on schedule. C) Assess the activated partial thromboplastin time (aPTT). D) Assess the international normalized ratio (INR).
Answer: A. Normal platelet count is between 150,000 mm³ (150 x 109/L) and 400,000 mm³ (400 x 109/L), so 50,000 mm³ (50 x 109/L) is quite low. If the platelet count falls below 20,000/mm3 (20 x 109/L) spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. LMWH can cause thrombocytopenia, so it should not be administered when the client's platelet count is low. The aPTT is not affected by LMWH, so its assessment is not necessary. Usually, LMWH is given in a low prophylactic dose and does not affect the INR.
The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? A) Perform a blood glucose check on a client who requires insulin. B) Verify the infusion rate on a continuous infusion insulin pump. C) Assess a client who reports tremors and irritability. D) Monitor a client who is reporting palpitations and anxiety.
Answer: A. Performing bedside glucose monitoring is a task that may be delegated to UAPs because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for UAPs. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for UAPs. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.
Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? A) American Diabetes Association (ADA) B) Centers for Disease Control and Prevention C) Primary health care provider office D) Pharmaceutical representative
Answer: A. The American Diabetes Association is the best agency to refer the diabetic client to. The ADA provides national and regional support and resources to clients with diabetes and their families.The Centers for Disease Control and Prevention does not specifically focus on diabetes. The client's primary health care provider's office is limited in the resources available to the client with diabetes. A pharmaceutical representative is not an appropriate resource for diabetes information and support.
The nurse and nursing student are caring for a client with pheochromocytoma who is admitted for surgery. Which of these statements by the student requires immediate intervention by the nurse? A) "When performing the gastrointestinal assessment, I need to palpate the client's abdomen." B) "I will review the chest x-ray results for pulmonary edema." C) "I will initiate a 24-hour urine collection now." D) "I have requested the client be placed with a roommate for distraction."
Answer: A. The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and trigger severe hypertension.Reviewing the chest x-ray for pulmonary edema is not necessary. The tumor on the adrenal gland causes sympathetic hyperactivity, increasing blood pressure and heart rate, not pulmonary edema. A 24-hour urine collection will already have been completed to determine the diagnosis of pheochromocytoma. A client diagnosed with a pheochromocytoma may feel anxious as part of the disease process, but providing a roommate for distraction will not reduce the client's anxiety.
The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first? A) Provide pain medications as needed. B) Apply cool compresses to the client's forehead. C) Increase food sources of iron in the client's diet. D) Encourage the client's use of two methods of birth control.
Answer: A. The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed. Analgesics are needed to treat sickle cell pain.Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.
Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? A) Obtain vital signs on a client receiving a blood transfusion B) Assist a client with folic acid deficiency in making diet choices C) Administer erythropoietin to a client with myelodysplastic syndrome D) Assess skin integrity on an anemic client who fell during ambulation
Answer: A. The appropriate task for the nurse to delegate to a UAP is obtaining vital signs on a client receiving a blood transfusion. This activity is within the scope of practice for UAPs.Assisting with prescribed diet choices, administering medication, and assessing clients are complex actions that must be done by licensed nurses.
The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? A) Respiratory rate of 36 breaths/min in a client receiving red blood cells B) Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion C) Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D) A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)
Answer: A. The assessment finding that requires immediate action by the nurse is a respiratory rate of 36 breaths/min in a client receiving red blood cells. An increased respiratory rate indicates a possible hemolytic transfusion reaction. The nurse must quickly stop the transfusion and assess the client further.Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever. Sleepiness is expected when Benadryl is administered. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response.
A client is being discharged with a prescription for propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? A) "I can return to my job at the day care center." B) "I must call the primary health care provider if my urine is dark." C) "I must faithfully take the drug every 8 hours." D) "I need to report weight gain."
Answer: A. The client would not return to the job at the day care center because PTU reduces blood cell counts and the immune response, which increases the risk for infection. The client does not, however, need to remain completely at home.Dark urine may indicate liver toxicity or failure, and the client must notify the primary health care provider immediately. Taking PTU regularly at the same time each day provides better drug levels and ensures consistent medication action. The client must notify the primary health care provider of weight gain because this may indicate hypothyroidism requiring titration of the medication to a lower dose.
Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? A) The dietary worker hands the disposable meal trays to the LPN assigned to the client. B) The social worker encourages the client to verbalize about stressors at home. C) A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. D) The health care provider orders vital signs, including temperature, every 8 hours.
Answer: A. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection.Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk of infection.
Which statement accurately explains otitis media? A) The inflammatory response is triggered by the invasion of foreign proteins. B) Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. C) It is caused by a left shift or increase in immature neutrophils. D) Many immune system cells released into the blood have specific effects.
Answer: A. The inflammatory bacterial response of otitis media is stimulated by invading foreign proteins caused by infection.Macrophages and neutrophils are involved in the process of inflammation, but otitis media is an inflammation caused by infection. It is not caused by a left shift or increase in immature neutrophil forms. The change in form is caused by infection, such as sepsis. The action of immune system cells occurs when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader. This does not cause inflammation.
The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention would the nurse implement first? A) Obtain prescribed blood cultures. B) Place the client on Bleeding Precautions. C) Initiate the administration of prescribed antibiotics. D) Give 1000 mL of IV normal saline to hydrate the client.
Answer: A. The intervention the nurse would first implement is to draw prescribed blood cultures. Obtaining blood cultures to identify the infectious agent correctly is the priority for this client.Placing the client on Bleeding Precautions is unnecessary. Administering antibiotics is important, but antibiotics must always be started after cultures are obtained. Hydrating the client is not the priority.
Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? A) A client with chronic microcytic anemia associated with alcohol use B) A client scheduled for a bone marrow biopsy with conscious sedation C) A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) D) A client with atrial fibrillation and an international normalized ratio of 6.6
Answer: A. The medical unit charge nurse assigns the LPN/LVN a client with chronic microcytic anemia related to alcohol use. Chronic microcytic anemia is not considered life-threatening and is within the skill level of an LPN/LVN.The client with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and would be assigned to RN staff members.
The charge nurse on the medical-surgical unit is making client assignments for the shift. Which client is the most appropriate to assign to an LPN/LVN? A) Client with Cushing's syndrome who requires orthostatic vital signs assessments B) Client with diabetes mellitus who was admitted with a blood glucose of 35 mg/dL (1.9 mmol/L) C) Client with exophthalmos who has many questions about endocrine function D) Client with possible pituitary adenoma who has just arrived on the nursing unit
Answer: A. The most appropriate client to assign to an LPN/LVN is the client with Cushing's syndrome. An LPN/LVN would be familiar with Cushing's syndrome and the method for assessment of orthostatic vital signs.The client with a blood glucose of 35 mg/dL (1.9 mmol/L) is unstable and requires interventions and subsequent monitoring by the professional nurse. The client with questions about endocrine function and the client with a possible pituitary adenoma have complex needs, including the need for education. These clients require the experience and scope of practice of the RN.
A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? A) Epinephrine (Adrenalin) B) Fexofenadine (Allegra) C) Cromolyn sodium (Nasalcrom) D) Zileuton (Zyflo)
Answer: A. The most appropriate drug for the nurse to give in this situation is epinephrine (Adrenalin). The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic drug used to treat anaphylaxis.Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug used to prevent symptoms of allergic rhinitis. It is not useful during an acute episode. Zileuton (Zyflo) is a leukotriene antagonist also used to prevent symptoms of allergic rhinitis, but is also not useful during an acute episode.
After receiving change-of-shift report about these four clients, which client does the nurse attend to first? A) Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L) B) Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due C) Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L (3.4 mmol/L) D) Client with pituitary adenoma who is reporting a severe headache
Answer: A. The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately.Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin cannot take priority over treatment of severe hypoglycemia. A serum potassium of 3.4 mEq/L (3.4 mmol/L) in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic) based on specific hospital levels. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency.
The nurse is planning to administer medications to a client with diabetes insipidus (DI) who has dry lips and mucous membranes and poor skin turgor. Which intervention will the nurse provide first? A) Encourage oral fluid intake B) Offer lip balm. C) Perform a 24-hour urine test. D) Withhold desmopressin acetate (DDAVP).
Answer: A. The nurse first needs to encourage fluid intake. Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI due to diuresis. This is a serious condition that requires ongoing fluid replacement to maintain perfusion until treatment is effective.Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct dehydration. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production. It is the anticipated treatment for DI and would not be withheld.
When caring for the older adult with decreased antidiuretic hormone (ADH) production, the nurse would include which of these in the plan of care? A) Encourage fluids every 2 hours. B) Plan for weight-bearing activities. C) Inspect the feet and legs for ulcers. D) Increase fiber in the diet.
Answer: A. The nurse needs to encourage the client to drink fluids every 2 hours. A decrease in ADH production causes urine to be more dilute, so urine might not concentrate when fluid intake is low. The older adult is at greater risk for dehydration as a result of urine loss. If fluids are not restricted because of another health problem, unlicensed assistive personnel (UAP) can offer fluids at least every 2 hours while the client is awake.Weight-bearing activities are appropriate for older adults to prevent bone loss, not fluid loss. Foot or leg ulcers that do not heal in 2 weeks would prompt an investigation into hyperglycemia and diabetes. Increasing fiber can be helpful for decreased metabolism such as occurs with hypothyroidism.
The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A) Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B) Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C) Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D) Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast
Answer: A. The nurse should see the client with chemotherapy-induced neutropenia first. Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people.The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.
The nurse is teaching a client about the expected outcome for treatment of syndrome of inappropriate antidiuretic hormone (SIADH). What does the nurse tell the client to look for? A) Decrease in difficulty in breathing B) Dry mucous membranes C) Increasing heart rate D) Muscle spasms
Answer: A. The nurse tells the client to look for a decrease in difficulty in breathing. The syndrome of inappropriate antidiuretic hormone (SIADH) is a disease where vasopressin (antidiuretic hormone [ADH]) is secreted even when plasma osmolarity is low or normal. Symptoms of fluid overload including dyspnea will resolve with treatment as the fluid retention decreases.Dry mucous membranes are a sign of fluid volume deficit or; fluid excess should resolve during treatment of SIADH, but not to the point of dehydration, an increased heart rate indicates increased fluid retention or dehydration and hypovolemia, and either condition is an indication that therapy is not effective. Muscle spasms are associated with hyponatremia, typically found in SIADH, and are an indication that hyponatremia is still present. Untreated hyponatremia can lead to seizures and coma.
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L (130 mmol/L), K+ 6.6 mEq/L (6.6 mmol/L), and glucose 72 mg/dL (4 mmol/L). Which prescription will the nurse implement first? A) Administer insulin with dextrose in normal saline. B) Give spironolactone (Aldactone) orally. C) Initiate ulcer prophylaxis protocol with a histamine2 (H2) blocker D) Obtain arterial blood gases.
Answer: A. The nurse would first administer insulin (20 to 50 units) with dextrose (20 to 50 mg) in normal saline to correct hyperkalemia. Insulin shifts potassium into cells to prevent or treat dysrhythmias.Spironolactone is a potassium-sparing diuretic that helps the body retain potassium and not eliminate it. Although H2 blocker therapy with ranitidine would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess cardiac dysrhythmias and peaked T waves associated with hyperkalemia. An electrocardiogram needs to be obtained instead.
A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? A) Check the blood glucose. B) Administer oxygen. C) Offer reassuracnce. D) Attach a cardiac monitor.
Answer: A. The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis.Based on the oxygen saturation, oxygen administration is not indicated. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.
A client with an endocrine disorder says, "I can't, you know, satisfy my wife anymore." What is the nurse's best response? A) "Can you please tell me more?" B) "Don't worry. That is normal." C) "How does she feel?" D) "Can I make an appointment for you with a counselor?"
Answer: A. The nurse's best response to the client is, "Can you please tell me more?" Asking the client to explain his concerns in an open-ended question allows the nurse to explore his feelings more thoroughly. Infertility, impotence, and other changes in sexual function may result from endocrine problems.Telling a client that something is "normal" is dismissive and incorrect. This issue to satisfy his wife is new to the client and is a concern for him. The focus of the nurse's response needs to be on the client, not on the wife initially. Referring the client to a counselor is not an appropriate first step. This action does not allow him to express his frustrations at the moment.
A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? A) Review the clinical records and ask the client about any known allergies. B) Check with the pharmacy for any known allergies for this client. C) Check the client's identification band for any allergies. D) Ask the nurse who previously cared for the client about any known allergies.
Answer: A. The nurse's first action is to check the client's clinical record for any known hypersensitivities as well as asking the client about any known allergies.The pharmacy is not responsible for obtaining information on all of the client's known allergies. Checking the client's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.
The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow for administering this blood product? A) Infuse the transfusion over a 15- to 30-minute period. B) Set up the infusion with the standard transfusion Y tubing. C) Give intravenous corticosteroids before starting the transfusion. D) Allow the platelets to stabilize at the client's bedside for 30 minutes.
Answer: A. The procedure the nurse follows to administer platelets to a hematopoietic stem cell transplant is to infuse the transfusion over a 15-to-30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period.A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received because they are considered to be quite fragile.
In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? A) "Have you had sex with men or women or both?" B) "I hope you use condoms to protect your partners." C) "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." D) "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."
Answer: A. The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate."I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental. Judgmental statements to clients by healthcare providers (HCPs) can impede the collaborative relationship and communication between client and HCP.
Which information must the organ transplant nurse emphasize before a client is discharged? A) "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." B) "You are at increased risk for cancer when you reach 60 years of age." C) "Immunosuppressant medications will decrease your risk for developing cancers." D) "After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population."
Answer: A. Use of immunosuppressant medications to prevent organ rejection increases the risk for cancer and the need for cancer screening.Advanced age is a risk factor for all people, not just for organ transplant recipients. Immunosuppressant medications must be taken for the life of the organ. The increased risk for developing cancer remains as long as the client continues to take immunosuppressant drugs.
The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? (Select all that apply). A) Limit sodium intake. B) Avoid beef and processed meats. C) Increase consumption of whole grains. D) Eat "colorful fruits and vegetables,", including greens. E) Avoid gas-producing vegetables such as cabbage.
Answer: B, C, D. Avoiding red meat and processed foods such as lunchmeats, and consuming bran and whole grains can reduce cancer risk and should be included in health education classes on diet and cancer risk reduction. Consuming foods high in vitamin A, including apricots, carrots, and leafy green and yellow vegetables, can also reduce cancer risk.Reducing sodium is helpful in the treatment of hypertension and heart and kidney failure, but no evidence suggests that lowering of sodium intake decreases the incidence of cancer. Eating cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage may actually reduce cancer risk.
A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? (Select all that apply). A) Pathophysiology of diabetes. B) Causes and treatment of hypoglycemia. C) Dietary control of blood glucose. D) Insulin administration. E) Physical activity and exercise
Answer: B, D. The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay.
Which actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply). A) Inspect the skin or coolness and pallor. B) Promote sufficient nutritional intake. C) Encourage fluid intake, as appropriate. D) Monitor the red blood cell (RBC) count. E) Obain cultures as needed. F) Remove unnecessary medical devices
Answer: B, E, F. Promoting sufficient nutritional intake helps prevent and detect early infection in at risk clients. Nutrition has a direct correlation to improvement of general health. Malnutrition, especially protein-calorie malnutrition, places clients at increased risk for infection. Blood cultures would be used to detect a possible systemic infection. Advocating for the removal of unnecessary medical devices (e.g., intravascular or urinary catheters, endotracheal tubes, synthetic implants) may also interfere with normal host defense mechanisms and may help prevent infection.Inspecting the skin does not prevent or detect systemic infections. Fluid intake is important but does not directly relate to prevention or detection of infection. Monitoring the RBC count does not prevent, nor would it detect, infection.
The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? A) "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." B) "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." C) "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." D) "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation."
Answer: B. "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. NX means that no regional lymph nodes can be assessed.No lymph nodes are involved and there is not another tumor present. A glioma is a benign tumor of the brain, so chemotherapy and radiation are not given. The client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.
The nurse is teaching a client about the correct procedure for a 24-hour urine test for a hormone level. Which statement by the client indicates a need for further teaching? A) "I need to keep the urine container cool in a separate refrigerator or cooler." B) "I will not eat any protein when I am collecting urine for this test." C) "I won't save the first urine sample of the day." D) "To end the collection, I must empty my bladder and add this urine to the collection."
Answer: B. A need for further teaching is needed when the client says that he/she will not eat any protein while collecting urine for a 24-hour urine test to evaluate a hormone level. Eating protein does not interfere with collection or testing of the urine sample.Because the specimen must be kept cool, it can be placed in an inexpensive cooler with ice. The client would not keep the specimen container with food or beverages. The timing of the 24-hour collection begins after the initial void of the day. To end a 24-hour urine specimen, emptying the bladder and adding it to the collection is the proper procedure.
The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery of his AIDS by his family? A) "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" B) "Is there somewhere private in the home where we can go and talk?" C) "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." D) "It is your duty to protect your family members from getting AIDS."
Answer: B. A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The nurse needs to have a private conversation with the client to discover the client's wishes.The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.
A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? A) Notify the provider of a weight loss of 0.45 kg (1 lb) or more per week. B) Report nocturia because it requires a dosage adjustment. C) Weigh yourself weekly while wearing similar clothing at the same time of day. D) Drink at least 3 L of fluid per day.
Answer: B. A) A weight gain or loss of 0.45 kg (1 lb) per week is not enough to suggest overhydration or dehydration. B) The client should receive the initial dose of desmopressin in the evening; the provider will increase the dosage until the client no longer has nocturia. C) The client should weigh himself daily to detect dehydration in its early stage. D) The client should drink an amount of fluid equal to his urine output each day.
A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect? A) Persistent diarrhea. B) Hypotension. C) Tachycardia. D) Increased urine output.
Answer: B. A) Hypothyroidism is more likely to cause constipation. B) Hypotension is an expected finding with hypothyroidism, along with bradypnea, dysrhythmias, cold intolerance, and cool, dry skin. C) Hypothyroidism commonly causes bradycardia. D) Hypothyroidism is more likely to cause a decrease in urine output.
A nurse is providing teaching to a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A) "SLE should not affect my lungs or breathing." B) "I should wear gloves when it is cold outside." C) "I should use a sunscreen with an SPF of at least 15." D) "Long-term immunosuppressive therapy could cure this disease."
Answer: B. A) SLE can affect all of a client's body systems; therefore, SLE can cause pleural effusions and pneumonia. B) Raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction in the client's fingers when exposed to cold temperatures. C) The client should select a sunscreen with an SPF of at least 30. D) SLE is a lifelong chronic autoimmune disease.
A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include? A) "Limit your fluid intake while taking this medication." B) "Take this medication on an empty stomach." C) "Take this medication with an antacid." D) "Change position slowly while taking this medication."
Answer: B. A) The client should take the medication with 8 oz of water. Since there are no fluid restrictions with this medication therapy, the client should drink 2 to 3 L of fluid daily. B) To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30 to 60 min after taking it. C) Aluminum-containing antacids and calcium supplements can reduce the effectiveness of thyroid replacement therapy. D) This medication does not cause orthostatic hypotension.
A nurse is caring for a client who reports a skin change. Which of the following findings hsould the nurse report to the provider? A) An elevated red lesion that arises from a scar. B) An asymmetrical papule that is pigmented. C) A collection of irregular dry papules that are black. D) A patch of silvery-white scales with a red epidermal base.
Answer: B. A) The nurse should identify an elevated red lesion that arises from a scar as a manifestation of a keloid, which does not need to be reported to the provider. B) The nurse should identify an asymmetrical papule that is pigmented as an indication of a malignant melanoma. The nurse should report the client's skin change to the provider. C) The nurse should identify a collection of irregular dry papules that are black in color as a manifestation of seborrheic keratosis, which does not need to be reported to the provider. D) The nurse should identify a patch of silvery-white scales with a red epidermal base as a manifestation of psoriasis, which does not need to be reported to the provider.
A nurse is providing teaching to a client who is scheduled for a Papanicolaou (Pap) test. The nurse should inform te client that she is being tested for which of the following? A) Ovarian cysts. B) Cervical cancer. C) Uterine cancer. D) Fibroids.
Answer: B. A) The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for ovarian cysts. B) The nurse should inform the client that a Pap test is used to screen for cervical cancer. C) The nurse should inform the client that a transvaginal ultrasound, along with an endometrial biopsy, is used to screen for uterine cancer. D) The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for fibroids.
A nurse is providing teaching to a group of clients regarding prevention of skin cancer. Which of the following risk factors should the nurse include in the teaching? A) Immunodeficiency disorder. B) Light skin pigmentation. C) Psoriasis. D) History of frostbite.
Answer: B. A) The nurse should inform the clients that having an immunodeficiency disorder does not place them at an increased risk for the development of skin cancer. B) The nurse should inform the clients that light skin pigmentation is a risk factor for the development of skin cancer. C) The nurse should inform the clients that psoriasis does not place them at an increased risk for the development of skin cancer. D) The nurse should inform the clients that a history of frostbite does not place them at an increased risk for the development of skin cancer.
A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? A) Expect the insulins to appear cloudy.. B) Draw up the insulins into separate syringes. C) Inject the insulins intramuscularly. D) Shake the insulins vigorously prior to administration.
Answer: B. A) The nurse should instruct the client to expect both insulins to appear clear and to discard any that appear cloudy. B) The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins. C) The nurse should instruct the client to inject the insulins into the subcutaneous tissue to promote proper absorption. D) The nurse should instruct the client to gently mix the insulin vials prior to administration to prevent altering the chemistry of the medication.
A nurse is caring for a client who has leukemia and a platelet count of 48,000/mm^3. Which of the following actions should the nurse take? A) Provide the client with a diet low in vitamin K. B) Test the client's urine and stool for occult blood. C) Place the client on contact precautions. D) Administer subcutaneous epoetin alfa.
Answer: B. A) The nurse should not provide the client with a diet that is low in vitamin K because this can further decrease coagulation. B) A client who is thrombocytopenic is at risk for occult bleeding. Therefore, the nurse should test the client's urine and stool for occult blood. C) The nurse should recognize that thrombocytopenia does not require contact precautions. However, the client might require neutropenia precautions and a private room. D) The nurse should not administer epoetin alfa because it is used to treat anemia and is not effective in increasing platelet production.
A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A) Lymphocyte 1,400/mm3. B) Decreased viral load. C) WBC count 3,500/mm3. D) Low CD4/CD8 ratio
Answer: B. A) The nurse should recognize that a client who has HIV can have lymphocyte values below 1,500/mm3, which does not indicate that the medication therapy is effective. B) The nurse should recognize that a client who has HIV and is receiving medication therapy should display a decreasing viral protein amount in the blood, indicating a positive response to the medication therapy. C) The nurse should recognize that a WBC count of 3,500/mm3 is lower than the expected reference range for a client who has HIV and does not indicate that the medication therapy is effective. D) The nurse should recognize that a low or decreasing ratio of CD4/CD8 cells in a client who has HIV indicates disease progression and does not indicate that the medication therapy is effective.
A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. TO confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests? A) Indirect laryngoscopy. B) Throat culture. C) Chest x-ray. D) Monospot test.
Answer: B. A) The nurse should recognize that an indirect laryngoscopy is used to visually assess pharyngeal structures. B) The nurse should recognize that a throat culture is used to confirm a diagnosis of bacterial pharyngitis by identifying specific micro-organisms present in the pharynx. C) The nurse should recognize that a chest x-ray is used to identify disorders such as pneumonia and pleural effusions. D) The nurse should recognize that a monospot test is used to detect mononucleosis, which is a viral infection.
A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? A) Shop for shoes early in the day. B) Monitor the temperature of bath water with a thermometer. C) Examine the skin and feet weekly for alterations in skin integrity. D) Round the edges of toenails when trimming them.
Answer: B. A) To make sure they fit, the client should shop for shoes later in the day when his feet are likely to have slight swelling. B) Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure a water temperature below 43.3° C (110° F). C) The client should examine his skin and feet daily. D) The client should trim his toenails straight across and smooth the edges with an emery board.
A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8°F oral. Which nursing intervention is the highest priority for this client? A) Administering furosemide (Lasix) B) Providing isotonic fluids C) Replacing potassium losses D) Restricting sodium
Answer: B. Acute adrenal insufficiency (Addisonian crisis) is a life-threatening condition in which the need for cortisol and aldosterone is greater than the body's supply. Providing isotonic fluid is the highest priority nursing intervention because hypotension and tachycardia indicate volume loss that is caused by acute adrenal insufficiency. Isotonic fluids will help to correct hyponatremia which typically accompanies adrenal insufficiency. IV access is also needed to administer IV medications such as hydrocortisone.Furosemide is a loop diuretic to increase fluid loss. This client is already experiencing fluid volume depletion related to insufficient cortisol and aldosterone. Potassium is normally increased in acute adrenal insufficiency, so replacing potassium is not needed. Sodium levels are already low, so restricting sodium is inappropriate. GI problems, such as nausea, vomiting, and diarrhea, often occur, increasing the effect of fluid loss.
A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? A) Inspect skin for lesions or changes. B) Promote comfort from Raynaud's phenomenon. C) Prevent foot drop and contractures. D) Decrease chilling of the extremities.
Answer: B. Acute pain occurs during Raynaud's phenomenon (the first symptom that occurs with SSc), and avoiding pressure from bed linens is a comfort measure. Skin ulcers and lesions can occur with SSc, but a foot board and a bed cradle do not assist with skin inspection. Bed cradles do not prevent foot drop or contractures; only foot boards do this. Decreased chilling and reduced vasospasms of the extremities can be accomplished by increasing the room temperature.
The nurse is starting the shift by making rounds. Which client would the nurse assess first? A) A 52-year-old who just had a bone marrow aspiration and is requesting pain medication B) A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism C) A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" D) A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway
Answer: B. After rounds, the nurse would first assess the 59-year-old client who has a nosebleed and is getting heparin to treat a pulmonary embolism. The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and must be assessed first for the severity of the situation.The client waiting for pain medication would be next on the nurse's "to do" list. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client who had a Rumpel-Leede test and the client with anemia are more stable and can be assessed later. The Rumpel-Leede test is a tourniquet test used to determine the presence of vitamin C deficiency or thrombocytopenia.
A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A) Taking the antibiotic before jogging 2 miles daily B) Taking the antibiotic most days. C) Taking the antibiotic as prescribed. D) Taking the antibiotic with a full glass of water.
Answer: B. Antibiotics not taken as prescribed can result in recurring symptoms, as well as the development of drug-resistant infections and other emerging infections.Taking the antibiotic before jogging is not a contributing factor to the client's relapse. The client who is taking antibiotics as prescribed is not likely to develop recurring symptoms. Taking antibiotics with a full glass of water is a positive action and neither hinders nor promotes antimicrobial therapy.
Which nursing activity can the nurse delegate to a home health aide? A) Changing the dressing for a client with a low absolute neutrophil count B) Assisting with bathing for a client with chronic rejection of a liver transplant. C) Teaching a client with bacterial pneumonia how to take the prescribed antibiotic. D) Assessing incisional tenderness for a client who had a recent kidney transplant.
Answer: B. Assisting with bathing for a client with chronic rejection of a liver transplant can be delegated to the home health aide.Changing the dressing for a client with a low absolute neutrophil count requires strict sterile technique by a licensed RN and should not be delegated because of the high risk for infection. Teaching about medications and assessments is within the scope of practice of the professional RN.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A) Hypoxia. B) Infection. C) Hemorrhage. D) Fluid overload (overhydration).
Answer: B. Avoiding infection is the priority potential problem when caring for a newly diagnosed client with leukemia.Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? A) Clean toothbrushes once a week. B) Bathe daily using an antimicrobial soap. C) Eat salad at least once a day. D) Wash dishes in cool water.
Answer: B. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin.Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher
The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? A) "I will drink a glass of water." B) "I will eat three graham crackers." C) "I will give myself 1 mg of glucagon." D) "I will sit down and rest."
Answer: B. Correct understanding of what the client needs to do if the client feels hungry and shaky is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.
In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include? A) "Limit your intake of fruits and vegetables." B) "Weight Watchers has healthy meal plans." C) "Limit fluid intake to 1500 mL/day." D) "Discuss with your health care provider about having your estrogen and progesterone levels checked to see where you are in menopause."
Answer: B. Crash diets and obesity are causes of secondary gout, so avoiding crash diets and keeping fit will prevent recurrence. Weight Watchers, with its healthy meal plans, is one way to help achieve this goal. Eating plenty of fruits and vegetables should be encouraged because they are low in purines, which may reduce the recurrence of gout. Fluids dilute urine and prevent the formation of urinary stones, so fluid intake should not be restricted. Primary gout affects postmenopausal women, so checking estrogen and progesterone levels is not indicated.
The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client? A) "Inspect the site for bleeding every 4 to 6 hours." B) "Place an ice pack over the site to reduce the bruising." C) "Avoid contact sports or activity that may traumatize the site for 24 hours." D) "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."
Answer: B. Discharge instructions after a bone marrow include placing an ice pack over the site to reduce bruising. Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure.The client must carefully monitor the site every 2 hours for the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. A mild analgesic is appropriate, but it needs to be aspirin-free. Acetaminophen (Tylenol) would be a good choice.
Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? A) "I told family members they need to wash their hands when they enter and leave the room." B) "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." C) "Yes, I understand the reasons why I have to wear gloves when I bathe the client." D) "The client's spouse told me she got HIV from a blood transfusion."
Answer: B. Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse.Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.
The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? A) Easy bruising. B) Dyspnea. C) Night sweats. D) Chest wound.
Answer: B. Dyspnea and complaints of difficulty breathing are signs of lung cancer, as are cough, hoarseness, shortness of breath, bloody sputum, arm or chest pain, and dysphagia.Easy bruising is a nonspecific finding, and not related to lung cancer. Night sweats is a symptom of the lymphomas. A chest wound is not specific to lung cancer.
Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A) New onset of fatigue. B) Edema of arms and hands. C) Dry cough. D) Weight gain
Answer: B. Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention.New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, and not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone (SIADH). Although this should be addressed, it is an early sign so it is not the priority.
Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A) Encourage family and friends to call the client. B) Provide education on the mode of transmission of infection. C) Encourage the client to watch television. D) Ask a certified hospital chaplain to visit the client.
Answer: B. Education is the most appropriate and main intervention for addressing a client's feeling of isolation when placed on Transmission-Based Precautions. It is important to teach the client and family about the mode of transmission and mechanisms that prevent spread to others. The nurse needs to assess coping mechanisms that the client has used in the past.Encouraging phone calls and distraction activities like watching television may be effective interventions. Engaging a certified hospital chaplain to visit the client may help alleviate the client's stress, anxiety, or depression.
Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take? A) Instruct the client to drink diet soda to prevent elevation of blood sugar. B) Administer the prescribed prednisone on schedule. C) Notify the health care provider of the random blood glucose result. D) Review the client's antinuclear antibody (ANA) level.
Answer: B. For this client, giving the medication per schedule is essential in treating the disease. Blood sugar is only slightly elevated and the blood glucose value will be monitored regularly because the client is receiving prednisone. Blood sugar is only slightly elevated, so encourage fluids other than soda (diet or otherwise). Blood glucose levels are performed and parameters are set as to when the health care provider should be notified, but usually this is done only if the random blood glucose level is greater than 150 mg/dl (8.325 mmol/L). Reviewing the client's ANA level is not required before prednisone is given; the client's ANA is elevated because of the RA.
The nurse is caring for a client with a parathyroid dysfunction. Which comment by the client indicates a need for further assessment? A) "I am worried about my bones breaking down." B) "Lately, I lose my temper more quickly." C) "The doctor will need to check my vitamin D levels." D) "My weight has been stable these past few years."
Answer: B. Further assessment is needed when the client says, "Lately, I lose my temper more quickly." Many endocrine problems can change a client's behavior, personality, and psychological responses. The client stating that he or she has become more quick-tempered warrants further assessment.PTH increases bone resorption (bone release of calcium into the blood from bone storage sites), thus weakening bones and increasing serum calcium. In the kidneys, PTH activates vitamin D, which then increases the absorption of calcium and phosphorus from the intestines. Vitamin D levels are affected by parathyroid dysfunction. Rapid changes in weight without diet changes are often associated with many endocrine disorders, so a stable weight is beneficial for the client.
The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? A) "The pneumonia vaccine is protection that I need." B) "Getting an annual 'flu shot' would be dangerous for me." C) "I must take my penicillin pills as prescribed, all the time." D) "Frequent handwashing is an important habit for me to develop."
Answer: B. Further teaching is needed when a young women with sickle cell disease says, "Getting an annual 'flu shot' would be dangerous for me." The client with SCD can receive annual influenza and pneumonia vaccinations. This helps prevent the development of these infections, which could cause a sickle cell crisis.The pneumonia vaccine is also appropriate for the client with sickle cell disease to receive. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection.
Which factor relates most directly to a diagnosis of primary immune deficiency? A) History of viral infection. B) Full-term infant surfactant deficiency. C) Contact with anthrax toxin. D) Corticosteroid therapy.
Answer: B. Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Primary immunodeficiency diseases (PI) are a group of more than 250 rare, chronic disorders in which part of the body's immune system is missing or functions improperly.Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.
Which statement about handwashing is in accordance with recommendations by the Centers for Disease Control and Prevention? A) If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B) Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C) Handwashing does not need to be done after resetting a client's IV pump. D) If the hands are not visibly soiled, washing the hands is not necessary.
Answer: B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Microorganisms that can be transmitted to another client can be found on intact skin.Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, any equipment connected to the client, and contaminated items; immediately after removing gloves; and between client contacts.
A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? A) Bradycardia. B) Hemoptysis. C) Increased urine output. D) Weight gain.
Answer: B. Hemoptysis (bloody sputum) is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present.Tachycardia and not bradycardia, decreased and not increased urine output, and weight loss and not weight gain are manifestations of Goodpasture's syndrome.
A client had a parathyroidectomy 8 hours ago. Which finding requires immediate attention? A) Edema at the surgical site B) Hoarseness. C) Pain on moving the head. D) Sore throat.
Answer: B. Hoarseness, stridor, or drooling is an indication of respiratory distress and requires immediate attention.Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A) Morphine. B) Ondansetron (Zofran). C) Naloxone (Narcan). D) Diazepam (Valium).
Answer: B. Ondansetron (Zofran) is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Lorazepam, a benzodiazepine, may also be given for nausea.Morphine is a narcotic analgesic or opiate and may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only.
The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? A) Administer antibiotics as prescribed. B) Transfuse ordered packed red blood cells. C) Teach pursed-lip breathing. D) Encourage increased fluid intake.
Answer: B. Packed red blood cells increase hemoglobin molecules and increases sites at which oxygen can attach and improves gas exchange.Antibiotics treat infection and do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.
"The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? A) "I do not know how long my wife will be able to take care of me at home." B) "The bus is coming to pick me up from the senior center three times a week so I can play cards." C) "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." D) "I do not know how much longer my neighbor can continue to help clean my house.""
Answer: B. Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively."
When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? A) "Condoms should be used when lesions are present on the penis." B) "Always position the condom with a space at the tip of an erect penis." C) "Make sure it fits loosely to allow for penile erection." D) "Use adequate lubrication, such as petroleum jelly."
Answer: B. Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom.Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only. Oil-based lubricants, for example, petroleum-based lubricants (such as petroleum jelly), can increase the likelihood of breakage and slipping of latex condoms due to loss of elasticity caused by these lubricants. Oil may also create tiny holes in the latex. Oil-based lubricants may be considered desirable for people who are in relationships not requiring condom use and who wish to avoid certain additives and preservatives often found in other lubricants.
Which activity performed by the community health nurse best reflects primary prevention of cancer? A) Assisting women to obtain free mammograms B) Teaching a class on cancer prevention C) Encouraging long-term smokers to get a chest x-ray D) Encouraging sexually active women to get annual Papanicolaou (Pap) smears
Answer: B. Primary prevention involves avoiding exposure to known causes of cancer. Education and teaching by the community health nurse assists clients with this strategy.Mammography is part of a secondary level of prevention, defined as screening for early detection. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. A Pap smear is a means of detecting cervical cancer early—secondary prevention.
A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? A) Collaborate with the client to select foods that are high in calories. B) Provide oral care to the client before meals to enhance appetite. C) Assess the perianal area every 8 hours for signs of skin breakdown. D) Discuss the need to avoid foods that are spicy or irritating.
Answer: B. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants.Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice, and would be done by licensed staff.
A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? A) 7:30 AM. B) 11:00 AM. C) 2:00 PM. D) 7:30 PM
Answer: B. Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2-4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m.The other options for peak times for regular insulin are incorrect.
A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? A) Intact skin and mucous membranes. B) Self-tolerance. C) Inflammatory response against invading foreign proteins. D) Antibody-antigen interaction.
Answer: B. Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps, known as phagocytosis (See Figure 17-6), are needed to produce a specific antibody directed against a specific antigen. These steps are necessary whenever the person is exposed to that antigen.
Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? A) Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day B) Disfiguring and embarrassing rash C) Peripheral neuropathies and cranial nerve palsies D) High risk for renal inflammation
Answer: B. Skin lesions associated with disfiguring and embarrassing rash are common to SLE and DLE. Fatigue and fever are common only to SLE. Neurologic manifestations and inflammation of the kidneys are common in SLE.
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? A) Encourage the client to cough and deep-breathe. B) Instruct the client not to strain during a bowel movement. C) Instruct the client to blow the nose if there is any postnasal drip. D) Place the client in the Trendelenburg position.
Answer: B. Straining during a bowel movement increases ICP and must be avoided. Laxatives or stool softeners may be given and fluid intake be encouraged to prevent straining.Although deep breathing is encouraged, the client must avoid coughing early after surgery because this increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. If the client has postnasal drip, he or she must inform the nurse and not blow the nose. Postnasal drip may indicate leakage of CSF. The head of the bed must be elevated after surgery.
Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's best response? A) "Do the client's mood swings make you feel angry?" B) "The mood swings would diminish with treatment." C) "The medications will make the mood swings disappear completely." D) "Your family member is sick. You must be client."
Answer: B. Telling the family that the client's mood swings would diminish over time with treatment will provide information to the family, as well as reassurance that this behavior is expected.Asking the family if the client's mood swings make them angry is a closed-ended question and could make the family members feel guilty. The response needs to be client centered. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick. Telling them to be client can also encourage feelings of guilt and does not address the family's concerns.
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? A) "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." B) "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." C) "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." D) "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."
Answer: B. The best statement by the student describing type IV hypersensitivity reaction is that the reaction of sensitized T cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity reaction. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.
Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? A) Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 × 109/L), segmented neutrophils (segs) (8.0 × 109/L), bands 5% (0.5 × 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile. B) Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile. C) Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 × 109/L), segs (7.0 × 109/L), bands 10.0% (1.1 × 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4°F (38°C). D) Older adult client with recent history of right hip replacement, with productive cough, WBC count 3,400 mm3 (3.4 × 109/L), segs (6.2 × 109/L), bands 5% (0.5 × 109/L), lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile.
Answer: B. The client most ready for discharge is the middle-aged client with history of multiple sclerosis because the complete blood count (CBC) is within normal limits.The older adult client with a history of congestive heart failure and elevated WBC and segs and slight crackles in lung bases is not ready for discharge. The young adult client with crackles in all lung lobes is not ready for discharge because of elevated WBCs, left shift, and febrile status. The older adult client with recent history of right hip replacement is not ready for discharge because the WBC is below normal even though the other parts of the differential are within normal limits. This client may have a viral infection with crackles in the lungs and low oxygen saturation.
The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? A) Hyponatremia. B) Hyperkalemia. C) Hypercalcemia. D) Hypomagnesemia.
Answer: B. The electrolyte imbalance the nurse needs to monitor after transfusing 2 units of blood to a postoperative client is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.
The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A) Cure of the cancer. B) Relief of symptoms or improved quality of life. C) ALlowing other therapies to be more effective. D) Prolonging the client's survival time.
Answer: B. The focus and goal of palliative surgery is to help relieve symptoms of end-stage cancer and improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.
Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? A) Older adult with Parkinson disease receiving a donation from an identical twin. B) Grand multipara female with a history of subsequent blood transfusions. C) Middle-aged man with a 20-pack-year history. D) Young adult with type 1 diabetes.
Answer: B. The grand multipara female with a history of subsequent blood transfusions should be assessed first because multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection. Hyperacute rejection occurs mostly in transplanted kidneys but is less common now with better HLA matching. Symptoms of rejection are apparent within minutes of attachment of the donated organ to the recipient's blood supply. The process usually cannot be stopped once it has started, and the rejected organ must be removed as soon as hyperacute rejection is diagnosed.The older adult with Parkinson disease receiving a donation from an identical twin has less chance of hyperacute rejection because his donor is an identical twin. Smoking places the middle-aged man with a 20-pack-year history at higher risk for postoperative respiratory difficulties, but not for hyperacute rejection. Type 1 diabetes requires close postoperative monitoring of blood sugar, but does not predispose the client to a hyperacute rejection.
Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A) Potential for lack of understanding related to side effects of chemotherapy B) Potential for injury related to sensory and motor deficits C) Potential for ineffective coping strategies related to loss of motor control D) Altered sexual function related to erectile dysfunction
Answer: B. The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities.Every chemotherapy client needs to be taught related side effects of chemotherapy. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.
A client is hospitalized for pituitary function testing. Which nursing action included in the client's plan of care will be most appropriate for the RN to delegate to the LPN/LVN? A) Assess the client for clinical manifestations of hypopituitarism. B) Administer regular insulin for the growth hormone stimulation test. C) Palpate the thyroid gland for size and firmness. D) Teach the client about the adrenocorticotropic hormone stimulation test.
Answer: B. The most appropriate nursing action for the RN to delegate to the LPN/LVN the administration of insulin. Medication administration is within the LPN/LVN scope of practice.Client assessment for clinical manifestations of hypopituitarism, palpating the thyroid gland, and client teaching are complex skills requiring education and expertise, and are best performed by an RN.
A client with multiple myeloma reports bone pain that is unrelieved by analgesics. What is the most appropriate response by the nurse? A) "Ask your doctor to prescribe more medication." B) "Would you like to try some relaxation techniques?" C) "I'll turn on some soothing classical music for you." D) "It is too soon for additional medication to be given."
Answer: B. The most appropriate response by the nurse to the client with multiple myeloma is "would you like to try some relaxation techniques"? Because most clients with multiple myeloma have local or generalized bone pain, analgesics, and alternative approaches for pain management, such as relaxation techniques are used for pain relief. This also offers the client a choice.Before prescribing additional medication, other avenues would be explored to relieve this client's pain. Although music therapy can be helpful, this response does not give the client a choice. Even if it is too soon to give additional medication, telling that to the client is not helpful because it dismisses the client's pain concerns.
The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? A) Current lifestyle B) Educational and literacy level C) Sexual orientation D) Current energy level
Answer: B. The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.
The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? A) Grains. B) Dairy products. C) Leafy vegetabes. D) Starchy vegetables.
Answer: B. The nurse encourages the client to eat dairy products such as milk, cheese, and eggs. These foods will provide the vitamin B12 that the client needs.Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.
The nurse is caring for a client with hyperuricemia associated with tumor lysis syndrome (TLS). Which medication does the nurse anticipate being ordered? A) Recombinant erythropoietin (Procrit). B) Allopurinol (Zyloprim) C) Potassium chloride. D) Radioactive iodine-131 (131I)
Answer: B. The nurse expects allopurinol (Zyloprim) to be ordered, because allopurinol decreases uric acid production and is indicated in TLS. TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances.Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous because the client is already hyperkalemic. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.
The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? A) Client taking repaglinide (Prandin) who has nausea and back pain B) Client taking glyburide (Diabeta) who is dizzy and sweaty C) Client taking metformin (Glucophage) who has abdominal cramps D) Client taking pioglitazone (Actos) who has bilateral ankle swelling
Answer: B. The nurse needs to first assess the client taking glyburide (Diabeta) who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.
A client who is admitted to the intensive care unit with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What will the nurse do next? A) Call the primary health care provider. B) Reduce any stimulation to the client. C) Keep the client's door open to visualize the client's actions. D) Tell the client to slow down.
Answer: B. The nurse needs to reduce stimulation to the client to prevent complications of hyperthyroidism including cardiac dysrhythmias. The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse also encourages the client to rest, keeps the environment as quiet as possible by closing the door to the room, limits visitors, and eliminates or postpones any nonessential care or treatments.Because the client's behavior is anticipated along with the increased metabolic rate, there is no need to call the primary health care provider. Keeping the client's door open can increase stimulation in the client's environment. Telling the client to slow down is unsupportive and unrealistic.
A client receiving methimazole (Tapazole) calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? A) Advise the client to go to a calming environment. B) Ask whether the client has increased cold sensitivity or weight gain. C) Instruct the client to see his primary health care provider immediately. D) Tell the client to check his pulse again and call back later.
Answer: B. The nurse's best response is to ask the client if he is experiencing increased sensitivity to cold and/or weight gain. These could be symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication.A calming environment will not increase the client's heart rate. The client will want to notify the primary health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client would notify the primary health care provider or go to the ED immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he rechecks his pulse. This time could also be spent providing education about normal ranges for that client.
A client has a bone marrow biopsy performed. What is the priority postprocedure nursing action? A) Inspect the site for ecchymosis B) Apply pressure to the biopsy site C) Send the biopsy specimens to the laboratory D) Teach the client to avoid vigorous activity
Answer: B. The priority postprocedure action after a bone marrow biopsy would be to stop bleeding by applying pressure to the site.Inspecting for ecchymosis, sending specimens to the laboratory and teaching the client about activity levels will be done after hemostasis has been achieved.
The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? A) "Can you prepare your own meals every day?" B) "How is your energy level compared with last year?" C) "Has your weight changed by 5 pounds (2.3 kg) or more this year?" D) "What medications do you take daily, weekly, and monthly?"
Answer: B. The question the nurse needs to ask the client about endurance in performing ADLs is "How is your energy level compared with last year"? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs.The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.
The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? A) "If I become hyperglycemic, it is a medical emergency." B) "If I become hypoglycemic, I could become unconscious." C) "Medical personnel may need confirmation of my insurance." D) "I may need to be admitted to the hospital suddenly."
Answer: B. The statement by the client that indicates a correct understanding about the need to wear a MedicAlert bracelet is, "If I become hypoglycemic, I could become unconscious." Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.Hyperglycemia does not pose the same type of acute medical emergency as hypoglycemia unless it is severe and acidosis develops. Insurance information does not appear on a MedicAlert bracelet. Information on the MedicAlert bracelet may be helpful if a sudden hospitalization occurs when the client cannot communicate. However, it is standard procedure to assess blood glucose in that instance.
The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A) "I will go barefoot in my house so that my feet are exposed to air." B) "I must inspect my shoes for foreign objects before putting them on." C) "I will soak my feet in warm water to soften calluses before trying to remove them." D) "I must wear canvas shoes as much as possible to decrease pressure on my feet."
Answer: B. The statement by the diabetic client that indicates that teaching was effective is, "I must inspect my shoes for foreign objects before putting them on." To avoid injury or trauma to the feet, shoes need to be checked for foreign objects before the feet are inserted in them.Clients with diabetes would not go barefoot because foot injuries can occur in those clients who lack sensation. To avoid injury or trauma, a callus needs to be removed by a podiatrist, not by the client. To prevent injury, the client with diabetes must wear protective shoes for support and not canvas shoes.
The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease? A) "Sickle cell disease will be inherited by your children." B) "The sickle cell trait will be inherited by your children." C) "Your children will have the disease, but your grandchildren will not." D) "Your children will not have the disease, but your grandchildren could."
Answer: B. The statement that explains to parents about the risk of a child having sickle cell disease is that the children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.The children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.
The nurse is assigned to care for four clients. Which client does the nurse assess first? A) Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm. B) Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature. C) Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia. D) Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count.
Answer: B. The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring, and is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated.Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.
The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? A) Vomiting. B) Back pain. C) Frequent urination. D) Cyanosis of the toes.
Answer: B. Typical sites of breast cancer metastasis include bone (manifested by back pain), lung, liver, and brain. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control.Vomiting is not a sign of metastatic cancer of the breast. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease
A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? A) "Avoid large crowds." B) "Use a soft-bristled toothbrush." C) "Drink at least 2 L of fluid per day." D) "Elevate your lower extremities when sitting."
Answer: B. Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema but is not specific to the client with thrombocytopenia.
A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? A) "This will not make any difference in the viral load." B) "Blood concentrations will be decreased, which will lead to increased viral replication." C) "If only one dose of medication is missed, this will not make a difference." D) "This will cause an increase in opportunistic infections."
Answer: B. When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.When the inhibitory concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. It does not cause an increase in opportunistic infections but places the client at increased risk for developing one. Therefore, it does make a difference and is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting.
Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A) Bathe in cold water. B) Wear cotton gloves when cooking. C) Consume a diet high in fiber. D) Make sure shoes are snug.
Answer: C. A high-fiber diet will assist with constipation related to neuropathy.The client should bathe in warm not cold water, not hotter than 96°F. Cotton gloves may prevent harm from scratching, but protective gloves should be worn for cooking, washing dishes, and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.
A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A) A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B) A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C) A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr
Answer: C. A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia.The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.
Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A) A client with sensory neuropathy who needs teaching about foot care B) A client with diabetic ketoacidosis who has an IV running at 250 mL/hr C) A client who needs blood glucose monitoring and insulin before each meal D) A client who was admitted with fatigue and shortness of breath
Answer: C. A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.The clients with sensory neuropathy, diabetic ketoacidosis, and the client with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for adults with diabetes-related complications.
A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? A) Diabetes insipidus. B) Pheochromocytoma. C) Addison's disease. D) Hyperthyroidism.
Answer: C. A) A 24-hr I&O, urine specific gravity, and urine osmolarity are used to diagnose diabetes insipidus. B) A 24-hr urine collection can detect catecholamines and other substances that can indicate pheochromocytoma. C) The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency. D) A thyroid scan and a thyroid stimulating hormone test are used to diagnose hyperthyroidism.
A nurse in the emergency department is assessing a newly admitted client. Which of the following findings places the client at increased risk for contracting hepatitis B? A) Residing in an institutional setting. B) Traveling to a foreign country. C) Engaging in unprotected sexual intercourse. D) Working with hazardous chemical waste materials.
Answer: C. A) A client who resides in an institutional setting is not at increased risk because hepatitis B is not transmitted by casual contact or through contaminated food and water. B) A client who travels to foreign countries is not at increased risk because hepatitis B is not transmitted by casual contact or through contaminated food and water. C) A client who engages in unprotected sexual intercourse is at increased risk because hepatitis B is transmitted by sexual contact. D) A client who works with hazardous chemical waste materials is not at increased risk because hepatitis B is not transmitted by chemical waste.
A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include? A) Testicular cancer is more common in men older than 65. B) With early treatment, the survival rate is 50%. C) Examine the testicles immediately after showering. D) Schedule an annual ultrasound to screen for testicular cancer.
Answer: C. A) Men who are between the ages of 15 to 39 have an increased risk for developing testicular cancer. B) The survival rate for testicular cancer, when diagnosed and treated early, is nearly 100%. C) The client should perform a testicular self-examination on a monthly basis by examining the testicles after a bath or shower to allow for easier palpation. D) Ultrasounds are not used to screen for testicular cancer; however, if there is a change in testicular size, shape, or texture, the provider might schedule an ultrasound.
A nurse is caring for a client who is taking propylthiouracil. The nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations? A) Appetite. B) Stools. C) Weight. D) Sweating.
Answer: C. A) Propylthiouracil decreases manifestations of hyperthyroidism, such as increased appetite. B) Propylthiouracil decreases manifestations of hyperthyroidism, such as an increase in bowel movements. C) Propylthiouracil suppresses the production of thyroid hormones and, therefore, allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high. D) Propylthiouracil decreases manifestations of hyperthyroidism, such as diaphoresis.
A nurse is teaching a client about glycosylaed hemoglobin (HbA1c) testing. Which of the following statemnets should the nurse identify as an indication that the client understands the information about this test? A) "I need to fast after midnight the night before the test." B) "A level of eight to ten percent suggests adequate blood glucose control." C) "This test's result is a good indicator of my average blood glucose levels." D) "I will use my hemoglobin A1c level to adjust my daily insulin doses."
Answer: C. A) The client does not need to fast before blood sampling for HbA1c. In fact, what the client eats the day before has no effect on the results of this test. B) Clients who have diabetes mellitus should keep their HbA1c below 7%. C) HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs. D) The client should use capillary blood glucose levels to adjust daily insulin doses with the provider's approval.
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A) Persistent, generalized lymphadenopathy. B) CD4-T-cells decreased to 750 cells/mm3. C) Small, purple-colored skin lesions. D) Fever and diarrhea lasting longer than 1 month.
Answer: C. A) The nurse should identify persistent, generalized lymphadenopathy as a manifestation of HIV. B) The nurse should identify a CD4-T-cell count of 750 cells/mm3 as an indication that the client has HIV. A diagnosis of AIDS requires the CD4-T-cell count to be below 200 cells/mm3. C) The nurse should identify the presence of small, purple-colored skin lesions as an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness. D) The nurse should identify fever and diarrhea as manifestations of HIV.
A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider? A) Slight asymmetrical breast size. B) Nipple inversion of one breast since puberty. C) Breast tissue with an orange-peel appearance. D) Elevated Montgomery's glands.
Answer: C. A) The nurse should identify that slight asymmetrical breast size is a common finding. The nurse should report a significant difference in breast size because this can indicate inflammation or a tumor. B) The nurse should report a recent inversion of a client's nipple because it can indicate a malignant tumor; however, the nurse does not need to report a nipple inversion since puberty. C) The nurse should report an orange-peel appearance of the client's skin because this can indicate a blockage of lymph channels, which is a manifestation of advanced breast cancer. D) The nurse should not report elevated Montgomery's glands because this is an expected finding for a client who is pregnant.
A nurse is teaching a client who is receiving chemotherapy. The client's laboratory results indicate bone marrow suppression. Which of the following instructions should the nurse include in the teaching? A) "Clean your toothbrush with warm water weekly." B) "Wear clothing that will minimize sun exposure." C) "Bathe with an antimicrobial soap twice per day." D) "Take aspirin for minor aches and pains."
Answer: C. A) The nurse should instruct the client to clean her toothbrush weekly with liquid bleach or run the toothbrush through the dishwasher to destroy micro-organisms. A client who has bone marrow suppression is at increased risk for infection. B) Sun exposure does not pose a risk to a client receiving chemotherapy. However, the nurse should instruct the client to use skin protection when spending time in the sun. Furthermore, the nurse should instruct the client to wear clothing that does not rub to prevent bruising or bleeding. C) The nurse should instruct the client to bathe twice per day with an antimicrobial soap to decrease her exposure to micro-organisms. A client who has bone marrow suppression is at increased risk for infection. D) The nurse should instruct the client not to take aspirin or other platelet inhibitors because a client who has bone marrow suppression is at increased risk for bleeding.
A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include? A) Rest for 3 days between periods of vigorous exercise. B) Increase insulin dosage before planned exercise. C) Ingest alcohol with food to reduce alcohol-induced hypoglycemia. D) Consume no more than three servings of alcohol per day.
Answer: C. A) The nurse should instruct the client to exercise at least three times per week and have no more than 2 consecutive days without exercise. B) The nurse should instruct the client to reduce insulin dosage before planned exercise to prevent hypoglycemia. C) Alcohol inhibits the liver from producing glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia. D) Men should drink no more than two servings of alcohol per day; women should drink no more than one serving of alcohol per day.
A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? A) "Depress the pump once before using the nasal spray for the first time." B) "Instill the medication four times per day." C) "Blow your nose gently prior to using the nasal spray." D) "Administer the nasal spray while in a side-lying position."
Answer: C. A) The nurse should instruct the client to prime the nasal spray pump by pressing down four times before the initial use. B) The nurse should instruct the client to instill the medication one to three times per day as prescribed. C) The nurse should instruct the client to blow his nose gently prior to use of the spray. This action prevents dilution of the medication with nasal secretions. D) The nurse should instruct the client to sit upright when administering the spray. This upright position prevents the spray from going down the throat.
A nurse is providing teaching to a client wh ohas an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? A) Wear a medical identification tag. B) Inform other health care professionals of the allergy. C) Carry an emergency anaphylaxis kit. D) Keep a food diary.
Answer: C. A) The nurse should instruct the client to wear a medical identification tag. However, this is not the priority instruction to include in the teaching. B) The nurse should instruct the client to inform other health care professionals of the allergy. However, this is not the priority instruction to include in the teaching. C) The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority instruction for the client is to be prepared for emergency treatment by carrying an emergency anaphylaxis kit. D) The nurse should instruct the client to keep a food diary to identify other food allergies. However, this is not the priority instruction to include in the teaching.
A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take? A) Palpate the client's abdomen. B) Monitor the client for hypotension. C) Elevate the head of the client's bed. D) Check the client's urine specific gravity.
Answer: C. A) The nurse should not palpate the abdomen of a client who has a pheochromocytoma because this can cause release of catecholamines and increase blood pressure. B) The nurse should monitor a client who has a pheochromocytoma for hypertension. C) The nurse should elevate the head of the client's bed to reduce blood pressure and abdominal pressure. D) The nurse should monitor the urine specific gravity of a client who has diabetes insipidus.
A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? A) The client has a grilled ham and cheese sandwich, a banana, and yogurt on his lunch tray. B) The client's family brings in a silk flower arrangement. C) The client's granddaughter is visiting and telling him about her first day of kindergarten. D) The client's assistive personnel places paper cups and plastic utensils in his room.
Answer: C. A) The nurse should recognize that these foods are part of a low-bacteria diet and are acceptable for a client who is immunocompromised. B) The nurse should recognize that the client can have an artificial flower arrangement, which poses no infection risk. C) The nurse should limit the client's visitors to healthy adults. A visit from a child who is attending school can place the client at risk for infection due to his immunocompromised status. D) The nurse should place individually wrapped paper and plastic supplies in the client's room for the client's use.
An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? A) Urine output. B) 12-lead electrocardiogram (ECG) C) Potassium level. D) Rate of IV fluids
Answer: C. After DKA therapy starts, serum potassium levels drop quickly. An ECG shows conduction changes and ectopy related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the ectopy is essential.Ectopy is not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause, which is most likely hypokalemia. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A) Assess the wound dressing for bleeding. B) Administer morphine sulfate for pain.. C) Monitor oxygen saturation using pulse oximetry. D) Support the head and neck with pillows.
Answer: C. Airway assessment and management is always the first priority with every client. This is especially important for a client t who has had surgery that involves potential bleeding and edema near the trachea. Remember the ABCs (airway, breathing, and circulation) of physical assessment.Assessing the wound dressing for bleeding is a high priority, which is performed after assessing airway and breathing. Pain control and supporting the head and neck with pillows are important priorities, but can be addressed after airway assessment.
The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A) Evaluating each other's handwashing technique B) Deciding which brand of handwashing soap to use C) Reinforcing the need for handwashing after caring for clients D) Determining which clients are most likely to infect other residents
Answer: C. All caregivers have a responsibility to reinforce basic handwashing, including that provided for nursing assistants.A higher level of administration is required to evaluate the performance of another worker. Deciding which brand of handwashing soap to use is done at the facility level by the infection control department. Determining which clients are most likely to infect other residents requires a higher level of education for client management.
A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? A) Obtain a 12-lead electrocardiogram (ECG). B) Call for a portable chest x-ray. C) Obtain blood cultures from two sites. D) Give cefazolin (Kefzol) 500 mg IV
Answer: C. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic.A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.
Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment? A) "I may lose my hair during this treatment." B) "I must be positioned in the same way during each treatment." C) "I will have a radioactive device in my body for a short time." D) "I will be placed in a semiprivate room for company."
Answer: C. Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific.Because radiation therapy is site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.
The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform? A) Piggyback the furosemide into the infusing blood. B) Give furosemide to the client intramuscularly (IM). C) Administer the furosemide after completion of the transfusion. D) Add furosemide to the normal saline that is infusing with the blood.
Answer: C. Completing the transfusion before administering furosemide is the best course of action in this scenario.Drugs are not to be administered with infusing blood products, because they can interact with the blood, causing risks for the client. Changing the admission route is not a nursing decision. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision.
A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? A) "Drinking alcoholic beverages should be avoided." B) "The health care provider should be notified 3 months before a planned pregnancy." C) "Any side effects of this drug will be mild." D) "I will avoid any live vaccines."
Answer: C. Further teaching is needed if the client states that, "Any side effects of this drug will be mild." Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug. Alcoholic beverages increase the risk for hepatotoxicity and should be avoided. Strict birth control is recommended for any client of childbearing age because of the possibility of birth defects. Severe reactions may occur when live vaccines are given because of the immunosuppressive effect of methotrexate.
The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? A) "I will be on this medicine for the rest of my life." B) "I must undergo regular kidney function tests." C) "I must regularly monitor my blood sugar." D) "My gums may become swollen because of this drug."
Answer: C. Further teaching is needed when the client says, "I must regularly monitor my blood sugar." Blood sugar is not affected by taking cyclosporine, so the client has no need to monitor blood sugar.The client must take cyclosporine for the rest of his or her life. (See chart 17-2) Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. Swollen gums are a side effect of taking cyclosporine.
The nurse is assessing a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires immediate notification to the primary health care provider? A) Dry lips and oral mucosa on examination B) Nasal drainage that tests negative for glucose C) Client report of a headache and stiff neck D) Urine specific gravity of 1.016
Answer: C. Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. The finding requires the nurse to immediately notify the primary health care provider.Dry lips and mouth are not unusual after surgery. The client was NPO and received anesthesia. Frequent oral rinses and the use of dental floss would be encouraged because the client cannot brush the teeth until the surgeon gives permission. Any nasal drainage is expected to test negative for glucose. Nasal drainage that tests positive for glucose indicates the presence of a cerebrospinal fluid leak. A urine specific gravity of 1.016 is within normal limits.
Which statement about the transmission of hepatitis C is correct? A) Feces are a likely body fluid by which to transmit the disease. B) Airborne Precautions are used for the prevention of hepatitis C. C) Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D) No precautions are necessary with the use of nail clippers or scissors.
Answer: C. Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection.Feces are not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors, so these items should be disinfected regularly.
Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? A) Local senior citizen center. B) Citizens for Better Care. C) Home health care agency. D) Meals on Wheels.
Answer: C. Home health care agencies can obtain referrals and order a nurse to assess the home situation and notify the health care provider of any in-home needs. These needs can include a nurse, an aide, physical therapist, occupational therapist, or social worker. Senior citizen centers provide activities, meals, and sometimes transportation, but do not help with ADLs. Citizens for Better Care is concerned with clients' rights and safety in health care facilities. The home health care agency may make a referral to Meals on Wheels if it is indicated, but this will not help with all ADLs or safety measures.
A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A) Decreased mononuclear leukocyte count. B) Decreased leukocyte count. C) Decreased neutrophil count. D) Elevated erythrocyte sedimentaiton rate.
Answer: C. In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils.An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH) admitted with change in mental status. To determine whether fluid restrictions have been effective, for which of these outcomes will the nurse monitor? A) Decreased hematocrit. B) Decreased serum osmolality. C) Increased serum sodium. D) Increased urine specific gravity.
Answer: C. Increased serum sodium due to fluid restriction indicates effective therapy.Restricting fluid would result in increasing hematocrit levels as the fluid volume excess resolves. Plasma osmolality is decreased as a result of SIADH, so treatment would result in this level rising to near normal. Urine specific gravity is increased with SIADH and would decrease to near normal with treatment.
The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? A) "When I injected heroin, I was exposed to HIV." B) "I don't understand how the antiretroviral drugs work." C) "I remember to take my antiretroviral drugs almost every day." D) "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."
Answer: C. It is important that clients take these drugs consistently, because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains. The nurse would immediately assess the reasons why the client does not take the medications daily and then would implement a plan to improve adherence.The nurse would assess whether the client is still injecting drugs and would make certain the client understands the risks for infection with another strain of HIV or other blood borne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.
An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? A) Ask the client about any numbness or tingling. B) Check for bone deformities in the client's back. C) Measure the client's intake and output hourly. D) Monitor the client for shortness of breath.
Answer: C. Measuring hourly intake and output is a commonly delegated nursing action that is within the UAP scope of practice.Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures. Physical assessment is a complex task that cannot be delegated to a UAP. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure. Careful monitoring for shortness of breath is the responsibility of the RN.
A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? A) "I am allergic to iodine." B) "My urinary stream is very weak." C) "My legs are numb and weak." D) "I am incontinent when I cough."
Answer: C. Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. Prostate cancer may frequently metastasize to the bone, specifically the spine.Allergy to iodine should be reported when contrast media will be used, but dye is not used in radiation therapy. A weak urinary stream and incontinence are common clinical manifestations of prostate cancer. Incontinence associated with coughing is typical of stress incontinence and is not a complication of cancer.
In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? A) Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma. B) Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency. C) Potential for infection transmission related to recurring opportunistic infections. D) High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans.
Answer: C. Protecting the client from further opportunistic infection such as Candida albicans is a priority. Secondary immune deficiencies are common and acquired as part of another disease or as a consequence of certain medications. The most common secondary immune deficiencies are caused by aging, malnutrition, certain medications, and some infections, such as HIV. The most common medications associated with secondary immune deficiencies are chemotherapy agents and immune suppressive medications, cancer, transplanted organ rejection, or autoimmune diseases.Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be secondary concern because Candida Albicans causes the mouth sores. Nutrition will be affected because of Candida Albicans; however, it is not a priority.
A 52-year-old client tells the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? A) "Don't worry, most lumps are discovered by women during breast self-examination." B) "Does anyone in your family have breast cancer?" C) "Finding a cancer in the early stages increases the chance for cure." D) "Have you noticed a lump or thickening in your breast?"
Answer: C. Providing truthful information about early cancer detection addresses the client's concerns.Mammography can detect lumps smaller than those discovered by palpation. Asking about family history or symptoms is not therapeutic because it does not address the client's fear of cancer.
The nurse is providing discharge instructions to a client receiving spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? A) "I must call the primary health care provider if I am more tired than usual." B) "I need to increase my salt intake." C) "I will eat a banana every day." D) "This drug will not control my heart rate."
Answer: C. Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, need to be avoided to prevent hyperkalemia.While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported. Sodium intake is not typically increased while taking a diuretic; this would exacerbate underlying problems for which the diuretic was prescribed. The client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.
The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? A) "I need to know my HIV status, so I must get tested before caring for any clients." B) "Putting on a gown and gloves will cover up the itchy sores on my elbows." C) "Washing my hands and putting on a gown and gloves is what I must do before starting care." D) "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."
Answer: C. Standard Precautions include hand hygiene and whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.Knowing HIV status is important for preventing transmission of HIV, but is not part of the Standard Precaution Protocol. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.
The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A) The student demonstrates asepsis by scrubbing the hub of IV tubing before administering an antibiotic. B) The nurse overhears the student explaining to the client the importance of handwashing. C) The student teaches the client that symptoms of neutropenia include fatigue and weakness. D) The nurse observes the student educating the client about hygiene and perineal care.
Answer: C. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected.Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.
A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? A) The client eating a morning meal of cereal and fruit B) The physical therapist walking with the client in the hallway C) Unlicensed assistive personnel (UAP) pulling the client up in bed by the shoulders D) Visitors talking with the client about going home
Answer: C. The UAP pulling the client up in bed by the shoulders requires the nurse to intervene. The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet would be used to reposition the client.The client with hyperparathyroidism is not restricted from eating and needs to maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.
The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? A) Reports of pain B) Increased temperature C) Bleeding from the nose. D) Decreased urine output.
Answer: C. The assessment finding on a newly admitted client with thrombocytopenia that needs immediate intervention by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for bleeding. The nosebleed would be attended to immediately.The client's report of pain, decreased urine output, and increased temperature are not the highest priority.
An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? A) Client with Graves' disease who needs discharge teaching after a total thyroidectomy B) Client with hyperparathyroidism who is just being admitted for a parathyroidectomy C) Client with type 2 diabetes who requires insulin while receiving prednisone (Deltasone) D) Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements
Answer: C. The best client to assign to the LPN/LVN is the client with infiltrative ophthalmopathy who needs high-dose prednisone administered. Medication administration is within the scope of practice of the LPN/LVN.Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications. Teaching is a complex task that is appropriate for the RN.
Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? A) Report the need for desensitization therapy. B) Convey the need for pharmacologic therapy to the health care provider. C) Communicate the need for avoidance therapy to the health care team. D) Discuss symptomatic therapy with the health care provider.
Answer: C. The best nursing action is to communicate the need for avoidance therapy to the health care team. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins.Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Discussing the need for pharmacologic therapy might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are not preventive but are effective only after the hypersensitivity reaction has already occurred.
A hematology unit is staffed by registered nurse's (RNs), licensed practical nurses (LPNs)/licensed vocational nurse (LVNs), and unlicensed assistive personnel (UAP). When the nurse manager is reviewing staff documentation, which entry indicates the need for staff education for his or her appropriate level of responsibility and client care? A) "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B) "Ambulated in hallway for 40 feet (12 m) and denies shortness of breath at rest or with ambulation. T.Y., LPN" C) "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D) "Vital signs 98.6°F (37.0°C), heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"
Answer: C. The documentation entry that needs education is the one from the UAP that states that the "client reports increased shortness of breath and that oxygen was increased to 4 L by nasal cannula." Determination of the need for oxygen and administration of oxygen must be done by licensed nurses who have the education and scope of practice required to administer it.All other documentation entries reflect appropriate delegation and assignment of care.
The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? A) Most clients with type 1 diabetes are born with it. B) People with type 1 diabetes are often obese. C) Those with type 2 diabetes make insulin, but in inadequate amounts. D) People with type 2 diabetes do not develop typical diabetic complications.
Answer: C. The explanation by the students that indicate understanding of the type of diabetes is "Those with type 2 diabetes make insulin, but in inadequate amounts." People with type 2 diabetes may also have resistance to existing insulin.Most clients with type 1 diabetes are not born with it. Although type 1 diabetes may occur early in life, it is considered an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person. Risk for type 1 DM is determined by inheritance of genes coding for the HLA-DR and HLA-DQA and DQB tissue types (McCance et al., 2014). However, inheritance of these genes only increases the risk, and most people with these genes do not develop type 1 DM. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for typical diabetic complications, especially cardiovascular diseases.
Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A) An experienced LPN/LVN who has worked on the medical unit for 10 years B) An RN with experience in the operating room who transferred a month ago to the medical unit C) A float RN with 7 years of experience on the inpatient oncology unit D) An RN who has worked mostly on the same-day surgery unit since graduating a year ago
Answer: C. The float RN with experience on the inpatient oncology unit would be familiar with complications and assessment for IV fluids and pneumonia.LPN/LVNs do not have the scope of practice to provide care to this client. The RN with experience in the operating room or the RN who has worked mostly on the same-day surgery unit does not have the experience needed to care for an unstable client on an unfamiliar unit.
When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A) Drug toxicity. B) Polycythemia. C) Infection. D) Dose-limiting side effects.
Answer: C. The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase.Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction.
A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? A) "Keep up the good work." B) "This is not good at all." C) "Have you been doing something differently?" D) "You need an increase in your insulin dose."
Answer: C. The most appropriate response by the nurse is telling the client that the level is high and then assessing the client's regimen or changes he or she may have made. This is the best format to formulate interventions to gain control of blood glucose. HbA1C levels for diabetic clients need to be less than 7%. A value of 9.4% shows poor control over the past 3 months.Telling the client to "keep up the good work" is incorrect. A(HbA1C) level of 9.4% is too high. Scolding the client by saying "this is not good," although true, does not take into account problems the client may be having with the regimen or an undiagnosed illness. Although it may be true that the client needs more insulin, an assessment of the client's regimen is needed before decisions are made about medications.
A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A) Wash fruits and vegetables with mild soap and water before eating. B) Intermittent exposure to known allergens will produce immunity. C) Remove cloth drapes, carpeting, and upholstered furniture. D) Be cautious when eating unprocessed honey.
Answer: C. The most important discharge instruction to give this client is to remove cloth drapes, carpet, and upholstery in order to reduce airborne pollen, dust mites, and mold.Washing fruits and vegetables pertains to food allergies. Clients do not develop immunity to known allergens by direct intermittent exposure. Some common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is said to help some people with allergies to pollen only; it does not have an impact on airborne allergens.
A 32-year-oldclient is recovering from a sickle cell crisis. The client's discomfort is controlled with pain medications and discharge planning has been initiated. What medication will the nurse anticipate to be prescribed before discharge? A) Heparin (Heparin). B) Warfarin (Coumadin). C) Hydroxurea (Droxia). D) Tissue plasminogen activator (t-PA).
Answer: C. The nurse anticipates Hydroxyurea to be prescribed for pain for a sickle cell disease client who is being discharge. Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD).Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.
The nurse assess the client with which hematologic condition first? A) A 32-year-old with pernicious anemia who needs a vitamin B12 injection B) A 67-year-old with acute myelocytic leukemia with petechiae on both legs C) An 81-year-old with thrombocytopenia and an increase in abdominal girth D) A 40-year-old with iron deficiency anemia who needs a Z-track iron injection
Answer: C. The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32-year-old with pernicious anemia, the 67-year-old with acute myelocytic leukemia, and the 40-year-old with iron deficiency anemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.
The nurse is caring for a client who has frequent episodes of hypoglycemia with loss of consciousness. During interdisciplinary rounds, which of these does the nurse suggest the client's family learn to use? A) Norepinephrine. B) Calcitonin. C) Glucagon. D) Insulin.
Answer: C. The nurse suggests that the client's family learn to inject Glucagon when the client has episodes of hypoglycemia and loss of consciousness. Glucagon is the hormone that binds to receptors on liver cells. This causes the liver cells to convert glycogen to glucose, increasing blood glucose levels.Norepinephrine is a catecholamine released from the adrenal medulla. It activates the sympathetic nervous system and creates a "fight or flight" response. Calcitonin regulates serum calcium, not glucose. Beta cells in the pancreas are responsible for synthesizing and secreting the hormone insulin which is responsible for lowering blood glucose by increasing its uptake by the cell.
A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? A) "Your diabetes is getting worse, so you will need to take insulin." B) "You can't take your metformin while in the hospital." C) Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." D) "You must take insulin from now on because the surgery will affect your diabetes."
Answer: C. The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.
A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? A) "It is overwhelming, isn't it?" B) "Let's see how much you can learn today, so you are less nervous." C) "Let's tackle it piece by piece. What is most scary to you?" D) "Many people live with diabetes and do it just fine."
Answer: C. The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client centered response, and acknowledges the client's concern, letting the client master survival skills first.Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in one day may add to his anxiety by overwhelming him with information and the need to "do it all" in one day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.
A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" Which is the nurse's best response to the client? A) "Yes, they do." B) "No, they don't." C) "The number varies with gender, age, and general health." D) "You have fewer red blood cells because you have anemia."
Answer: C. The nurse's best response to the client with anemia about most people having the same number of blood cells is, "The number varies with gender, age, and general health." This statement is the most educational and reasonable response to the client's question.Responding "yes, they do." and "no, they don't." are not educational statements. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.
A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? A) Infuse normal saline at 200 mL/hr. B) Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. C) Discontinue infusing the antibiotic. D) Give diphenhydramine (Benadryl) 100 mg IV.
Answer: C. The nurse's first action should be to discontinue the antibiotic. The antibiotic is the most likely cause of the client's apparent anaphylactic reaction.Infusing normal saline and administering epinephrine and diphenhydramine may be indicated, but these are not the nurse's first action.
A client is hospitalized with a possible disorder of the adrenal cortex. Which nursing activity is best for the charge nurse to delegate to an experienced nursing assistant? A) Ask about risk factors for adrenocortical problems. B) Assess the client's response to physiologic stressors. C) Check the client's blood glucose levels every 4 hours. D) Teach the client how to do a 24-hour urine collection.
Answer: C. The nursing activity that is the best one for the charge nurse to delegate to an experienced nursing assistant is checking the client's blood glucose every 4 hours. Blood glucose monitoring is within the nursing assistant's scope of practice if the nursing assistant has received education and evaluation in the skill.Asking the client about risk factors for adrenocortical problems is not part of a nursing assistant's education. Assessing the client's response to physiologic stressors requires the more complex skill set of licensed nursing staff. Teaching the proper method for a 24-hour urine collection is a multistep process, and would not be delegated to a nursing assistant.
A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? A) "It will thin my blood." B) "It is used to dissolve blood clots." C) "It should prevent my blood from clotting." D) "It might cause me to get injured more often."
Answer: C. The statement that shows the client understands anticoagulant drug action is, "it will prevent my blood from clotting." Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots.Anticoagulants do not cause any change in the thickness or viscosity of the blood.Anticoagulants do not dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries but may cause more bleeding and bruising when the client is injured.
Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A) Refer a client with a daily alcohol consumption of 12 beers for counseling B) Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism C) Report any bleeding noted when catheter care is given to a client with a history of hemophilia D) Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure
Answer: C. The task the nurse delegates to the UAP is to report any bleeding when catheter care is given to a client with a history of hemophilia. Reporting findings during routine care is expected and required of unlicensed staff members.Referring a client for alcohol counseling, drawing a partial thromboplastin time, and performing a capillary fragility test are more complex and would be done by licensed nursing staff.
The nurse is assessing a client for hematologic risks. Which health history question would the nurse ask to determine if the risk cannot be reduced or eliminated? A) "Where do you work?" B) "Tell me what you eat in a day." C) "Does anyone in your family bleed a lot?" D) "Do you seem to have excessive bleeding or bruising?"
Answer: C. To determine if hematologic risks exist while obtaining a health history from a client, the nurse asks if anyone in the client's family bleeds a lot. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed.Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed. Diet can affect risk, but it is a health behavior that can be changed.Excessive bleeding or bruising is a symptom, not a risk.
An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? A) Use an abduction pillow between the legs. B) Keep heels off the bed. C) Avoid using a straight razor. D) Re-orient frequently.
Answer: C. Using a straight razor should be avoided. The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin that can occur when shaving. Using an abduction pillow between the legs is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning. Keeping the heels off the bed prevents pressure ulcers during the in-hospital postoperative period. Changes in mental status can occur immediately after surgery as a result of anesthesia.
The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A) "The doctor will place a small needle in your back and will withdraw some fluid." B) "You will be sedated during the procedure, so you will not be aware of anything." C) "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." D) "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."
Answer: C. When describing a bone marrow biopsy procedure to a client, it is accurate to describe a crunching sound or scraping sensation when the needle punctures the bone. Proper expectations minimize the client's fear during the procedure.A very large-bore needle is used for a bone marrow biopsy, not a small needle, and the puncture is made in the hip or in the sternum, not the back. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site.
When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A) Administering a biological response modifier B) Encouraging oral care with commercial mouthwash. C) Providing oral care with a disposable mouth swab. D) Maintaining NPO until the lesions have resolved
Answer: C. The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care.Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition and hydration are important during cancer treatment; a local anesthetic may be prescribed.
The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply). A) Heavy menses. B) Smooth facial skin. C) Hyperkalemia. D) Breast tenderness. E) Weight loss. F) Deep vein thrombosis.
Answer: D, F. Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur.Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, may also occur. Fluid retention with weight gain also typically happens.
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone(SIADH). Which of the following findings should the nurse report to the provider? A) 2+ deep-tendon reflexes. B) Potassium 3.7 mEq/L. C) Urine specific gravity 1.025. D) Sodium 110 mEq/L
Answer: D. A) Deep-tendon reflexes of 2+ are within the expected reference range. B) This serum potassium level is within the expected reference range. C) This urine specific gravity is within the expected reference range. D) A client who has SIADH retains fluids, which causes dilutional hyponatremia.
A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor and report which of the following findings to the provider immediately? A) Nausea and vomiting. B) Vaginitis. C) Furry tongue. D) Watery diarrhea.
Answer: D. A) Nausea and vomiting are adverse effects of clindamycin. However, another finding is the priority. B) Vaginitis can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. C) Furry tongue can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. D) The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. Therefore, the priority finding is diarrhea. The nurse should report this finding to the provider immediately and discontinue the medication.
A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) "I should stop taking my insulin if I feel nauseous." B) "I will test my urine for protein when I start to feel ill." C) "I should check my blood glucose level every 8 hours." D) "I will call my doctor if my blood sugar is more than 250 milligrams per deciliter."
Answer: D. A) The client should continue taking the usual dose of insulin, even when not feeling well. B) The client should check her urine for ketones when her blood glucose levels are greater than 240 mg/dL. C) The client should check her blood glucose level every 4 hr during illness. D) The client should call the provider if her blood glucose levels exceed 250 mg/dL during illness.
A nurse is reviewing the daily laboratory results for a female client who has leukemia. Which of the following values is an expected finding? A) Hgb 14 g/dL. B) Hct 40%. C) Platelets 170,000/mm3. D) WBC count 21,000/mm3
Answer: D. A) The nurse should expect a client who has acute leukemia to have a decreased Hgb level. B) The nurse should expect a client who has acute leukemia to have a decreased Hct level. C) The nurse should expect a client who has acute leukemia to have a decreased platelet count. D) The nurse should expect a client who has acute leukemia to have an elevated WBC count.
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following should the nurse include in the teaching? A) Expect manifestations to subside in 1 to 2 weeks. B) Increase intake of vitamin D. C) Anticipate constipation. D) Avoid crowds.
Answer: D. A) The nurse should inform the client that it takes 4 to 6 weeks for the manifestations of rheumatoid arthritis to respond to methotrexate therapy. B) The nurse should instruct the client to increase his intake of folic acid, not vitamin D, to help decrease the adverse effects of methotrexate. C) The nurse should inform the client that diarrhea is an adverse effect of methotrexate. D) The nurse should instruct the client to avoid crowds when taking methotrexate. Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection.
A nurse is providing teaching to a client who has a new prescription for amoxicillin to treat a respiratory infection. Which of the following statements by the client indicates an understanding of the teaching? A) "I will keep taking this medication until I feel better." B) "I should expect to have constipation while taking this medication." C) "I should take this medication on an empty stomach." D) "I will use a backup method of birth control while I am taking this medication."
Answer: D. A) The nurse should instruct the client to take the full dose of antibiotics, even if her condition improves, to ensure the infection is eliminated. B) The nurse should inform the client that diarrhea is an adverse effect of amoxicillin. C) The nurse should inform the client that amoxicillin is a medication that can be taken with food. D) The nurse should inform the client that antibiotics accelerate the elimination of oral contraceptives, making them less effective.
A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? A) Palpation of testes B) Human chorionic gonadotropin level. C) Pelvic ultrasound. D) Digital rectal examination.
Answer: D. A) The nurse should recognize that palpation of a client's testes is used to screen for testicular cancer, rather than prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. B) The nurse should recognize that human chorionic gonadotropin is used to diagnose testicular cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. C) The nurse should recognize that a transrectal ultrasound, not a pelvic ultrasound, is used to screen for prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. D) The nurse should recognize that a digital rectal examination is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer.
Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? A) Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. B) Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. C) Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. D) Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.
Answer: D. After exposure to asbestos, a client's protection from cancer depends on a balance between helper and inducer T cells and suppressor T cells. This balance occurs when helper and inducer T cells outnumber suppressor T cells by a ratio of 2:1.The activity of cytotoxic and cytolytic T cells is most effective against self cells infected by parasites. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T cells. When suppressor T cells are increased, immune function is suppressed and the client is at risk for infection.
The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? A) Avoid asbestos. B) Wear sunscreen. C) Get the human papilloma virus (HPV) vaccine. D) DO not smoke cigarettes.
Answer: D. All of these actions are part of cancer prevention; however, tobacco is the single most important source of preventable carcinogenesis.Although asbestos may present a risk for lung cancer, it is not a likely exposure for teens. Asbestos may be found in older homes and buildings, although most schools have been through an asbestos abatement program so should not pose a risk. If some teens may be involved in the construction industry during the summer, they need to be made aware of asbestos risks. Lifetime exposure to the sun and the use of tanning beds will increase the risk for cancer, but not as much as tobacco use. The HPV vaccine will decrease the risk for cervical cancer, but will not have as much of an impact on cancer prevention as avoiding tobacco.
A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A) Explain that this occurs in some clients and is usually permanent. B) Inform the client that a small glass of wine may help her relax. C) Protect the client from infection. D) Allow the client an opportunity to express her feelings.
Answer: D. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client.Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.
The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A) "How much exercise do you get?" B) "What is your endurance level?" C) "Are your feet or hands cold, even when you are in bed?" D) "Do you feel more tired after you get up and go to the bathroom?"
Answer: D. Asking about feeling tired after using the bathroom is the best question to ask to assess a client's endurance level. This question is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provides needed answers.The hospitalized client typically does not get much exercise. This would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague. The client may not know how to answer this question. Asking about cold feet or hands does not address the client's endurance.
Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? A) Monitor the oral mucosa for pallor, bleeding, or ulceration B) Ask about the amount of blood loss with each menstrual period C) Check for sternal tenderness while applying fingertip pressure D) Count the respiratory rate before and after ambulating 20 feet (6 m)
Answer: D. Counting the respiratory rate before and after ambulation is within the scope of practice for a UAP. The UAP will report this information to the RN.Monitoring oral mucosa requires skilled assessment techniques and knowledge of normal parameters, asking the client about the amount of blood loss with each menstrual period, and checking for sternal tenderness would be done by the RN.
The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? A) "RA is inflammatory. OA is degenerative." B) "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation." C) "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." D) "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."
Answer: D. Further teaching is needed if the client states that, "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints. RA is an inflammatory process, while OA is a degenerative process. Research is being done to find a possible genetic cause for OA, but age, trauma, obesity, and occupation are the main causes of degeneration. RA occurs most often in women, usually between 35 and 45 years of age, whereas older age is a cause of OA.
The nurse reviews the vital signs of a client diagnosed with Graves' disease and notes that the client's temperature is 99.6°F (37.6°C). After notifying the primary health care provider, what does the nurse do next? A) Administers acetaminophen B) Alerts the Rapid Response Team C) Asks any visitors to leave D) Assesses the client's cardiac status
Answer: D. Graves' disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client's cardiac status as atrial fibrillation or other dysrhythmia may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias.Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time as no instability has been noted. Asking visitors to leave is not necessary if the visitors are providing comfort to the client.
A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? A) Document symptoms of incisional infection or meningitis. B) Give over-the-counter laxatives if the client is constipated. C) Set up medications as prescribed for the day. D) Test any nasal drainage for the presence of glucose.
Answer: D. Home health aides can perform testing for nasal drainage for the presence of glucose after education and validation of the skill. After delegating this task, the nurse would follow up on the result to determine if the primary health care provider needs to be contacted. Cerebrospinal fluid (CSF) will test positive using a glucose "dipstick." Nasal drainage that is positive for glucose after a transsphenoidal hypophysectomy would indicate a CSF leak that would require immediate notification of the primary health care provider.Assessing for symptoms of infection and documenting them in the record, medication administration, and setting up medication are not within the scope of practice of the home health aide.
A client with newly diagnosed hypothyroidism tells the nurse, "I just want to feel better now. Why can't I just get a standard dose of medication instead of all this dosage adjustment?" The nurse explains that starting levothyroxine sodium (Synthroid) at a high dose may cause which of these problems? A) Bradycardia and decreased level of consciousness B) Decreased respiratory rate and hypoxemia C) Hypotension and shock D) Hypertension and heart failure
Answer: D. Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state.The client would experience tachycardia, not bradycardia. The client may have an increased respiratory rate when taking high doses of thyroid replacement therapy. Shock may develop, but only as a late effect and as the result of "pump failure."
An HIV positive client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? A) Therapeutic highly active antiretroviral therapy (HAART) level. B) Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot. C) Positive Papanicolaou (Pap) test. D) Improved CD4+ T-cell count and reduced viral load
Answer: D. Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication.Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication..
The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A) Veins of the legs. B) Lung. C) Heart. D) Abdominal cavity.
Answer: D. Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity.Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.
Which type of cancer has been associated with Down syndrome? A) Breast cancer. B) Colorectal cancer. C) Malignant melanoma. D) Leukemia.
Answer: D. Leukemia is associated with Down syndrome and Turner syndrome.Breast cancer is often found clustered in families, not in association with Down syndrome. Colorectal cancer is associated with familial polyposis. Malignant melanoma is associated with familial clustering and sun exposure.
An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A) Storing drugs in dark locations at room temperature B) Wearing soft clothing C) Wearing a hat and sunglasses when going outside D) Reducing all direct and indirect sources of light.
Answer: D. Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy. It can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties.Drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light. Texture of the clothing is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.
A priority problem of hyperthermia is identified by the long-term-care RN who is caring for a client with a urinary tract infection. Which intervention is most appropriate to delegate to a nursing assistant? A) Monitor for improvement after antibiotic therapy is initiated. B) Teach the client the reason for taking antibiotics as prescribed. C) Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D) Increase fluid intake by assisting the client to choose approved and preferred beverages.
Answer: D. Nursing assistants can provide dietary choices to clients, and allowing clients to select the beverage of their choice will improve oral intake. In clients with hyperthermia (fever), fluid volume loss is increased from rapid evaporation of body fluids and increased perspiration. As body temperature increases, fluid volume loss increases, placing the client at risk of becoming dehydrated. Offering a choice of beverage may increase oral intake and help prevent/treat hyperthermia.Monitoring for improvement and teaching the client require advanced education and are within the scope of the RN. Administering acetaminophen (Tylenol) is within the scope of the licensed nurse, not a nursing assistant.
The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult male client indicates understanding of the nurse's instructions? A) "Cigarette smoking always causes lung cancer." B) "Taking multivitamins will prevent me from developing cancer." C) "If I have only one shot of whiskey a day, I probably will not develop cancer." D) "I need to report the pain going down my legs to my health care provider."
Answer: D. Pain in the back of the legs could indicate prostate cancer in an older adult male.Cigarette smoking is implicated in causing lung cancer and other types of cancer, but it does not always cause cancer. Investigation is ongoing about the efficacy of vitamins A and C in cancer prevention, but at this time taking vitamins does not prevent cancer. Limiting alcohol to one drink per day is only one preventive measure.
The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? A) Add 20 mEq of KCl to each liter of IV fluid B) IV regular insulin at 2 units/hr C) IV normal saline at 100 mL/hr D) 1 ampule Sodium Bicarbonate IV now
Answer: D. Sodium Bicarbonate is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state that presents with hyperglycemia and absence of ketosis/acidosis.Insulin puts potassium into the cell. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from osmotic diuresis and electrolyte shifts. IV regular insulin at 2 units/hr will help correct hyperglycemia. IV normal saline at 100 mL/hr will help correct dehydration.
A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? A) Day of discharge. B) On admission. C) When the client states readiness. D) While performing the test in the hospital
Answer: D. Teaching the client about the operation of the machine while performing the test in the hospital is the best time for the nurse to introduce the client to SMBG. The teaching can be reinforced each time testing is performed on the client and again before discharge.Instructing the client on the day of admission or the day of discharge would not allow time for redemonstration and correction of the skill if needed. Other time-consuming activities are done on those days and could distract the client and make the client feel overwhelmed. Also, waiting for the client to state readiness may postpone the instructions too long.
Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? A) RN who has worked for the home health agency for 5 years in maternal-child health. B) RN who has extensive critical care nursing experience and has worked in home health for a year. C) RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit. D) RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency.
Answer: D. The RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency has the experience and understanding of the needs of a posttransplantation client, as well as knowledge of cyclosporine, and would be the best choice.An RN who has worked for the home health agency for 5 years in maternal-child health, an RN who has extensive critical care nursing experience and has worked in home health for a year, and an RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit would not have specific knowledge and information on the care provided and medications used in posttransplantation clients.
A 56-year-oldclient admitted with a diagnosis of acute myelogenous leukemia (AML) has been prescribed intravenous (IV) cytosine arabinoside and an IV infusion of daunorubicin. The client develops an infection. Which action would the nurse take to determine that the appropriate antibiotic has been prescribed to treat this condition? A) Monitor the client's white blood cell (WBC) count level B) Evaluate the client's liver function tests (LFTs) and serum creatinine levels C) Recognize that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML D) Check the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection
Answer: D. The best action the nurse takes to determine if the appropriate antibiotic has been prescribed is to check the culture and sensitivity test results to be sure that the prescribed antibiotic is effective against the organism causing the infection. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection.Although the WBC count is elevated in infection, this test does not influence which antibiotic will be effective in fighting the infection. Although LFTs and kidney function tests may be influenced by antibiotics, these tests do not determine the effectiveness of the antibiotic. Vancomycin may not be effective in all infections. Culturing of the infection site and determining the organism's sensitivity to a cohort of drugs are needed. This will provide data on drugs that are capable of eradicating the infection in this client.
The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? A) Client who is receiving IV hydrocortisone for an Addisonian crisis B) Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer C) Client being discharged after a unilateral adrenalectomy to remove a pheochromocytoma D) Client with Cushing's syndrome who requires frequent glucose monitoring and administration of insulin
Answer: D. The best client to assign to the RN who was floated to the medical-surgical unit from the pediatric unit is the client with Cushing's syndrome. An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration related to this client.A client in Addisonian crisis would best be monitored by an RN from the medical-surgical floor. Although the float RN could complete the admission history, the client with SIADH secondary to lung cancer might require hypertonic saline and correction of hyponatremia. Teaching and orientation to the unit that is best provided by a nurse more familiar with that area. Discharge teaching specific to adrenalectomy would be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with care of postoperative adult clients with endocrine disorders.
Which client is at greatest risk for experiencing a hemolytic transfusion reaction? A) A 42-year-old client with allergies B) A 78-year-old client with arthritis C) A 58-year-old immune-suppressed client D) A 34-year-old client with type O blood
Answer: D. The client at greatest risk for experiencing a hemolytic transfusion reaction is the 34-year-old client with type O blood. Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.The client with allergies would be most susceptible to an allergic transfusion reaction. The older adult client with arthritis would be most susceptible to circulatory overload. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease.
The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? A) Client with Hashimoto's thyroiditis and a large goiter B) Client with hypothyroidism and an apical pulse of 51 beats/min C) Client with parathyroid adenoma and flank pain due to a kidney stone D) Client who had a parathyroidectomy yesterday and has muscle twitching
Answer: D. The client who needs to be assessed first is the one-day postoperative client who had a parathyroidectomy and has muscle twitching. This client is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed.Clients with Hashimoto's thyroiditis are usually stable. This client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and would be asked about pain medication as soon as possible, but this client does not need to be assessed first.
A recently admitted client who is in sickle cell crisis requests "something for pain." What medication would the nurse be prepared to administer? A) Oral ibuprofen (Motrin) B) Oral morphine sulfate (MS-Contin) C) Intramuscular (IM) morphine sulfate D) Intravenous (IV) hydromorphone (Dilaudid)
Answer: D. The client with sickle cell disease needs IV pain relief, and it needs to be administered on a routine schedule (i.e., before the client has to request it).Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control. However, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis. IV analgesics would be used until his or her condition stabilizes. Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin.
A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? A) "I cannot share my toothpaste with anyone." B) "I must flush the toilet three times after I use it." C) "I need to wash my clothes separately from everyone else's clothes." D) "I'm ready to hold my newborn grandson now."
Answer: D. The client's statement that indicates further teaching is needed is, "I'm ready to hold my newborn grandson now." Clients undergoing oral 131I therapy need to avoid close contact with pregnant women, infants, and young children for 1 week after treatment. Clients would remain at least 1 meter (39 inches, or roughly 3 feet) away, and limit exposure to less than 1 hour per day.Toothpaste cannot be shared for at least one week. Some radioactivity will remain in the client's salivary glands for up to 1 week after treatment. Care needs to be taken to avoid exposing others to the saliva. Flushing the toilet three times after use will ensure that all urine has been diluted and removed. It is best to use a toilet that is not used by others for at least 2 weeks after receiving the radioactive iodine. Clothing needs to be washed separately and the washing machine then needs to be run empty for a full cycle before it is used to wash the clothing of others.
The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? A) Cataracts. B) Crohn's disease. C) Diabetes mellitus. D) Hypertension
Answer: D. The health care professional should be notified if the client has hypertension because decongestants have actions similar to adrenergic drugs, causing vasoconstriction and increasing blood pressure.Decongestants are not contraindicated in clients with cataracts, Crohn's disease, or diabetes mellitus.
A client admitted with a diagnosis of acute myelogenous leukemia is prescribed intravenous (IV) cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this drug therapy? A) Nausea. B) Stomatitis. C) Liver toxicity. D) Bone marrow suppression.
Answer: D. The major side effect of this drug therapy is bone marrow suppression. Intravenous cytosine arabinoside and daunorubicin are a commonly prescribed course of aggressive chemotherapy, and bone marrow suppression is a major side effect. The client is even more at risk for infection than before treatment began.Liver toxicity, nausea, and stomatitis are not the major problems with this therapy.
A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? A) Assess skin turgor and mucous membranes for hydration status. B) Discuss the dietary restrictions for 24-hour urine testing. C) Plan ways to control the environment that will avoid stimulating the client. D) Remind the client to not order coffee with meals
Answer: D. The most appropriate nursing action for the charge nurse to delegate to the nursing assistant is to remind the client to not order coffee with meals. Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because the effects of catecholamines that stimulate blood pressure changes. The nursing assistant's scope of practice includes assisting clients with ordering meals, and reminding clients about previous nursing instructions.Client assessment, client teaching, and environment planning are higher level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.
A client with leukemia is being discharged from the hospital. The nurse's discharge instructions say to keep regularly scheduled follow-up primary health care provider appointments. The client says, "I don't have transportation." Which is the most appropriate nursing response? A) "You can take the bus." B) "I might be able to take you." C) "A pharmaceutical company might be able to help." D) "The local American Cancer Society may be able to help."
Answer: D. The most appropriate nursing response to the client who does not have transportation for follow-up appointments is that "the local American Cancer Society may be able to help." Many local units of the American Cancer Society offer free transportation to clients with cancer, including those with leukemia.Telling the client to take the bus is dismissive and does not take into consideration the client's situation (e.g., the client may live nowhere near a bus route). Although the nurse offering to take the client is compassionate, it is not appropriate for the nurse to offer the client transportation. Suggesting a pharmaceutical company is not the best answer. Drug companies typically do not provide this type of service.
Which nursing intervention most effectively protects a client with thrombocytopenia? A) Take rectal temperatures B) Avoid the use of dentures C) Apply warm compresses on trauma sites D) Encourage the use of an electric shaver
Answer: D. The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time.To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.
A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? A) Segmented neutrophils, 62%. B) Lymphocytes, 28%. C) Bands, 5%. D) Basophils, 4%.
Answer: D. The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation. This is common with chronic sinusitis.62% is a normal segmented neutrophil and refers to mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. For lymphocytes, 28% is a normal count in the differential. For bands, 4% is a normal count. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.
The nurse is reviewing the laboratory test results for a client with a possible pituitary disorder. Which information requires immediate intervention by the nurse? A) Blood glucose 125 mg/dL (6.9mmol/L) B) Blood urea nitrogen (BUN) 40 mg/dL (14.3 mmol/L) C) Serum potassium 5.0 mEq/L (5.0 mmol/L D) Serum sodium 110 mEq/L (110 mmol/L)
Answer: D. The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). A result of 110 mEq/L (110 mmol/L) represents severe hyponatremia leading to dangerous complications. The client is at risk for increased intracranial pressure, seizures, and death as the intravascular fluid shifts toward the brain. The RN must act quickly because this situation requires immediate intervention.The normal range for fasting blood glucose is 60 to 110 mg/dL <3.3 to 6.1 mmol/L); 125 mg/dL (6.9 mmol/L) is high, but is not considered dangerous. The normal range for BUN is 7 to 20 mg/dL (2.5 to 7.1 mmol/L); 40 mg/dL (14.3 mmol/L) is high, but does not require immediate intervention. The normal range for serum potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); 5.0 mEq/L (5.0 mmol/L) is high normal.
Which client does the nurse assign as a roommate for a client with aplastic anemia? A) A 34-year-old with idiopathic thrombocytopenia who is taking steroids B) A 23-year-old with sickle cell disease who has two draining leg ulcers C) A 30-year-old with leukemia who is receiving induction chemotherapy D) A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol)
Answer: D. The nurse assigns as a roommate to the client with aplastic anemia a 28-year-old with glucose-6-pgisphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol. Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia would be free from infection or infection risk.The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.
A client recovering from a sickle cell crisis is to be discharged. The nurse says to the client, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the primary health care provider (PHCP) will prescribe? A) Cefaclor (Ceclor) B) Vancomycin (Vancocin) C) Gentamicin (Garamycin) D) Penicillin V (Pen-V K)
Answer: D. The nurse expects the PHCP to prescribe Penicillin V for a client recovering from sickle cell crisis who is at risk for infection. Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease.Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.
Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A) Carefully wash hands that are visibly soiled. B) Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. C) Wear a mask with eye protection and perform proper handwashing. D) Wear gloves when contact with body secretions or body fluids is expected.
Answer: D. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires contact precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile.Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile.
When caring for a client with hypercortisolism the nurse notices that the phlebotomist, who plans to draw blood from the client, displays symptoms of a cold. What would the nurse do? A) Request another phlebotomist be sent from the laboratory. B) Monitor the client for cold-like symptoms. C) Refuse to allow the phlebotomist to enter the client's room. D) Ensure the phlebotomist wears a facemask.
Answer: D. The nurse needs to make sure the phlebotomist wears a facemask. A client with hypercortisolism will be immunosuppressed. Anyone with a suspected upper respiratory infection who must enter the client's room needs to wear a mask to prevent the spread of infection.Asking for another phlebotomist might be an option in some facilities, but it is not necessary. The phlebotomist, not the client, is exhibiting cold-like symptoms, so monitoring the client for these symptoms is not appropriate. Refusing to allow the phlebotomist to enter the room will delay treatment.
A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response? A) "You will see effects of this medication immediately." B) "You will see effects of this medication within 1 week." C) "You will see full effects from this medication within 1 to 2 days." D) "You will see some effects of this medication within 2 weeks."
Answer: D. The nurse's best response is that the client will see some effects of this medication within 2 weeks. Methimazole (Tapazole) blocks thyroid hormone production by preventing iodide binding in the thyroid gland. The response to these drugs is delayed because the client may have large amounts of stored thyroid hormones that continue to be released. It may take several more weeks before metabolism returns to normal.Although onset of action is 30 to 40 minutes after an oral dose, the client will not see therapeutic effects immediately. Effects will take 2 weeks to become apparent when methimazole is used. Methimazole needs to be taken every 8 hours for an extended period of time. Levels of triiodothyronine (T3) and thyroxine (T4) will be monitored and dosages adjusted as levels fall.
A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? A) "You are not getting enough iron." B) "When you are sick you need to rest more." C) "How many hours are you sleeping at night?" D) "Your cells are delivering less oxygen than you need."
Answer: D. The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis.
A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? A) "Platelets will make your blood clot." B) "Your platelets finish the clotting process." C) "Blood clotting is prevented by your platelets." D) "The clotting process begins with your platelets."
Answer: D. The nurse's best response to why platelets are important is that, "The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis.Platelets do not clot blood but are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting. Rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.
A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? A) Instruct the client to continue with the current diet and metformin use. B) Discuss the need to check blood glucose several times every day. C)Talk about the possibility of adding rapid-acting insulin to the regimen. D) Ask the client about current dietary intake and medication use.
Answer: D. The nurse's next action would be to assess the client's adherence to the currently prescribed diet and medications. The nurse would also check for any stressors or undocumented illnesses. Glycosylated hemoglobin (HbA1C) levels >8% indicate poor diabetes control and need for adherence to regimen or changes in therapy.Instructing the client to continue with current diet and metformin use is inappropriate without further assessment. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is higher than the target range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse would not assume that adding insulin, which must be prescribed by the primary health care provider, is the answer without assessing the underlying reason for the treatment failure.
Which statement about the process of malignant transformation is correct? A) Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. B) Insulin and estrogen enhance the division of an initiated cell during the promotion phase. C) Tumors form when carcinogens invade the gene structure of the cell in the latency phase. D) Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.
Answer: D. The promotion phase of malignant transformation consists of progression when the blood supply changes from diffusion to TAF.If cell division is halted, mutation of genes does not lead to cancer development in the initiation phase. Insulin and estrogen increase cell division. Also in the initiation phase, carcinogens invade the DNA of the nucleus of a single cell. A 1-cm tumor consists of 1 billion cells. The latency phase occurs between initiation and tumor formation.
A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? A) Anxiety. B) Urticaria. C) Pruritis. D) Stridor.
Answer: D. The symptom that requires the most immediate action by the nurse is stridor which indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority.Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress.
The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? A) Begin a running program. B) Take up knitting to slow down joint degeneration. C) Eat at least 2 cups (17 ounces of yogurt per day. D) Wear supportive shoes.
Answer: D. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A) Ask the client's name B) Check the client's armband C) Verify the client's room number D) Review all information with another registered nurse (RN)
Answer: D. With another registered nurse, all information must be reviewed. This process includes verifying the client by name and number, checking blood compatibility, and noting the expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.
The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? A) Blocking histamine from binding to receptors B) Preventing synthesis of mediators. C) Preventing mast cell membranes from opening. D) Blocking the leukotriene receptor.
Answer: D. Zafirlukast is a leukotriene antagonist that works by preventing the occurrence of allergic rhinitis by blocking the leukotriene receptor.Zafirlukast is not an antihistamine. Antihistamines such as diphenhydramine (Benadryl) block histamines from binding to receptors. Zafirlukast is not a corticosteroid. Corticosteroids prevent synthesis of mediators. Mast cell-stabilizing drugs such as cromolyn sodium (Nasalcrom) prevent mast cell membranes from opening when an allergen binds to immunoglobulin E; zafirlukast is not a mast cell-stabilizing drug.
The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? A) Temperature of 96.6°F (35.9°C) B) Reports of joint pain C) Pink and dry oral mucosa D) Palpable lump in the client's axilla
Answer: D. Clients taking immunosuppressive drugs to prevent rejection are at increased risk for the development of cancer; any lump should be reported to the physician.Fever should be reported to the physician, but this client's temperature is normal. It is not necessary to report joint pain to the transplant team; it is not a sign of rejection and is not a complication of transplant. A pink and dry oral mucosa may be a sign of dehydration, but it is not necessary to report this to the transplant team.
The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time? ______
Answer: Two (2) sprays per dose. 40 g of medication every 24 hours is to be given in doses administered every 12 hours. First, determine number of doses needed: 24 ÷ 12 = 2 doses Then, determine the amount of medication to be given in each of those two (2) doses: 40 ÷ 2 = 20 g of medication per dose Finally, determine how many sprays are needed to deliver the 20 mg when each spray delivers 10 g: 20 ÷ 10 = 2 sprays TEST-TAKING HINT: The test taker should take each step of the problem one at a time and check the answer with the drop-down calculator if taking the examination on a computer.
_____: The release of tumor cells into the blood; the most common cause of cancer spread.
Bloodborne metastasis
_____: Swelling at the proximal interphalangeal joints in osteoarthritis involving the hands.
Bouchard's nodes
_____: Drugs prescribed to slow the progression of mild rheumatoid disease before it worsens, such as hydroxychloroquine, sulfasalazine, or minocycline.
Disease-modifying antirheumatic drugs (DMARDs)
_____: A method of infection control in which the level of disease-causing organisms is reduced but the organisms are not killed; adequate when an item is entering a body area that has resident bacteria or normal flora, such as the respiratory tract.
Disinfection
_____: Infection control guidelines from the U.S. Centers for Disease Control and Prevention; used for patients with infections spread by the droplet transmission route, such as influenza.
Droplet precautions
_____: Difficulty in swallowing.
Dysphagia
_____: System of classifying cellular aspects of a cancer tumor.
Grading
_____: Toxic diffuse goiter characterized by hyperthyroidism, enlargement of the thyroid gland, abnormal protrusion of the eyes, and dry, waxy swelling of the front surfaces of the lower legs.
Graves' disease
_____: Unit of measurement for an absorbed radiation dose.
Gray (gy)
_____: Swelling at the distal interphalangeal joints in osteoarthritis that involves the hands.
Heberden's nodes
_____: Abnormally high levels of blood glucose.
Hyperglycemia
_____: Chronic high blood insulin levels.
Hyperinsulinemia
_____: A reduction of oxygen supply to the tissues.
Hypoxia
_____: The process of binding an antibody to an antigen to cover the antigen's active site and to make the antigen harmless without destroying it.
Inactivation (neutralization)
_____: Pertaining to abnormal leukemic cells that come from the lymphoid pathways.
Lymphocytic
_____: The process of changing a normal cell into a cancer cell.
Malignant transformation
_____: A collection of related health problems with insulin resistance as a main feature. Other features include obesity, low levels of physical activity, hypertension, high blood levels of cholesterol, and elevated triglyceride levels. Metabolic syndrome increases the risk for coronary heart disease. Also called syndrome X.
Metabolic syndrome
_____: Abnormal heart sound that reflects turbulent blood flow through normal or abnormal valves; murmurs are classified according to their timing in the cardiac cycle (systolic or diastolic) and their intensity depending on their level of loudness.
Murmurs
_____: Pertaining to leukemias in which the abnormal cells come from the myeloid pathways.
Myelogenous
_____: Dry, waxy swelling of the skin that is accompanied by nonpitting edema (especially around the eyes, in the hands and feet, and between the shoulder blades) and is associated with primary hypothyroidism.
Myxedema
_____: The condition of maintaining a constant output of a system by exerting an inhibitory control on a key step by a product of that system. Used in a series of reactions that control hormone secretion and cellular activity based on responses to correct any movement away from normal function. An example of a simple negative feedback hormone response is the control of insulin secretion in which the action of insulin (decreasing blood glucose levels) is the opposite of the condition that stimulated insulin secretion (elevated blood glucose levels).
Negative feedback control mechanism
_____: Vascular granulation tissue composed of inflammatory cells that forms in a joint space; erodes articular cartilage and eventually destroys bone.
Pannus
_____: Abnormal or unusual nerve sensations of touch, such as tingling and burning.
Paresthesia
_____: Abnormal or unusual nerve sensations of touch, such as tingling and burning.
Paresthesias
_____: Resistance to infection that is of short duration (days or months) and either natural by transplacental transfer from the mother or artificial by injection of antibodies (e.g., immunoglobulin).
Passive immunity
_____: Any microorganism capable of producing disease.
Pathogen
_____: Infection control protocol that refers to the use of gloves, isolation gowns, face protection, and respirators with N95 or higher filtration.
Personal protective equipment (PPE)
_____: Pinpoint red spots on the mucous membranes, palate, conjunctivae, or skin.
Petechiae
_____: The precursor cell involved in the production of red blood cells.
Pluripotent stem cell
_____: Inflammation of the metatarsophalangeal joint of the great toe.
Podagra
_____: A disease that involves massive production of red blood cells, leukocytes, and platelets.
Polycythemia vera (PV)
_____: A chronic, progressive, systemic, inflammatory autoimmune disease process that primarily affects the synovial joints; one of the most common connective tissue diseases and the most destructive to the joints.
Rheumatoid arhtritis (RA)
_____: Early detection of a disease or condition, sometimes before signs and symptoms are evident, to prevent or limit permanent disability or death.
Secondary prevention
_____: In patients with advanced rheumatoid arthritis, the triad of dry eyes, dry mouth, and dry vagina caused by the obstruction of secretory ducts and glands by inflammatory cells and immune complexes.
Sjogren's syndrome
_____: Infection control guidelines from the U.S. Centers for Disease Control and Prevention stating that all body excretions, secretions, and moist membranes and tissues are potentially infectious; combines protective measures from Universal Precautions and Body Substance Isolation.
Standard precautions
_____: An immature, undifferentiated cell produced by the bone marrow.
Stem cell
_____: Term used to describe the tracking of infections by health care agencies.
Surveillance
_____: The risk of the host to infection; may be increased by the breakdown of host defenses against pathogens.
Susceptibility
_____: A life-threatening event that occurs in patients with uncontrolled hyperthyroidism and is usually caused by Graves' disease. Key manifestations include fever, tachycardia, and systolic hypertension.
Thyroid storm (Thyroid crisis)
_____: The condition caused by excessive amounts of thyroid hormones.
Thyrotoxicosis
_____: In patients with fibromyalgia syndrome, tender areas that can typically be palpated to elicit pain in a predictable, reproducible pattern.
Trigger points
_____: A hormone produced by the follicular cells of the thyroid gland.
Triiodothyronine (T3)
_____: Drugs with the main action of inhibiting activation of tyrosine kinases. There are many different TKIs. Some are unique to the cell type; others may be present only in cancer cells that express a specific gene mutation. As a result, the different TKI drugs are effective in disrupting the growth of some cancer cell types and not others.
Tyrosine kinase inhibitors (TKIs)
_____: A chronic inflammatory process that affects the mucosal lining of the colon or rectum; one of a group of bowel diseases of unknown etiology characterized by remissions and exacerbations. It can result in loose stools containing blood and mucus, poor absorption of vital nutrients, and thickening of the colon wall.
Ulcerative colitis (UC)
_____: A complication of diabetes; the abnormal appearance of retinal veins in which areas of swelling and constriction along a segment of vein resemble links of sausage. Such bleeding occurs in areas of retinal ischemia and is a predictor of proliferative diabetic retinopathy.
Venous beading
_____: The presence of viruses in the blood.
Viremia
A nursing assistant (NA) is assigned to care for a client who had a cemented total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision by the nurse? A) "I'll keep an abduction pillow in place at all times." B) "I'll tell the client not to place a pillow under the surgical knee." C) "I'll apply ice packs to decrease swelling in the knee as ordered." D) "I'll check to make sure the client's leg is not rotated."
ANS: A. Abduction pillows are not used for patients after a total knee arthroplasty.
The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. 1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication. 4. Carry a medical identification card or bracelet. 5. Teach how to take thyroid medications correctly.
ANSWER: 1, 2, 3, 4. 1. Weight loss indicates the medication may not be effective and will probably need to be increased. 2. The client needs to know emotional highs and lows are secondary to hyperthyroidism. With treatment, this emotional lability will subside. 3. Any over-the-counter medications (for example, alcohol-based medications) may negatively affect the client's hyperthyroidism or medications being used for treatment. 4. This will help any HCP immediately know of the client's condition, especially if the client is unable to tell the HCP. 5. The client with hyperthyroidism will be on antithyroid medications, not thyroid medications. TEST-TAKING HINT: This alternate-type question instructs the test taker to select all the interventions that apply. The test taker must read and evaluate each option as to whether it applies or not.
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy
ANSWER: 1, 2, 4. 1. Sunlight or UV light exposure has been shown to initiate an exacerbation of SLE, so the client should be taught to protect the skin when in the sun. 2. A fever may be the first indication of an exacerbation of SLE. 3. Dyspnea is not expected and could signal respiratory involvement. 4. Raynaud's phenomenon is a condition in which the digits of the hands and feet turn red, blue, or white in response to heat or cold and stress. It occurs with some immune inflammatory processes. 5. SLE is a chronic disease and there is no known cure. TEST-TAKING HINT: Dyspnea is an uncomfortable sensation of not being able to breathe. Usually clients are not told this is normal regardless of the disease process.
Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply. 1. Recommend the client not to engage in unprotected sexual activity. 2. Instruct the client not to inform past sexual partners of HIV status. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell healthcare personnel of HIV status.
ANSWER: 1, 3, 4, 5. 1. HIV is transmitted via sexual activity. 2. HIV is transmitted via sexual activity, and the client may have been HIV positive for up to a year and not aware of it, so all past sexual partners should be informed of the HIV status. 3. Blood donations are screened and excluded for this virus, as are organs/tissues from a client with HIV, because the virus can be transmitted to clients receiving the organ or tissue. 4. HIV can be transmitted to the fetus from the pregnant woman with HIV. 5. The client should tell the HCP, especially dentists, about the HIV status, but the client does not have to tell health-care personnel about the HIV status. Health-care personnel should always follow Standard Precautions.
The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply. 1. Avoid alcohol. 2. Pace activities. 3. Stop smoking. 4. Eat a balanced diet. 5. Use a safety razor.
ANSWER: 1,2,4. 1. Alcohol consumption interferes with the absorption of nutrients. 2. The client will be short of breath with activity and therefore should pace activities. 3. Although all clients should be told to stop smoking, smoking will not directly affect the client's diagnosis. 4. The client should eat a well-balanced diet to be able to manufacture blood cells. 5. The client should use an electric razor to diminish the risk of cuts and bleeding.
The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership? 1. Call a meeting and educate the staff on the new delivery system being used. 2. Organize a committee to investigate the various types of delivery systems. 3. Wait until another unit has implemented the new system and see if it works out. 4. Discuss with the nursing staff if a new delivery system should be adopted.
ANSWER: 1. 1. An autocratic style is one in which the person in charge makes the decision without consulting anyone else. 2. This behavior is an example of a democratic leadership style. 3. This behavior is an example of laissez-faire leadership style. 4. This behavior is an example of democratic leadership style. TEST-TAKING HINT: The test taker could choose the correct answer if the test taker knew terms such as "autocratic" and "democratic."
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. Which data should the nurse assess when administering magnesium sulfate to the client? 1. Deep tendon reflexes. 2. Arterial blood gases. 3. Skin turgor. 4. Capillary refill time
ANSWER: 1. 1. If deep tendon reflexes are hypoactive or absent, the nurse should hold the magnesium and notify the health-care provider. 2. The arterial blood gases are not affected by the serum magnesium level. 3. The client's skin turgor will not be affected by the client's serum magnesium level. 4. The client's capillary refill time is not affected by the client's serum magnesium level
The client is diagnosed with systemic lupus erythematosus (SLE). Which area of the body in the figure below should the nurse assess for a butterfly rash? 1. Face. 2. Chest. 3. Thigh. 4. Feet.
ANSWER: 1. 1. The client with SLE often has a reddened area over both cheeks known as a butterfly rash; it is diagnostic of a client with SLE. 2. The client does not have a butterfly rash on the chest area. 3. The client does not have a butterfly rash on the upper-thigh area. 4. The client diagnosed with SLE does not have a butterfly rash on the feet.
The client's laboratory values are RBCs 5.5 (×10^6 )/mm3 , WBCs 8.9 (×10^3 )/mm3 , and platelets 189 (×10^3 )/mm3 . Which intervention should the nurse implement? 1. Prepare to administer packed red blood cells. 2. Continue to monitor the client. 3. Request an order for Neupogen, a biologic response modifier. 4. Institute bleeding precautions.
ANSWER: 2. 1. The normal RBC is 4.7 to 6.1 (× 106 ) for males and 4.2 to 5.4 (× 106 ) for females. The RBC is within normal limits. 2. All the laboratory values are within normal limits. The nurse should continue to monitor the client. 3. The normal WBC is 4.5 to 11 (× 103 ), so a biologic response modifier to increase the numbers of WBCs is not needed. 4. Thrombocytopenia does not occur until the client's platelet count is less than 100 (× 103 ); there is no reason to institute bleeding precautions.
Which psychosocial problem should be included in the plan of care for a female client diagnosed with Cushing's syndrome? 1. Altered glucose metabolism. 2. Body image disturbance. 3. Risk for suicide. 4. Impaired wound healing
ANSWER: 2. 1. This is not a psychosocial problem; it is a physiological problem in clients diagnosed with Cushing's syndrome. 2. The client with Cushing's syndrome has body changes, including moon face, buffalo hump, truncal obesity, hirsutism, and striae and bruising, all of which affect the client's body image. 3. This is a psychosocial problem, but it is not one that commonly occurs in clients diagnosed with Cushing's syndrome. 4. This is not a psychosocial problem; it is a physiological problem, which does occur in clients diagnosed with Cushing's syndrome.
Which client problem is priority for a client diagnosed with RA? 1. Activity intolerance. 2. Fluid and electrolyte imbalance. 3. Alteration in comfort. 4. Excessive nutritional intake.
ANSWER: 3. 1. Activity intolerance is an appropriate client problem, but it is not priority over pain. 2. The client with RA does not experience fluid and electrolyte disturbance. 3. The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem. 4. Clients diagnosed with RA usually experience anorexia and weight loss, unless they are taking long-term steroids. TEST-TAKING HINT: The question is asking for the priority problem, and pain is priority according to Maslow's hierarchy of needs.
Which risk factor should the nurse expect to find in the client diagnosed with pancreatic cancer? 1. Chewing tobacco. 2. Low-fat diet. 3. Chronic alcoholism. 4. Exposure to industrial chemicals
ANSWER: 4. 1. A history of smoking cigarettes is pertinent, but a history of chewing tobacco is not. 2. A diet high in fat, not low in fat, is a risk factor. 3. Chronic alcoholism is not a risk factor, but chronic pancreatitis is a risk factor. 4. Exposure to industrial chemicals or environmental toxins is a risk factor for pancreatic cancer.
The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed? 1. Infection. 2. Anemia. 3. Nutrition. 4. Grieving.
ANSWER: 4. 1. Treating infections, which require HCP orders for cultures and antibiotics, is a collaborative problem. 2. The treatment of anemia is a collaborative problem. 3. The provision of adequate nutrition requires collaboration among the nurse, HCP, and dietitian. 4. Grieving is an independent problem, and the nurse can assess and treat this problem with or without collaboration. TEST-TAKING HINT: The stem of the question asks for an independent intervention. If the test taker understands the problem and the treatment needs, options "1," "2," and "3" can be eliminated.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client? 1. Instruct the client to decrease alcohol intake. 2. Explain the need to avoid all stress. 3. Discuss the importance of stopping smoking. 4. Teach the correct way to take pancreatic enzymes.
ANSWER:3. 1. Alcohol must be avoided entirely because it can cause stones to form, blocking pancreatic ducts and the outflow of pancreatic juice, causing further inflammation and destruction of the pancreas. 2. Stress stimulates the pancreas and should be dealt with, but it is unrealistic to think a client can avoid all stress. By definition, the absence of all stress is death. 3. Smoking stimulates the pancreas to release pancreatic enzymes and should be stopped. 4. The client has acute pancreatitis, and pancreatic enzymes are only needed for chronic pancreatitis. TEST-TAKING HINT: The test taker should eliminate option "2" because of the word "all," which is an absolute and there are few absolutes in health care. The test taker should note the adjective "acute" in the stem, which may help the test taker eliminate option "4" because enzymes are administered for a chronic condition
_____: The process or act of removing
Ablative
_____: A life-threatening event in which the need for cortisol and aldosterone is greater than the available supply. Also called addisonian crisis.
Acute adrenal insufficiency
_____: The immunity that a person's body makes (or can receive) as an adaptive response to invasion by organisms or foreign proteins; occurs either naturally or artificially through lymphocyte responses and can be either active or passive.
Adaptive immunity
_____: An excess of glucocorticoids caused by a problem in the adrenal cortex, usually a benign tumor (adrenal adenoma). This usually occurs in only one adrenal gland.
Adrenal Cushing's disease
_____: Acute adrenocortical insufficiency, which can be life threatening.
Adrenal crisis
_____: The chief mineralocorticoid produced by the adrenal cortex. Aldosterone increases kidney reabsorption of sodium and water, thus restoring blood pressure, blood volume, and blood sodium levels. Aldosterone secretion is regulated by the renin-angiotensin system, serum potassium ion concentration, and adrenocorticotropic hormone.
Aldosterone
_____: A foreign protein that is capable of causing a hypersensitivity response, or allergy, that ranges from uncomfortable (itchy, watery eyes or sneezing) to life threatening (allergic asthma, anaphylaxis, bronchoconstriction, or circulatory collapse); causes a release of natural chemicals, such as histamine, in the body.
Allergen
_____: An increased or excessive response to the presence of a foreign protein or allergen (antigen) to which the patient has been previously exposed.
Allergy
_____: The transplantation of bone marrow from a sibling.
Allogeneic bone marrow transplantation
_____: The absence of menstrual periods in women.
Amenorrhea
When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply). A) Explain to the client that the colostomy is only temporary. B) Encourage the client to participate in changing the ostomy. C) Obtain a psychiatric consultation. D) Offer to have a person who is coping with a colostomy visit with the client. E) Encourage the client and family members to express their feelings and concerns.
Answer B, D, E. Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication.Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.
The nurse is instructing a client who will undergo an adrenal suppression test. Which statement by the client indicates that teaching was effective? A) "I am being tested to see whether my hormone glands are hyperactive." B) "I am being tested to see whether my hormone glands are hypoactive." C) "I am being tested to see whether my kidneys work at all." D) "I will be given more hormones as a trigger."
Answer: A. Suppression tests are used when hormone levels are high or in the upper range of normal. Failure of suppression of hormone production during testing indicates hyper function and hyperactivity.A provocative (stimulation) test assesses whether hormone glands are hypoactive. The adrenal glands are endocrine glands that are located on the kidneys. A suppression test does not measure kidney function. Hormones are given as a trigger in a provocative (stimulation) test.
A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action? A) Stop the transfusion. B) Call the Rapid Response Team. C) Slow the infusion rate of the transfusion. D) Obtain vital signs and continue to monitor.
Answer: A. The nurse's first action when a client receiving a blood transfusion says, "I don't feel right," is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately.Calling the Rapid Response Team or obtaining vital signs is not the first thing that must be done. The nurse would not slow the infusion rate but would stop it altogether.
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? A) Anxiety. B) Headache. C) Nausea. D) Weight loss.
Answer: B. A side effect of fludrocortisone is hypertension, likely related to hyponatremia and fluid retention. New onset of headache must be reported, and the client's blood pressure would be monitored.Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction, but not a side effect of fludrocortisone. Sodium-related fluid retention and weight gain, not loss, are possible with fludrocortisone therapy.
A nurse is providing care for four clients. Which of the following clients is at the greatest risk for pneumonia? A) A school-age child who has a history of asthma. B) An older adult client who has dysphagia. C) A young adult client living in a college dormitory. D) A middle adult client using an incentive spirometer following surgery.
Answer: B. A) A school-age child who has a history of asthma is at risk for pneumonia, especially if the child's equipment is not well-maintained and decontaminated. However, another client is at greater risk. B) An older adult client who has dysphagia is at greatest risk for pneumonia due to the increased risk for aspiration when eating. C) A young adult client living in a college dormitory is at risk for pneumonia, especially when in a crowded area during flu season. However, another client is at greater risk. D) A middle-age adult who is postoperative is at risk for acquiring pneumonia. However, since the client is using an incentive spirometer to prevent pneumonia, another client is at greater risk.
Which element is a risk factor for osteoarthritis (OA)? A) Thin build. B) Obesity. C) Nonsmoker. D) Male.
Answer: B. Being obese places an individual at higher risk for slow joint degeneration and the development of OA. Having a thin build does not place an individual at higher risk for slow joint degeneration and the development of OA. Smoking leads to knee cartilage loss, especially in clients with a family history of knee OA. Women tend to develop OA more than men, and it is believed that obesity may be a contributing factor; as women age and have children, they tend to gain more weight than men.
Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3 (17 × 109/L)? A) Increasing shortness of breath. B) Diminished bilateral breath sounds. C) Change in mental status. D) Weight gain of 4 pounds (1.8 kg) in 1 day.
Answer: C. A change in mental status could result from spontaneous bleeding and, in this case, a cerebral hemorrhage may have developed.Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which are not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.
A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? A) Sodium 150 mEq/L. B) Weight gain. C) Calcium 12.8 mg/dL. D) Moon face.
Answer: C. A) A client who has adrenal insufficiency has a sodium level below the expected reference range. B) Weight loss is a finding with adrenal insufficiency. C) A client who has adrenal insufficiency has a calcium level above the expected reference range. D) A rounded face is a finding with Cushing's disease.
A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? A) Leukemia. B) Aplastic anemia. C) Hemolytic anemia. D) Infectious process.
Answer: C. The nurse suspects that the client has hemolytic anemia. An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation.A low white blood cell count is expected in clients with leukemia. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection.
A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? A) Infuse 1 unit of platelets. B) Restrict daily fluid intake. C) Give oral spironolactone. D) Administer IV hydrocortisone sodium.
Answer: D. A) Although this client needs to increase circulatory volume, infusing platelets is not the correct way to accomplish this. B) The client's hypovolemia is an indication for rapid fluid replacement. C) Administering a potassium-sparing diuretic will further increase the client's potassium level, thus worsening the hyperkalemia. D) Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency.
The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? A) Glaucoma. B) Hypertension. C) Hypothyroidism. D) SUlfa allergy.
Answer: D. Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies. Sulfasalazine (Azulfidine) is not contraindicated in clients with glaucoma, hypertension, or hypothyroidism.
_____: The defense response that produces antibodies directed against certain pathogens. The antibodies inactivate the pathogens and protect against future infection from that microorganism.
Antibody-mediated immunity (AMI; antibody-mediated immune system)
_____: A procedure in which whole blood is withdrawn from the patient, a blood component (e.g., stem cells) is filtered out, and the plasma is returned to the patient.
Apheresis
_____: Pain in a joint.
Arthralgia
_____: Inflammation of one or more joints.
Arthritis
_____: Joint surfaces.
Articulations
PH - 7.31 CO2 - 54 HCO3 - 24 A) Compensated Metabolic Alkalosis. B) Uncompensated Respiratory Acidosis. C) Uncompensated Metabolic Acidosis. D) Partially Compensated Respiratory Acdidosis
B
_____: Altered cell growth that is harmless and does not require intervention.
Benign
_____: Loss of bone density due to demineralization resulting from the release of calcium from storage areas in bones.
Bone resorption
_____: Swishing sound in the larger arteries (carotid, aortic, femoral, and popliteal) that can be heard with a stethoscope or Doppler probe; may indicate narrowing of the artery and is usually associated with atherosclerotic disease.
Bruit
_____: Extreme body wasting and malnutrition that develop from an imbalance between food intake and energy use.
Cachexia
_____: (1) A person who harbors an infectious agent without symptoms of active disease; (2) in genetics, a person who has one mutated allele for a recessive genetic disorder. A carrier does not usually have any manifestations of the disorder but can pass the mutated allele to his or her children.
Carrier
_____: Hormones (dopamine, epinephrine, and norepinephrine) released by the adrenal medulla in response to stimulation of the sympathetic nervous system.
Catecholamines
_____: A technique that allows for collection of the person's own red blood cells during surgery, which is then reinfused directly back to the patient via a closed system.
Cell saver system
_____: Microbial resistance that is mediated by the action of specifically sensitized T-lymphocytes.
Cell-mediated immunity
_____: The physiologic processes used to control cellular growth, replication, and differentiation (maturation into a specific cell type) to maintain homeostasis.
Cellular regulation
_____: The treatment of cancer with chemical agents that have systemic effects; used to cure and to increase survival time.
Chemotherapy
_____: The loss of sensory or motor function of peripheral nerves associated with exposure to certain anticancer drugs.
Chemotherapy-induced peripheral neuropathy (CIPN)
_____: A chronic illness characterized by severe fatigue for 6 months or longer, usually following flu-like symptoms. At least four of the following criteria are required for diagnosis: sore throat; substantial impairment in short-term memory or concentration; tender lymph nodes; muscle pain; multiple joint pain with redness or swelling; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours.
Chronic fatigue syndrome (CFS)
_____: A form of immunohemolytic anemia (in which the immune system attacks a person's own red blood cells for unknown reasons) that occurs with complement protein fixation on immunoglobulin M (IgM). In this condition, the arteries in the hands and feet constrict profoundly in response to cold temperatures or stress.
Cold antibody anemia
_____: Actions triggered by some classes of antibodies that can remove or destroy antigen.
Complement activation and fixation
_____: The main glucocorticoid produced by the adrenal cortex.
Cortisol
_____: Hypercortisolism caused by oversecretion of hormones by the adrenal cortex.
Cushing's disease (Cushing's syndrome; hypercotisolism)
_____: Having cell-damaging effects.
Cytotoxic
PH - 7.16 CO2 - 21 HCO3 - 11 A) Compensated Metabolic Alkalosis. B) Uncompensated Respiratory Acidosis. C) Uncompensated Metabolic Acidosis. D) Partially Compensated Metabolic Acidosis.
D
_____: Large purple, blue, or yellow bruises of the skin resulting from small hemorrhages; these bruises are larger than petechiae.
Ecchymoses
_____: An accumulation of fluid, such as in a joint (where it may limit movement).
Effusion
_____: A substance that induces nausea and vomiting.
Emetogenic
_____: A red blood cell (RBC). Red blood cells are the major cells in the blood and are responsible for tissue oxygenation.
Erythrocyte (RBC)
_____: The selective maturation of stem cells into mature erythrocytes.
Erythropoiesis
_____: Inflammation of the esophagus.
Esophagitis
_____: The normal diploid number for a cell.
Euploidy
_____: Having normal thyroid function.
Euthyroid
_____: An increase in severity of a disease. Also called flare-up.
Exacerbation
_____: Plasma that is frozen immediately after donation so that the clotting factors are preserved.
Fresh frozen plasma (FFP)
_____: In patients with rheumatoid arthritis, morning stiffness that lasts between 45 minutes and several hours after awakening.
Gel phenomenon
_____: A hormone secreted by the pancreas that increases blood glucose levels. It is a "counterregulatory" hormone that has actions opposite those of insulin. It causes the release of glucose from cell storage sites whenever blood glucose levels are low.
Glucagon
_____: The conversion of proteins and amino acids to glucose in the body.
Gluconeogenesis
_____: A supplement that may decrease inflammation.
Glucosamine
_____: A term referring to blood glucose.
Glycemic
_____: The production of glycogen in the body.
Glycogenesis
_____: The breakdown of glycogen into glucose.
Glycogenolysis
_____: A standardized test that measures how much glucose permanently attaches to the hemoglobin molecule. A1C levels greater than 6.5% are diagnostic of diabetes mellitus.
Glycosylated hemoglobin (A1C)
_____: Enlargement of the thyroid gland.
Goiter
_____: Hormones that stimulate the ovaries and testes to produce sex hormones.
Gonadotropins
_____: The male and female reproductive endocrine glands. Male gonads are the testes, and female gonads are the ovaries.
Gonads
_____: A systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation.
Gout
_____: The vomiting of blood.
Hematemesis
_____: The percentage of packed red blood cells per deciliter of blood.
Hematocrit
_____: Blood in the urine.
Hematuria
_____: Surgical replacement of part of the shoulder joint, typically the humeral component, as an alternative to total shoulder arthroplasty.
Hemiarthroplasty
_____: Normal adult hemoglobin. The molecule has two alpha chains and two beta chains of amino acids.
Hemoglobin A [HbA]
_____: An abnormal beta chain of hemoglobin associated with sickle cell disease that is sensitive to low oxygen content of red blood cells.
Hemoglobin S [HbS]
_____: The characteristic of destroying red blood cells.
Hemolytic
_____: Anemia caused by the destruction of red blood cells.
Hemolytic anemia
_____: The aggregation of platelets into "white clots" that can cause thrombosis, usually in the form of an acute arterial occlusion; occurs with heparin administration. Also called white clot syndrome.
Heparin-induced thrombocytopenia (HIT)
_____: Abnormal growth of body hair, especially on the face, chest, and the linea alba of the abdomen of women.
Hirsutism
_____: The narrow range of normal conditions (e.g., body temperature, blood electrolyte values, blood pH, blood volume) in the human body; the tendency to maintain a constant balance in normal body states.
Homeostasis
_____: Chemical produced in the body that exerts its effects on specific tissues known as target tissues.
Hormone
_____: An elevated level of potassium in the blood.
Hyperkalemia
_____: An elevation of serum lipid (fat) levels in the blood.
Hyperlipidemia
_____: Hormone oversecretion that occurs with pituitary tumors or hyperplasia.
Hyperpituitarism
_____: An overreaction to a foreign substance.
Hypersensitivity
_____: A condition caused by excessive production of thyroid hormone.
Hyperthyroidism
_____: Elevated levels (150 mg/dL or above) of triglyceride in the blood.
Hypertriglyceridemia
_____: An excess of uric acid in the blood.
Hyperuricemia
_____: The quality of being thicker than normal.
Hyperviscous
_____: A total serum calcium level below 9.0 mg/dL or 2.25 mmol/L.
Hypocalcemia
_____: A decreased serum potassium level; a common electrolyte imbalance.
Hypokalemia
_____: A serum sodium level below 136 mEq/L (mmol/L).
Hyponatremia
_____: Surgical removal of the pituitary gland.
Hypophysectomy
_____: Resistance to infection; usually associated with the presence of antibodies or cells that act on specific microorganisms.
Immunity
_____: A condition of the eyes that results from changes in tear composition, lacrimal gland malfunction, or altered tear distribution
Keratoconjunctivitis sicca (dry eye syndrome)
_____: Substances, including acetone, that are produced as by-products of the incomplete metabolism of fatty acids. When insulin is not available (as in uncontrolled diabetes mellitus), they accumulate in the blood and cause metabolic acidosis.
Ketone bodies (ketones)
_____: White blood cell (WBC); this immune system cell protects the body from the effects of invasion by organisms.
Leukocyte (WBC)
_____: Sexual desire.
Libido
_____: Breakage, for example, of a cell membrane.
Lysis
_____: The growth and spread of cancer.
Metastasis
_____: To spread cancer from the main tumor site to many other body sites.
Metastasize
_____: Referring to disease, such as cancer, that transfers from one organ to another organ or part not directly connected; pertains to additional tumors that form after cancer cells move from the primary location by breaking off from the original group and establishing remote colonies.
Metastatic
_____: The genomes of all the microorganisms that coexist in and on an adult and can affect cellular regulation.
Microbiome
_____: Abnormally small in size, such as an abnormally small red blood cell.
Microcytic
_____: Referring to small blood vessels.
Microvascular
_____: In the early stage of rheumatoid arthritis, symptoms that are migrating or involve more joints.
Migratory arhtritis
_____: Cell division.
Mitosis
_____: The percentage of actively dividing cells within a tumor.
Mitotic index
_____: A rare, serious complication of untreated or poorly treated hypothyroidism in which decreased metabolism causes the heart muscle to become flabby and the chamber size to increase, resulting in decreased cardiac output and decreased perfusion to the brain and other vital organs.
Myxedema coma
_____: In cancer treatment therapy, the period of greatest bone marrow suppression, when the patient's platelet count may be very low.
Nadir
_____: Treatment of a cancerous tumor with chemotherapy to shrink the tumor before it is surgically removed.
Neoadjuvant therapy
_____: Any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues.
Neoplasia
_____: Pathologic change in the kidney that reduces kidney function and leads to renal failure.
Nephropathy
_____: The posterior lobe of the pituitary gland that stores hormones produced in the hypothalamus.
Neurohypophysis
_____: A problem in nerve tissue that can cause muscle weakness.
Neuropathy
_____: Decreased numbers of leukocytes, especially neutrophils, which causes immunosuppression.
Neutropenia
_____: Increased number of circulating neutrophils.
Neutrophilia
_____: The need to urinate excessively at night.
Nocturia (nocturnal polyuria)
_____: In health care, accidental failure by a patient to take medication.
Nonadherence
_____: In health care, deliberate failure by a patient to take medication.
Noncompliance
_____: The microorganisms living in or on the human host without causing disease; the bacteria that are characteristic of each body location. Normal flora often compete with and prevent infection from unfamiliar microorganisms attempting to invade a body site.
Normal flora
_____: A federal agency that protects workers from injury or illness at their place of employment.
Occupational Safety and Heath Administration (OSHA)
_____: Scant or infrequent menses.
Oligomenorrhea
_____: Proto-oncogene that has been "turned on" and can cause cells to change from normal cells to cancer cells.
Oncogene
_____: Cancer development.
Oncogenesis
_____: Virus that causes cancer.
Oncovirus
_____: Infection caused by organisms that are present as part of the normal environment and would be kept in check by normal immune function.
Opportunistic infections
_____: Pertaining to or caused by standing erect.
Orthostatic
_____: Noninflammatory form of arthritis characterized by the progressive deterioration and loss of cartilage in one or more joints; most common form of arthritis.
Osteoarthritis
_____: The death of bone tissue, usually because the blood supply to the bone is disrupted. Usually a complication of a hip fracture or any fracture in which there is displacement of bone.
Osteonecrosis
_____: A metabolic disease in which bone demineralization results in decreased density and subsequent fractures.
Osteoporosis
_____: The transfer of oxygen from hemoglobin to tissues.
Oxygen dissociation
_____: The process of engulfing, ingesting, killing, and disposing of an invading organism by neutrophils and macrophages; a key process of inflammation.
Phagocytosis
_____: Abnormal sensitivity to light.
Photophobia
_____: A member of the rehabilitation health care team who helps the patient achieve mobility and who teaches techniques for performing certain activities of daily living.
Physical therapist (PT, RPT)
_____: Oversecretion of ACTH by the anterior pituitary gland, which causes hyperplasia of the adrenal cortex in both adrenal glands and an excess of most hormones secreted by the adrenal cortex.
Pituitary Cushing's disease
_____: Excessive intake of water.
Polydipsia
_____: Excessive eating.
Polyphagia
_____: Frequent and excessive urination.
Polyuria
_____: Device with a high efficiency particulate air (HEPA) filter and battery to promote positive pressure air flow; more effective than an N95 respirator.
Power air-purifying respirator (PAPR)
_____: The increased levels of insulin that are secreted after eating. Within 10 minutes of eating, an early burst of insulin secretion occurs, which is followed by an increasing insulin release that lasts as long as hyperglycemia is present.
Prandial (insulin secretion)
_____: The formation of large, insoluble antigen-antibody complexes during the antibody-binding process.
Precipitation
_____: An impaired fasting glucose (IFG) or impaired glucose tolerance (IGT).
Prediabetes
_____: A total joint arthroplasty procedure that has been performed for the first time.
Primary arthroplasty
_____: Strategies used to avoid or delay the actual occurrence of a specific disease.
Primary prevention
_____: The original tumor, usually identified by the tissue from which it arose (parent tissue), such as in breast cancer or lung cancer.
Primary tumor
_____: Red blood cell
RBC
_____: The amount of radiation absorbed by the tissue.
Radiation dose
_____: A hormone that is produced in the juxtaglomerular complex of the kidney and that helps regulate blood flow, glomerular filtration rate, and blood pressure. Renin is secreted when sensing cells (macula densa) in the distal convoluted tubule sense changes in blood volume and pressure
Renin
_____: An inflammation of the nasal mucosa.
Rhinitis
_____: A mechanism of injury in which the head is turned excessively beyond the normal range.
Rotation
_____: In immunology, the ability to recognize self cells versus non-self cells, which is necessary to prevent healthy body cells from being destroyed along with invading cells.
Self-tolerance
_____: A method of infection control in which all living organisms and bacterial spores are destroyed; used on items that invade human tissue where bacteria are not commonly found.
Sterilization
_____: Persistent hyponatremia, hypovolemia, and inappropriately elevated urine osmolality that occurs when vasopressin (antidiuretic hormone) is secreted even when plasma osmolarity is low or normal.
Syndrome of inappropriate antidiuretic hormone (SIADH) (Schwartz-Bartter syndrome)
_____: A chronic, progressive inflammatory connective tissue disorder that can cause major body organs and systems to fail; characterized by spontaneous remissions and exacerbations.
Systemic lupus erythematosus
_____: A chronic connective tissue disease characterized by inflammation, fibrosis, and sclerosis of the skin and vital organs. Also called scleroderma and formerly called progressive systemic sclerosis.
Systemic sclerosis (SSc)(Scleroderma)
_____: System developed by the American Joint Committee on Cancer to describe the anatomic extent of cancers.
TNM (Tumor, node, metastisis)
_____: A hormone that is produced by the follicular cells of the thyroid gland and that increases metabolism.
Thyroxine (T4)
_____: Receptors on immune system cells of humans and other animals that interact with the surface of any invading organism and allow recognition of non-self so actions are taken to rid the body of this invader.
Toll-like receptors (TLR)s
_____: A collection of uric acid crystals that form hard irregular, painless nodules on the ears, arms, and fingers of patients with gout.
Tophi
_____: urgical creation of a joint, or total joint replacement; commonly performed in patients with osteoarthritis
Total joint arthroplasty (TJA)(Total joint replacement, TJR)
_____: The surgical removal of all of the thyroid tissue.
Total thyroidectomy
_____: Hyperthyroidism caused by multiple thyroid nodules, which may be enlarged thyroid tissues or adenomas, and a goiter that has been present for several years.
Toxic multinodular goiter
_____: Protein molecule released by bacteria that affects host cell at a distant site. Continued multiplication of a pathogen is sometimes accompanied by toxin production.
Toxin
_____: The (tracheal) stoma, or opening, that results from a tracheotomy.
Tracheostomy
_____: Test that measures the presence of human immune deficiency virus genetic material (ribonucleic acid) or other viral proteins in the patient's blood.
Viral load testing
_____: The presence of male secondary sex characteristics.
Virilization
_____: A term used to describe the frequency with which a pathogen causes disease (degree of communicability) and its ability to invade and damage a host. Virulence can also indicate the severity of the disease; often used as a synonym for pathogenicity.
Virulence
_____: An abnormality of the skin characterized by patchy areas of pigment loss with increased pigmentation at the edges. It is seen with primary hypofunction of the adrenal glands and is due to autoimmune destruction of melanocytes in the skin.
Vitiligo
_____: White blood cell
WBC
