ATI Med Surg Exam 1 Practice Questions

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

10 mL

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."

A. "I should remove the skin from poultry before eating it." The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

A. "I would never have believed I could get used to enjoying my food without salt."

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? A. "I'll stick with soft foods for now." B. "My family will be bringing me fresh flowers today." C. "I'll use a new disposable razor each day." D. "I'll blow my nose more often to avoid nosebleeds."

A. "I'll stick with soft foods for now." Thrombocytopenia (a low platelet count) is common after a bone marrow transplant. To prevent bleeding until the client's platelet count improves, the client should avoid hard foods that could cause mouth trauma. Incorrect Answers: C. To reduce the risk of injury and bleeding, the client should use an electric shaver rather than a razor.

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

A. Chicken breast and corn on the cob The nurse should identify that chicken breast is low in cholesterol, and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching.

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. Decreased albumin Correct Answer: A. Decreased albumin A decrease in the albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

A. Discuss ways the client can reduce the number of cigarettes smoked per day The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. Dry cough A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis. Incorrect Answers:B. Rhinitis is not a manifestation of inhalation anthrax; however, rhinitis is typically seen with colds and influenza. C. A sore throat is not a manifestation of inhalation anthrax; however, a sore throat is typically seen with colds and influenza. D. Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax.

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

A. Dysphagia Dysphagia (difficulty swallowing) can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking

A. Eat high-calorie foods first Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

A. Eggs The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs. Incorrect Answers:B. A client who has pernicious anemia needs vitamin B12-rich foods. Squash does not contain vitamin B12. C. Kale does not contain vitamin B12. D. Tofu does not contain vitamin B12.

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

A. Necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery. Incorrect Answers:B. U waves indicate hypokalemia. C. Although absent P waves can reflect other dysrhythmias, they are common with sustained ventricular tachycardia, which hypomagnesemia can cause. D. Ventricular tachycardia often reflects coronary insufficiency, which results in poor oxygenation of the heart.

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? A. Position the client supine with his legs elevated when in bed B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr C. Tell the client to sit with his legs dependent after ambulating D. Instruct the client to wear knee-length socks for 2 weeks after surgery

A. Position the client supine with his legs elevated when in bed The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.

A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of insoluble fiber D. Limit alcohol intake to ≤3 servings per day

A. Reduce dietary sodium A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs.

During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall

A. Remote

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.

A. The client rigidly extends his arms. A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. Incorrect Answers:B. Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. C. Functional residual capacity measures the amount of air in the lungs after normal expiration. D. Residual volume measures the amount of air in the lungs after forced expiration.

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8°C (102°F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend. Incorrect Answers:B. An elevated temperature is a sign of an infection and can be associated with the purulent drainage obtained. However, this is not a manifestation of a pneumothorax. E. Clients who experience a tension pneumothorax exhibit respiratory distress and tachypnea until a chest tube is inserted to re-inflate the lung.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

A. Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery. Incorrect Answers:B. The appearance of Q waves indicates infarction, not reperfusion. C. The elevated ST segments indicate infarction, not reperfusion. D. The recurrence of chest pain can indicate an extension of acute MI. With reperfusion, chest pain should subside.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. "You can expect your vision to return immediately after the procedure." B. "You should avoid reading for 1 week." C. "You can remove eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 lb."

B. "You should avoid reading for 1 week." The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina. Incorrect Answers:A. The client's vision will not be restored immediately after the procedure because of swelling of the eye and the dilating effects of eye drops. The client's vision should return gradually over several weeks. C. The client should wear eye shields for 2 to 6 weeks after surgery when sleeping to protect the eye from injury. D. The client should not lift objects that weigh more than 20 pounds to prevent an increase in intraocular pressure.

A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? A. "Expect the test to take about 3 hr." B. "You'll begin by lying still with your eyes closed." C. "You'll sleep for the duration of the procedure." D. "Expect some mild electrical shocks during the test."

B. "You'll begin by lying still with your eyes closed." The client will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording. Incorrect Answers:A. An EEG takes 45 minutes to 2 hours. C. The nurse should explain the need to lie still but should also prepare the client for other activities such as hyperventilation and photic stimulation from flashing strobe lights. D. An EEG documents brain activity. Electrical shocks are not used during this test.

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (Select all that apply.) A. A client who is postmenopausal B. A client who is a vegetarian C. A middle adult male client D. A client who is pregnant E. A toddler who is overweight

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections

B. Addressing the client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

B. Apply pressure to the catheter removal site for 5 min A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss. Incorrect Answers: A. The application of heat increases blood flow to the area, which increases the client's risk of bleeding. C. Elevating the arm is recommended to decrease blood flow to the area, which decreases the client's risk for bleeding. D. Cleaning the site with alcohol is recommended prior to insertion to prevent infection at the insertion site. After discontinuation, the nurse should apply a sterile dressing.

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

B. Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C.Motor loss on one side of the body D. Bleeding from the top of the scalp

B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

B. Crackles in the lung bases Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B. Ensure an adequate airway The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opioid toxicity.

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38°C (100.4°F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea

B. PaO2 50 mmHg This client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? A. Obtain blood samples to test platelet function B. Prepare for replacement of the missing clotting factor C. Administer aspirin for the client's pain D. Place the bleeding joint in the dependent position

B. Prepare for replacement of the missing clotting factor Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis, which can result in a long-term loss of range of motion in repeatedly affected joints.

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. Respiratory acidosis

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? A. Insert an oral airway B. Turn the client onto a side C. Restrict movement of the client's limbs D. Place a pillow under the client's head

B. Turn the client onto a side Incorrect Answers: A. The nurse should not try to insert anything into the client's mouth during a seizure because this can increase the risk of injury to the client and to the nurse. C. The nurse should not try to restrict the client's movement because this can cause injury to the client or the nurse. D. The nurse should remove pillows from the client's bed to protect the client's airway.

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. "I can keep my dentures in during the procedure." B. "I am allowed only clear liquids prior to the procedure." C. "A tissue sample might be obtained during the procedure." D. "A signed consent form is not required for this procedure."

C. "A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing. Incorrect Answers:A. The client needs to remove dentures, glasses, or contacts so they can be stored safely until after the procedure is completed. B. The client should ingest nothing by mouth for 6 hours prior to the procedure to reduce the risk of aspiration. D. A signed consent form is required prior to a bronchoscopy because it requires sedation, and risk is involved. By signing the consent form, the client is demonstrating an understanding of the procedure and the risks.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make? A. "Each client is different; we cannot predict what will happen." B. "I can see that you are worried, but it's too soon to predict what will happen." C. "Acute episodes are usually followed by remissions, which can vary in duration." D. "It's too early to think about the future; let's focus on the present and take each day as it comes."

C. "Acute episodes are usually followed by remissions, which can vary in duration." This client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.

A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting." D. "Use dental floss daily."

C. "Elevate your legs when sitting." Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? A. "I need to stay active to prevent blood clots in my legs." B. "If I have a bad headache, I can take aspirin to get rid of it." C. "I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

C. "I should eliminate uncooked foods from my diet for now." The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods. Incorrect Answers:A. Although staying active is always a good strategy, clients who have aplastic anemia are not at particular risk for deep-vein thrombosis because a common manifestation of this disorder is a low platelet count. B. Clients with aplastic anemia should not take aspirin because it can increase bleeding tendencies. D. Although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have iron-deficiency anemia, not aplastic anemia.

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for a while." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor if I see any blood in my urine or stool." D. "I'll have to take the blood thinner for a few more days."

C. "I'll call the doctor if I see any blood in my urine or stool." Correct Answer: C. "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately. Incorrect Answers:A. The client might have to limit activities for a while but should report any leg swelling or tenderness as an indication of clot formation. B. The vena cava filter remains in place either until the provider determines there is not a high risk for clot formation or permanently. D. Clients who had a pulmonary embolism typically require anticoagulant therapy for weeks to years after the acute event.

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."

C. "Keep your cell phone 6 inches away from your pacemaker when making a call." The nurse should instruct the client to keep a cell phone 6 inches away from the pacemaker when making a call to avoid interfering with the function of the generator inside the client's pacemaker. Incorrect Answers:A. The client does not need a provider's prescription to alert airport security when traveling. A card should be given to the client after surgery stating that he has a pacemaker and listing the type and model. The nurse should instruct the client to carry this card at all times and show it to airport security when he travels. B. The client does not need to stand 3 feet away while using a microwave. Proper shielding is part of microwave manufacturing, so this safety measure does not need to be taken. D. The client can take a bath or shower as long as he gives careful attention to the pacemaker site. The client should not stand directly under the shower or submerge himself in a tub of water, as this would allow the pacemaker to get extremely wet.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? A. "I should try to drink at least 2 liters of fluid per day." B. "I can still fly out to visit my sister in Colorado for a while." C. "Physical activity is good for me, but I need to avoid overexertion." D. "I can still go skiing during the cold winter months."

C. "Physical activity is good for me, but I need to avoid overexertion." To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities. Incorrect Answers:A. To help prevent a recurrence of sickle cell crisis, the client should drink 3 to 4 L of fluid per day. B. To help prevent a recurrence of sickle cell crisis, the client should avoid traveling to high altitudes and in airplanes since passenger cabins are non-pressurized. D. To help prevent a recurrence of sickle cell crisis, the client should avoid recreational activities that require persistent exposure to cold weather.

A nurse is providing teaching to a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. increase caffeine intake C. Avoid sudden movements D. Increase sodium intake

C. Avoid sudden movements

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax.

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? A.No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesias in both hands

C. Development of hives when eating shrimp An allergy to shellfish is a contraindication for the use of contrast media during a CT scan. The nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan.

A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees

C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position Elevating the head of the bed 25° to 30° with the client's head in a neutral midline position helps prevent an increase in intracranial pressure. Increased intracranial pressure is a major risk factor for complications in the first 72 hours following the onset of a CVA.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position

C. Evaluate the client for stridor Correct Answer: C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

C. Grilled chicken salad with fresh tomatoes Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are free of preservatives and, therefore, are likely to be low in sodium. However, it is essential to make sure the food preparer has not added salt generously to the chicken and the salad.

A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased bronchospasms C. Increased urine output D. Increased temperature

C. Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A.Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)

C. Instruct the client to perform the Valsalva maneuver during removal The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space.

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client presents with symptoms. D. Oxygen therapy is ineffective following a lobectomy.

C. Lung cancer usually has metastasized before the client presents with symptoms. The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short-term and long-term care options for the client.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. Metered-dose inhaler B. Continuous passive motion machine C. Oral-nasal suction equipment D. External defibrillator pads

C. Oral-nasal suction equipment A client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? A. Attorney B. Physical therapy C. Respite care D. Occupational therapy

C. Respite care The nurse should make a referral for respite care for the caregiver. Respite care can provide needed relief for caregivers in an expedient, short-term arrangement.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? A. The client cannot name simple objects or formulate sentences or phrases. B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue. C. The client is unable to understand words or sentences she hears. D. The client speaks words that substitute for those she intends to say.

C. The client is unable to understand words or sentences she hears. Clients who cannot understand words or sentences they hear have receptive aphasia. Incorrect Answers:A. Clients who cannot name simple objects or formulate sentences or phrases has expressive aphasia. B. Clients who have difficulty articulating correctly due to weakness or paralysis of the muscles that produce speech have dysarthria. D. Clients who speak words in place of those they intend to say have apraxia.

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8 hr during the night prior to the test

C. Thoroughly shampoo her hair prior to the EEG The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG. Incorrect Answers: A. The nurse should instruct the client to eat regularly scheduled meals prior to the EEG because a low blood glucose level resulting from NPO status can alter EEG results. B. A sedative is not administered the night before a standard EEG because a sedative depresses CNS functioning and can alter EEG results. D. The nurse should instruct the client to be sleep-deprived prior to the EEG to increase the likelihood of recording seizure activity. The nurse should instruct the client to awaken at 0200 to 0300 on the morning of the EEG

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. Incorrect Answers:A. Infective endocarditis occurs when bacteria invade the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. B. Pericarditis can occur from 10 days to 2 months following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. D. Pulmonary emboli occur if the client develops heart failure following a myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or deep-vein thrombosis.

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

C. Vitamin C Vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and capillary fragility.

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? A. "I'm not going to be able to cough for a while after the surgery." B. "After I recover from the anesthesia, I'll be able to eat regular food again." C. "After the surgery, my voice will gradually return but might be weak." D. "I understand that I will have a permanent tracheostomy after the surgery."

D. "I understand that I will have a permanent tracheostomy after the surgery." With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent. Incorrect Answers:A. After the surgery, the client should be able to carry out postoperative exercises such as coughing and breathing deeply to help clear secretions. B. After the surgery, the client will receive enteral nutrition via a feeding tube for 7 to 10 days. C. After a total laryngectomy, the client will have no natural voice because the surgeon will remove the entire larynx.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.

D. A TIA can precede an ischemic stroke. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness. Incorrect Answers:A. TIAs are brief episodes of a neurological deficit that last less than 24 hours after onset without any permanent disabilities. B. TIAs are caused by a temporary reduction of oxygen supply to the brain, such as from a thromboembolism or cerebral vasospasm. A hemorrhagic stroke can be the result of cerebral bleeding. C. Cerebral edema can be the result of a stroke. TIAs do not produce edema of the cerebrum.

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. Incorrect Answers:A. The client might require mechanical ventilation to stabilize the respiratory status; however, there is no indication at this time for a tracheostomy. B. A thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, or tuberculosis or for a client who requires microscopic examination of the pleural fluid. C. While the client will require several portable chest X-rays, there is no immediate indication for a CT scan of the chest.

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A.Measuring heart rate B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex

D. Confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk.

A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are due to an obstruction of the structure that connects the middle ear to the throat. The nurse should identify that the provider was referring to which of the following structures? A. Oval window B. Auricle C. Tympanic membrane D. Eustachian tube

D. Eustachian tube

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal edema B. Mouth breathing C. Periorbital ecchymosis D. Frequent swallowing

D. Frequent swallowing Frequent swallowing indicates posterior nasal bleeding and possibly hemorrhage. The nurse should notify the surgeon promptly about this finding. Incorrect Answers:A. Edema of the nose, eyes, and face is an expected finding following rhinoplasty. B. Mouth breathing is an expected finding following rhinoplasty. The presence of nasal packing hinders the ability to breathe through the nose. C. Ecchymosis of the nose, eyes, and face is an expected finding following rhinoplasty.

A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus

D. Hypothalamus The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort

D. Lower back discomfort An abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about a long-term cardiac conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Monitor for bleeding

D. Monitor for bleeding Correct Answer: D. Monitor for bleeding Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured. Incorrect Answers:A. The nurse should provide teaching about cardiac rehabilitation prior to the client's discharge from the hospital. B. The nurse should plan to administer scheduled doses of aspirin post-procedure. This maintains the patency of the client's coronary arteries following the PTCA by preventing platelet aggregation and thrombus formation around the newly placed stent. C. The nurse should monitor for peak laboratory markers of myocardial damage following a myocardial infarction and reperfusion with thrombolytic therapy.

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? A. Prevent depression in the client B. Refer the client to occupational therapy C. Support the client's family D. Monitor the client for increased intracranial pressure (ICP)

D. Monitor the client for increased intracranial pressure (ICP) The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased level of consciousness and a change in pupils.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula

D. Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

D. Noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? A. Finding the bathroom in the dark B. Driving at night C. Seeing numbers on highway signs D. Reading the newspaper

D. Reading the newspaper With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

D. Report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nurse is showing a client who has right-sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak. B. The client's airway secretions were last suctioned 2 hr ago. C. The client coughs and expectorates a large mucous plug. D. The nurse auscultates coarse crackles in the lung fields.

D. The nurse auscultates coarse crackles in the lung fields. Correct Answer: D. The nurse auscultates coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions. Incorrect Answers:A. A client who has a tracheostomy with an inflated cuff in place is unable to speak. B. The nurse should assess the need for suctioning every 2 hours and suction as necessary. C. The nurse should assess the client's airway after coughing and only suction the client's secretions if the client is not able to cough and expectorate secretions.

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

D. Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.