CASI Review

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65. A nurse in a provider's office is reviewing the medical record of a client who has fibrocystic breast condition. Which of the following is an expected finding? A. Palpable rubberlike lump in the upper outer quadrant B. BRCA1 gene mutation C. An elevated CA-125 D. Peau d'orange dimpling of the breast

A A. CORRECT: Clients who have fibrocystic breast condition typically have breast pain and rubbery lumps in the upper outer quadrant of the breasts. B. incorrEct: BRCA1 gene mutation is a risk factor for breast cancer. C. incorrEct: An elevated CA-125 is a finding associated with ovarian cancer. D. incorrEct: Peau d'orange dimpling of the breast is a finding associated with breast cancer. NcleX® connection: physiological adaptations, pathophysiolog

47. A nurse is caring for a client who is receiving TPN solution. It has been 24 hr since the current bag of solution was hung, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag. B. Infuse the remaining solution at the current rate and then hang a new bag. C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag. D. Remove the current bag and hang a bag of lactated Ringer's solution

A A. CORRECT: The current bag of TPN should not hang more than 24 hr due to the risk of infection. B. INCORRECT: The current bag of TPN should not hang more than 24 hr due to the risk of infection. C. INCORRECT: The rate of infusion of TPN infusion should never be increased abruptly due to the risk of hyperglycemia. D. INCORRECT: Administration of TPN should never be discontinued abruptly due to the sudden change in blood glucose that can occur.

14. A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement

A A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. B. INCORRECT: Insertion of a nasogastric tube is not the priority nursing action at this time. C. INCORRECT: Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. INCORRECT: Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

72. A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated. C. Contact precautions are used during wound care. D. Dressing changes are performed using aseptic technique

A A. CORRECT: Treatment of osteomyelitis includes continuing antibiotic therapy for 3 months. B. INCORRECT: Relief of pain does not indicate that osteomyelitis is resolved, and the client should continue antibiotic therapy as prescribed. C. INCORRECT: When performing wound care, standard precautions are implemented, because a wound due to osteomyelitis is classified as a dirty wound and is usually left open for healing. D. INCORRECT: Clean technique is used when performing a dressing change of a wound due to osteomyelitis, because the wound is classified as a dirty wound and is usually left open for healing

44. A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A A. CORRECT: Hyperkalemia, an increase in serum potassium, is a laboratory ﬁnding associated with diabetic ketoacidosis. B. INCORRECT: Hyponatremia, a decrease in serum sodium, is a laboratory ﬁnding associated with heart failure. C. INCORRECT: Hypernatremia, an increase in serum sodium, is a laboratory ﬁnding associated with Cushing's syndrome. D. INCORRECT: Hypocalcemia, a decrease in serum calcium, is a laboratory ﬁnding is found in clients following a thyroidectomy.

72. A nurse is assessing a client who has a casted compound fracture of the right forearm. Which of the following findings is an early indication of neurovascular compromise? A. Paresthesia B. Pulselessness C. Paralysis D. Pallor

A A. CORRECT: Paresthesia is an early sign of neurovascular compromise, which is suggestive of compartment syndrome. B. INCORRECT: Pulselessness is a late sign of neurovascular compromise, which is suggestive of compartment syndrome. C. INCORRECT: Paralysis is a late sign of neurovascular compromise, which is suggestive of compartment syndrome. D. INCORRECT: Pallor is a late sign of neurovascular compromise due to inadequate profusion to the distal extremity, which is suggestive of compartment syndrome

32. A nurse is caring for a client who has heart failure and asks how to limit ﬂuid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse? A. "Pour the amount of ﬂuid you drink into an empty 2 liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of ﬂuid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much ﬂuid."

A A. CORRECT: Pouring the amount of ﬂuid consumed into an empty 2 L bottle provides a visual guide for the client as to the amount consumed and how to plan daily intake. B. INCORRECT: Glasses and cups vary in size and may contain more than 8 oz. C. INCORRECT: Offering a vague frame of reference does not assist with accurate ﬂuid measurement. D. INCORRECT: Suggesting that the client take sips of water or ice chips does not assist with accurate ﬂuid measurement.

44. A nurse is caring for a client who has laboratory ﬁndings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory ﬁndings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr D. Administration of glucocorticoids

A A. CORRECT: Receiving three tap water enemas can result in a decrease in serum sodium and potassium in the client. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution. B. INCORRECT: Receiving 0.9% sodium chloride solution IV at 50 mL/hr would not produce these results. C. INCORRECT: Receiving 5% dextrose in water solution with 20 mEq of K+ at 80 mL/hr would not produce these results. D. INCORRECT: Receiving glucocorticoids would not produce these results.

16. A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A A. CORRECT: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. B. INCORRECT: Preventing contractures is important, but it is not the highest priority. C. INCORRECT: Preventing skin breakdown is important, but is not the highest priority. D. INCORRECT: Preventing postural hypotension is important, but it is not the highest priority

6. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform ﬁrst? A. Keep the client in a side-lying position. B. Monitor the client's vital signs. C. Reorient the client to the environment. D. Check the client for injuries

A A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth. B. INCORRECT: Monitoring vital signs to determine the stability of the client is important, but it is not the priority nursing action. C. INCORRECT: Reorienting the client to the environment because the client may feel confused after a seizure is important, but it is not the priority nursing action. D. INCORRECT: Checking the client for injuries that may of occurred from involuntary movement during the seizure is important, but it is not the priority nursing action.

44. A nurse is caring for a client who has a laboratory ﬁnding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations? A. ECG changes B. Constipation C. Polyuria D. Hypotension

A A. CORRECT: The nurse should assess the client for ECG changes. Potassium levels can affect the heart and result in arrhythmias. B. INCORRECT: Constipation is a clinical manifestation of hypokalemia. C. INCORRECT: Polyuria is a clinical manifestation of hypokalemia. D. INCORRECT: Hypotension is a clinical manifestation of hypokalemia

56. A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform ﬁrst? A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer prescribed antituberculosis medications. D. Recommend a screening test for family members.

A A. CORRECT: The safety risk to the nurse and others is transmission of the infection. The ﬁrst action is to place the client on airborne precautions. B. INCORRECT: Obtaining a sputum culture is an appropriate action, but it does not address the safety risk and therefore is not the ﬁrst action the nurse should take. C. INCORRECT: Administering prescribed medications is an appropriate action, but it does not address the safety risk and therefore is not the ﬁrst action the nurse should take. D. INCORRECT: Recommending screening tests for those in close contact with the client is an appropriate action, but it does not address the safety risk and therefore is not the ﬁrst action the nurse should take.

97. A nurse is caring for a client who reports nausea and vomiting 2 days postoperative after hysterectomy. Which of the following actions should the nurse perform first? A. Assess bowel sounds. B. Administer antiemetic medication. C. Restart prescribed IV fluids. D. Insert a prescribed nasogastric tube.

A A. CORRECT: Using the nursing process, the first step is to assess the client. Assessing bowel sounds is the correct action by the nurse. B. IncOrrEct: Administer an antiemetic medication may alleviate the nausea and vomiting but is not the first nursing action. C. IncOrrEct: Restarting the prescribed IV fluids will prevent dehydration but is not the first nursing action. D. IncOrrEct: Inserting a prescribed nasogastric tube can alleviate nausea and vomiting but is not the first nursing action.

2. A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and dropped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Head-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head

A A. CORRECT: The nurse should open the client's airway by the head-tilt, chin-lift because the client is unresponsive without suspicion of trauma. B. INCORRECT: The nurse should not open the client's airway with the modified jaw thrust because this method is used for a client who is unresponsive with suspected traumatic neck injury. C. INCORRECT: The nurse should not open the client's airway with hyperextension of the head because hyperextension of the head can close off the airway and cause injury. D. INCORRECT: The nurse should not open the client's airway with flexion of the head because flexion of the head does not open the airway.

49. A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole (Nexium). Which of the following should be included in the teaching? (Select all that apply.) A. Take the medication 1 hr before a meal. B. Limit NSAIDs when taking this medication. C. Expect skin flushing when taking this medication. D. Increase fiber intake when taking this medication. E. Chew the medication thoroughly before swallowing.

A, B A. CORRECT: The client is instructed to take the medication 1 hr before meals. B. CORRECT: The client is instructed to limit taking NSAIDs when on this medication. C. iNCORRECT: Skin flushing is not an adverse effect of this medication. D. iNCORRECT: Fiber intake does not need to be increased when taking this medication. E. iNCORRECT: The client is instructed to swallow the capsule whole. It should not be crushed or chewed.

65. A nurse is instructing a client how to perform Kegel exercises. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform a set of exercises four times a daily. B. Contract the circumvaginal and/or perirectal muscles. C. Gradually increase the contraction period to 10 seconds. D. Follow each contraction with at least a 10-second relaxation period. E. Perform while sitting, lying, and standing. F. Tighten abdominal muscles during contractions

A, B C, D, E A. CORRECT: The client should perform a set of exercises at least four times a day. B. CORRECT: The client should contract her circumvaginal and perirectal muscles as if trying to stop the flow of urine or passing flatus. C. CORRECT: The client should hold the contraction for 10 seconds. She may need to gradually increase the contraction period to reach this goal. D. CORRECT: The client should follow each contraction with a period of relaxation of 10 to 15 seconds. E. CORRECT: The client should perform the exercises in all three positions. F. incorrEct: The client should relax her other muscles, such as those in her abdomen and her thighs. NcleX® connection: Health promotion and maintenance, Health promotion/disease prevention

72. A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of safe management? (Select all that apply.) A. "I will clean the pins twice a day." B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." D. "I will move my leg by lifting the device in the middle." E. "I will remove any crusting that forms at the pin site."

A, B, C A. CORRECT: Clean the external fixation pins one to two times each day to remove exudate that may harbor bacteria. B. CORRECT: Using a separate cotton swab on each pin will decrease the risk of cross-contamination, which could cause pin site infection. C. CORRECT: Notify the provider if a pin is loose because the provider will know how much to tighten the pin and prevent damage to the tissue and bone. D. INCORRECT: The external fixation device should never be used to lift or move the affected leg, due to the risk of injuring and dislocating the fractured bone. E. INCORRECT: Crusting at the pin site provides a natural barrier from bacteria and should not be removed.

60. A nurse is planning care for a client who has postrenal acute kidney injury due to metastatic cancer. The client has a serum creatinine of 5 mg/dL. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Provide a high-protein diet. B. Assess the urine for blood. C. Monitor for intermittent anuria. D. Administer diuretic medication. E. Provide NSAIDs for pain.

A, B, C A. CORRECT: The nurse should provide the client with a high-protein diet because of the high rate of protein breakdown that occurs with acute kidney injury. B. CORRECT: The nurse should assess the client's urine for blood, stones, and particles indicating an obstruction of the urinary structures that leave the kidney. C. CORRECT: The nurse should assess the client for intermittent anuria because of possible bilateral obstruction of the urinary structures that leave the kidney. D. INCORRECT: The nurse should not administer a diuretic medication because it can increase destruction of the remaining nephrons in the kidney. E. INCORRECT: The nurse should not administer NSAIDs, which are nephrotoxic to the nephrons in the kidney, for pain.

55. A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment ﬁndings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

A, B, C A. CORRECT: Pain and tenderness at the wound site are expected ﬁndings with an incisional infection. B. CORRECT: Fever and chills are expected ﬁndings with an incisional infection. C. CORRECT: Reddened or inﬂamed wound edges are expected ﬁndings with an incisional infection. D. INCORRECT: Serosanguineous drainage is more common immediately after surgery. Purulent drainage is an expected ﬁnding with an incisional infection. E. INCORRECT: Changes in thirst have many causes. That ﬁnding alone does not indicate an incisional infection.

30. A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood ﬂow to the heart is stopped

A, B, C A. CORRECT: The use of cardiopulmonary bypass reduces the client's demand for oxygen, which reduces the risk of inadequate oxygenation of vital organs. B. CORRECT: Motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery. C. CORRECT: The core body temperature is lowered for the procedure, and rewarming then occurs through heat exchanges on the cardiopulmonary bypass machine. D. INCORRECT: The use of cardiopulmonary bypass decreases the rate of metabolism. E. INCORRECT: Blood ﬂow to the heart is maintained by the action of the cardiopulmonary bypass machine.

6. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Overwhelming fatigue should be avoided. B. Caffeinated products should be removed from the diet. C. Looking at ﬂashing lights should be limited. D. Aerobic exercise may be performed. E. Episodes of hypoventilation should be limited. F. Use of aerosol hairspray is recommended.

A, B, C A. INCORRECT: The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. INCORRECT: The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. INCORRECT: The nurse should instruct the client to have period blood tests to determine the therapeutic level of phenytoin.

A, B, C, A. CORRECT: Pain and tenderness at the wound site are expected ﬁndings with an incisional infection. B. CORRECT: Fever and chills are expected ﬁndings with an incisional infection. C. CORRECT: Reddened or inﬂamed wound edges are expected ﬁndings with an incisional infection. D. INCORRECT: Serosanguineous drainage is more common immediately after surgery. Purulent drainage is an expected ﬁnding with an incisional infection. E. INCORRECT: Changes in thirst have many causes. That ﬁnding alone does not indicate an incisional infection.

97. A nurse is reviewing the health records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply.) A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client taking warfarin (Coumadin) daily D. A client who had a bowel prep E. A client who has a BMI of 26

A, B, C, D A. CORRECT: An increased WBC indicates an underlying infection and places the client at risk for postoperative complications. B. CORRECT: An insulin pump indicates the client has type 1 diabetes mellitus and places the client at risk of postoperative complications. C. CORRECT: A client who takes warfarin daily is at risk for bleeding and postoperative complications. D. CORRECT: Receiving a bowel prep to cleanse the colon can cause dehydration and places the client at risk for complications. E. IncOrrEct: A BMI of 26 is within the expected reference range and does not place the client at risk for postoperative complications.

97. A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply.) A. Urine output less than 25 mL/hr B. Hematocrit 48% C. BUN 24 mg/dL D. Tenting of skin over the sternum E. Apical pulse rate 62/min

A, B, C, D A. CORRECT: Urine output less than 25 mL/hr is a manifestation of hypovolemia and requires intervention by IV fluid therapy. B. CORRECT: Hematocrit of 48% indicates concentrated blood volume and is a manifestation of hypovolemia, requiring intervention by IV fluid therapy. C. CORRECT: BUN of 24 mg/dL indicates decreased kidney function and can be a manifestation of hypovolemia, requiring intervention with IV fluid therapy. D. CORRECT: Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring intervention with IV fluid therapy. E. IncOrrEct: An apical pulse rate of 62/min is not a manifestation of hypovolemia

6. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the ﬂoor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

A, B, C, D, E A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the ﬂoor to prevent falling. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. INCORRECT: The nurse should not restrain the client, which may cause an injury or more seizure activity.

83. . A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega-3 fatty acids in the diet.

A, B, C, E A. CORRECT: Healthy nutrition should include decreasing the consumption of meats and processed foods, which can prevent diabetes and hyperlipidemia. B. CORRECT: Healthy nutrition should include lowering LDL by decreasing intake of saturated fats, which can prevent diabetes and hyperlipidemia. C. CORRECT: Healthy nutrition should include increasing dietary fiber to control weight gain and decrease the risk of diabetes and hyperlipidemia. D. INCORRECT: The recommendation for saturated fat intake is no more than 7% of total daily caloric intake. E. CORRECT: Healthy nutrition should include omega-3 fatty acids for secondary prevention of diabetes and heart disease.

56. A nurse is caring for a client who has type 2 diabetes mellitus and is to undergo excretory urography. Which of the following are appropriate nursing actions prior to this procedure? (Select all that apply.) A. Identify client allergy to seafood. B. Hold metformin (Glucophage) for 24 hr. C. Administer an enema. D. Obtain client's serum coagulation profile. E. Assess client for history of asthma.

A, B, C, E A. CORRECT: The client who has an allergy to seafood is at higher risk for an allergic reaction to the contrast dye used in the procedure. B. CORRECT: The client who takes metformin is at risk for lactic acidosis from the contrast dye with iodine used during the procedure. C. CORRECT: The client should receive an enema to remove fecal contents, fluid, and gas from the colon for a more clear visualization. D. INCORRECT: A serum coagulation profile should be obtained for a client prior to a kidney biopsy. E. CORRECT: A client who has a history of asthma has a higher risk of having an asthma attack as an allergic response to the contrast dye used during the procedure.

97. A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage the use of the incentive spirometer every 2 hr. B. Instruct to splint incision when coughing and deep breathing. C. Reposition the client every 2 hr. D. Administer antibiotic therapy. E. Assist with early ambulation.

A, B, C, E A. CORRECT: The use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis. B. CORRECT: Incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing which prevents atelectasis. C. CORRECT: Repositioning the client every 2 hr will cause the client to deep breathe and expand the lungs to prevent atelectasis. D. IncOrrEct: Antibiotic therapy is used to prevent/treat infection and does not prevent atelectasis. E. CORRECT: Early ambulation expands the lungs through deep breathing and prevents atelectasis

15. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected ﬁndings? (Select all that apply.) A. Impulse control difﬁculty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of awareness

A, B, C, E A. CORRECT: A client who has experienced a right-hemispheric stroke will exhibit impulse control difﬁculty, such as the urgency to use the restroom. B. CORRECT: A client who has experienced a right-hemispheric stroke will exhibit left-sided hemiplegia. C. CORRECT: A client who has experienced a right-hemispheric stroke will experience a loss in depth perception. D. INCORRECT: A client who has experienced a left-hemispheric stroke will experience aphasia. E. CORRECT: A client who has experienced a right-hemispheric stroke will demonstrate a lack of awareness of surroundings.

15. A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Use thickened liquids. C. Place food on the client's unaffected side of her mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck ﬂexed.

A, B, C, E A. CORRECT: Have suction equipment available for use is correct. Suction equipment should be available in case of choking and aspiration. B. CORRECT: The client should be given thickened liquids, which are easier to swallow. C. CORRECT: Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration. D. INCORRECT: Due to the risk of aspiration, an assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning may be needed if choking occurs. E. CORRECT: The client should be taught to ﬂex her neck, tucking the chin down and under, to close the epiglottis during swallowing.

32. A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? (Select all that apply.) A. Cheddar cheese, 2 oz B. Hot dog C. Canned tuna, 3 oz D. Roast chicken breast, 3 oz E. Baked ham, 3 oz

A, B, C, E A. CORRECT: Processed cheese contains 800 mg sodium per 2 oz. B. CORRECT: A hot dog contains 615 mg sodium. C. CORRECT: Canned tuna contains 350 mg sodium per 3 oz. D. INCORRECT: Lean meats, ﬁsh, and poultry contain 30 to 90 mg of sodium per 3 oz. E. CORRECT: Lean, baked ham contains 1,020 mg sodium per 3 oz.

60. A nurse is planning care for a client who has stage 4 chronic kidney disease. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Assess for jugular vein distention. B. Provide frequent mouth rinses. C. Auscultate for a pleural friction rub. D. Assess using the Glasgow Coma Scale. E. Monitor for dysrhythmias.

A, B, C, E A. CORRECT: The nurse should assess for jugular vein distention, which may indicate fluid overload and congestive heart failure. B. CORRECT: The nurse should provide frequent mouth rinses due to uremic halitosis caused by urea waste in the blood. C. CORRECT: The nurse should auscultate for a pleural friction rub related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention. D. INCORRECT: The Glasgow Coma Scale is used for a client who has a head injury to identify increased intracranial pressure, not for a client who has chronic kidney disease. E. CORRECT: The nurse should monitor for dysrhythmias related to increased serum potassium, which is not being excreted by the kidneys.

69. A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.) A. Maintain continuous passive motion device. B. Palpate dorsopedal pulses. C. Place pillow behind the knee. D. Elevate heels off bed. E. Apply heat therapy to incision.

A, B, D A. CORRECT: A continuous passive motion device promotes motion in the knee and prevents scar tissue formation. B. CORRECT: The nurse should assess the strength of the pulses of both lower extremities to help determine adequate circulation. C. INCORRECT: A pillow should not be placed behind the knee to avoid flexion contractures. D. CORRECT: The nurse should prevent pressure ulcers on the client's heels by elevating the heels off the bed with a pillow. E. INCORRECT: The nurse should apply cold therapy, not heat therapy, to reduce postoperative swelling.

14. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A, B, D A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. INCORRECT: Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. INCORRECT: Hypertension, not hypotension, is a finding associated with increased ICP.

79. A nurse in a provider's ofﬁce is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole (Tapazole). Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Monitor CBC. B. Monitor triiodothyronine (T3). C. Inform the client that the medication should not be taken for more than 3 months. D. Advise the client to take the medication at the same time every day. E. Inform the client that an adverse effect of this medication is iodine toxicity.

A, B, D A. CORRECT: Methimazole can cause a number of hematologic effects, including leukopenia and thrombocytopenia. Therefore, the nurse should monitor the client's CBC. B. CORRECT: Methimazole reduces thyroid hormone production. Therefore, the nurse should monitor the client's T3. C. INCORRECT: Methimazole can be prescribed for the client who has Graves' disease for 1 to 2 years. D. CORRECT: Methimazole should be taken at the same time every day to maintain blood levels. E. INCORRECT: Iodine toxicity is an adverse effect of Lugol's solution

40. To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 15 inches in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane

A, B, D A. CoRRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg. B. CoRRECT: The client should keep two points of support on the ground at all times for stability. C. INCORRECT: The client should place the cane 6 to 10 inches in front of her feet before advancing. D. CoRRECT: The client should advance the weaker leg first, followed by the stronger leg. E. INCORRECT: The client should advance the stronger leg past the cane

79. A nurse is preparing to receive a client from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply.) A. Suction equipment B. Humidiﬁed air C. Flashlight D. Tracheostomy tray E. Oxygen delivery equipment

A, B, D, E A. CORRECT: The client may require oral or tracheal suctioning. Therefore, the nurse should ensure that this equipment is available. B. CORRECT: Humidiﬁed air thins secretions and promotes respiratory exchange. Therefore, this equipment should be available. C. INCORRECT: A ﬂashlight is used to measure the reaction of the pupils to light for a client who has an intracranial disorder. This test is not indicated for this client. D. CORRECT: The client may experience respiratory obstruction. Therefore, this equipment should be available. E. CORRECT: The client may require supplemental oxygen due to respiratory complications. Therefore, this equipment should be available.

43. A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A, B, D, E A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is concentrated due to urinary output being decreased. C. INCORRECT: Bradycardia is not a clinical manifestation present with fluid volume deficit. D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.

43. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A, B, D, E A. CORRECT: Dyspnea is a clinical manifestation present with fluid volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling to breath to obtain oxygen. B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the excess of fluid within the body. Weight gain can be a result of edema. C. INCORRECT: Bradycardia is not a clinical manifestation related to fluid volume excess. D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess fluid. E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body.

1. A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Ask the dietitian to assist with meal planning. B. Contact the client's support system. C. Assess for age-related cognitive awareness. D. Encourage the use of a daily medication dispenser. E. Provide educational materials for home use.

A, B, D, E A. CORRECT: The nurse provides resources to strengthen coping abilities by asking the dietician to assist the client with meal planning. This will improve client compliance. B. CORRECT: The nurse can contact members of the client's support system and encourage the client to use this support during times of illness and stress to improve compliance. C. INCORRECT: Assessing the client for age-related cognitive awareness is important but it is not an appropriate intervention that enhances the client's compliance. D. CORRECT: The nurse encourages the use of a daily medication dispenser to reduce health risks and improve medication compliance by the client. E. CORRECT: The nurse provides educational materials to the client to improve health awareness and reduce health risks after discharge

33. A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema

A, B, E A. CORRECT: Dyspnea is a clinical manifestation of right-sided valvular heart disease. B. CORRECT: A client's report of fatigue is a clinical manifestation of right-sided valvular heart disease. C. INCORRECT: A normal or rapid pulse and an irregularly irregular rhythm are clinical manifestations of right-sided valvular heart disease. D. INCORRECT: A pleural friction rub is a manifestation of pleurisy or pneumonia. E. CORRECT: Peripheral edema is a clinical manifestation of right-sided valvular heart disease.

49. A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following are expected findings? (Select all that apply.) A. Rigid abdomen B. Tachycardia C. Elevated blood pressure D. Circumoral cyanosis E. Rebound tenderness

A, B, E A. CORRECT: Manifestations of perforation include a rigid, board-like abdomen. B. CORRECT: Tachycardia occurs due to gastrointestinal bleeding that accompanies a perforation. C. iNCORRECT: Hypotension is an expected finding in a client who has a perforation and bleeding. D. iNCORRECT: Circumoral cyanosis is not a manifestation of perforation. E. CORRECT: Rebound tenderness is an expected finding in a client who has a perforation

28. A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow-up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes

A, B, E A. CoRRECT: The client's ECG rhythm is documented following the procedure. B. CoRRECT: Energy settings used during the procedure are documented. C. incorrEcT: IV fluid intake is not documented during defibrillation. D. incorrEcT: Urinary output is not documented during defibrillation. E. CoRRECT: The condition of the client's skin where electrodes were placed is documented

32. A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected ﬁndings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

A, B, E A. CORRECT: Tachypnea is an expected ﬁnding in a client who has pulmonary edema. B. CORRECT: A persistent cough with pink, frothy sputum is an expected ﬁnding in a client who has pulmonary edema. C. INCORRECT: Decreased urinary output is an expected ﬁnding in a client who has pulmonary edema. D. INCORRECT: Pink, frothy sputum is an expected ﬁnding in a client who has pulmonary edema. E. CORRECT: Orthopnea is an expected ﬁnding in a client who has pulmonary edema.

1. A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse identifies which of the following as a modifiable variable? (Select all that apply.) A. A male who smokes on social occasions B. A female with a BMI of 28 C. An adult with alopecia D. An adolescent with Trisomy 21 E. An infant with reflux

A, B, E Remember modifiable are things that can be modified or changed! A. CORRECT: The nurse identifies smoking as a modifiable variable that can be changed by providing the client with educational materials and information on smoking cessation. B. CORRECT: The nurse identifies a BMI of 28 as a modifiable variable that can be changed by providing the client with educational materials and information on weight reduction and exercising. C. INCORRECT: The nurse identifies alopecia as a nonmodifiable variable because alopecia is a genetic disorder. D. INCORRECT: The nurse identifies Trisomy 21 as a nonmodifiable variable because Trisomy 21 is genetic in origin. E. CORRECT: The nurse identifies reflux as a modifiable variable that may be changed by providing the parents with step-by-step educational information about the infant's treatment

47. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Obtain a capillary blood glucose four times daily. B. Administer prescribed medications through a secondary port on the TPN IV tubing. C. Monitor vital signs three times during the 12-hr shift. D. Change the TPN IV tubing every 24 hr. E. Ensure a daily aPTT is obtained.

A, C, D A. CORRECT: The client is at risk for hyperglycemia during the administration of TPN and may require supplemental insulin. B. INCORRECT: No other medications or ﬂuids should be administered through the same IV tubing being used to administer TPN due to the increased risk of infection and disruption of the rate of TPN infusion. C. CORRECT: Vital signs are recommended every 4 to 8 hr to assess for ﬂuid volume excess and infection. D. CORRECT: It is recommended to change the IV tubing that is used to administer TPN every 24 hr. E. INCORRECT: The aPTT measures the coagulability of the blood, which is unnecessary during the administration of TPN.

72. A nurse is completing an assessment of a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings indicate compartment syndrome? (Select all that apply.) A. Intense pain when the left foot is passively moved B. Edematous left toes compared to the right C. Hard, swollen muscle in the left leg D. Burning and tingling of the distal left foot E. Minimal pain relief following a second dose of opioid medication

A, C, D, E A. CORRECT: Intense pain of the left foot when passively moved may indicate pressure from edema on nerve endings and is a neurological sign of compartment syndrome. B. INCORRECT: Edema of the left toes is an expected finding in a client who has a fracture of the left tibia and fibula. C. CORRECT: A hard, swollen muscle on the affected extremity indicates edema build-up in the area of injury and is a sign of compartment syndrome. D. CORRECT: Burning and tingling of the left foot indicates pressure from edema on nerve endings and is an early neurological sign of compartment syndrome. E. CORRECT: Minimal pain relief after receiving opioid medication may indicate pressure from edema on nerve endings and is an early neurological sign of compartment syndrome.

2. A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids.

A, C, D, E A. CORRECT: This is an appropriate action by the nurse because the body temperature can rise more quickly when heat is applied to dry skin. B. INCORRECT: The nurse should increase the temperature of the room to help return the client to a normal body temperature. C. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warm blankets are applied. D. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when a heat lamp is safely applied. E. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warmed IV fluids are infused.

60 Nurse is assessing a client who has prerenal acute kidney injury (AKI). Which of the following should the nurse include in the assessment? (Select all that apply.) A. Blood pressure B. Cardiac enzymes C. Urine output D. Serum creatinine E. Serum electrolytes

A, C, D, E A. CORRECT: Assessment of blood pressure for hypotension in a client who has prerenal AKI should assist in determining hypovolemia. B. INCORRECT: Assessment of cardiac enzymes is not indicated for a client who has prerenal AKI. C. CORRECT: Assessment of urine output in a client who has prerenal AKI should assist in determining oliguria. D. CORRECT: Assessment of serum creatinine should assist in determining the extent of the AKI and the need for intervention. E. CORRECT: Assessment of serum electrolytes should assist in determining the extent of the AKI and the need for intervention.

33. A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present

A, C, E A. CORRECT: A history of congenital malformations is a risk factor for valvular heart disease. B. INCORRECT: Having a streptococcal infection or rheumatic fever during childhood is a risk factor for valvular heart disease. C. CORRECT: Hypertension places a client at risk for valvular heart disease. D. INCORRECT: A sudden weight gain of 10 lb could indicate fluid collection related to left-sided valvular heart disease. E. CORRECT: A murmur indicates turbulent blood flow, which is often due to valvular heart disease.

69. A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Clean the incision daily with soap and water. B. Turn the toes inward when sitting or lying. C. Sit in a straight-backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.

A, C, E A. CORRECT: Washing the surgical incision daily with soap and water decreases the risk of infection. B. INCORRECT: Toes should be externally rotated. This prevents dislocation of the hip prosthesis. C. CORRECT: The client who uses a straight-backed armchair decreases the chance of bending at a greater than 90° angle, which may cause dislocation of the hip prosthesis. D. INCORRECT: The client who bends at the waist places the hip in a position greater than a 90° angle, which may cause dislocation of the hip prosthesis. E. CORRECT: The client who uses a toilet riser decreases the chance of bending greater than 90° degrees, which may cause dislocation of the hip prosthesis.

56. A nurse in a residential care facility is assessing an older adult client. Which of the following ﬁndings should the nurse recognize as atypical indications of an infection? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation

A, C, E A. CORRECT: Urinary incontinence is an atypical indication of infection in an older adult client. B. INCORRECT: Malaise is a typical indication of infection. C. CORRECT: Acute confusion is an atypical indication of infection in an older adult client. D. INCORRECT: Fever is a typical indication of infection. E. CORRECT: Agitation is an atypical indication of infection in an older adult client.

55. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed.

A, D A. CORRECT: Slight elevation reduces shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. INCORRECT: Massaging the skin over bony prominences can traumatize deep tissues. C. INCORRECT: Cornstarch can create gritty particles that can abrade sensitive skin. D. CORRECT: The client should sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. INCORRECT: Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr.

55. A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and ﬁnds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees bent. E. Offer the client a warm beverage, such as herbal tea.

A, D A. CORRECT: The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. INCORRECT: An abdominal binder can help prevent, not treat, a wound evisceration. C. INCORRECT: The nurse should not handle or apply pressure to any exposed organs or tissues because these actions increase the risks of trauma and perforation. D. CORRECT: This position minimizes pressure on the abdominal area. E. INCORRECT: The nurse must keep the client NPO in anticipation of the surgical team taking him back to the surgical suite for repair of the evisceration.

69. A nurse is completing a preoperative teaching plan for a client who is to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.) A. Encouraging complete autologous blood donation B. Sitting in a low reclining chair C. Having the client roll onto the operative hip D. Using an abductor pillow when turning E. Performing isometric exercises

A, D, E A. CORRECT: The client should be encouraged to donate blood that can be used postoperatively. B. INCORRECT: The client should anticipate sitting in a high chair to keep the hip at a 90° angle. This prevents dislocation. C. INCORRECT: The client should not turn to the operative side. D. CORRECT: The client should use an abductor device or pillow between the legs when turning. This helps avoid dislocation of the affected hip. E. CORRECT: The client should perform isometric exercises to prevent blood clots and maintain muscle tone.

28. A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A, D, E A. CoRRECT: A client who has an acid-base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. B. incorrEcT: A serum potassium of 4.3 mEq/L is within the expected reference range and does not increase the risk of a dysrhythmia. C. incorrEcT: SaO2 of 96% is within the expected reference range and does not increase the risk of a dysrhythmia. D. CoRRECT: A client who has lung disease, such as COPD, is at risk for a dysrhythmia. E. CoRRECT: A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia.

55. A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.) A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A, E A. CORRECT: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. INCORRECT: Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. INCORRECT: Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. INCORRECT: Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CORRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

56. A nurse is discussing the infection process at a staff education session. Which of the following examples are appropriate for the nurse to include when discussing the direct contact mode of transmission? (Select all that apply.) A. A client vomits on a nurse's uniform. B. A nurse has a needle stick injury. C. A mosquito bites a hiker in the woods. D. A nurse ﬁnds a hole in his glove while handling a soiled dressing. E. A person fails to wash her hands after using the bathroom.

A, E A. CORRECT: Transmission from a client's emesis is identiﬁed as person-to-person or direct contact. B. INCORRECT: Transmission from a needle or other inanimate object is identiﬁed as indirect contact. C. INCORRECT: Transmission from an insect is identiﬁed as vector-borne. D. INCORRECT: Transmission from a soiled dressing or other inanimate object is identiﬁed as indirect contact. E. CORRECT: Transmission from a client's contaminated hands is identiﬁed as person-to-person or direct contact.

15. A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Look directly at the client when speaking. C. Allow extra time for the client to answer. D. Complete sentences that the client cannot ﬁnish. E. Give instructions one step at a time.

A,B, C, E A. CORRECT: Clients who have global aphasia will have difﬁculty with both speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. CORRECT: One strategy that can enhance understanding while speaking is looking directly at the client. C. CORRECT: One strategy that can enhance understanding is allowing the client extra time to answer. D. INCORRECT: The nurse should allow the client adequate time to ﬁnish sentences and not complete the sentences for him. E. CORRECT: One strategy that can enhance understanding is giving instructions one step at a time

60. A nurse is caring for a client who has stage 4 chronic kidney disease. Which of the following is an expected laboratory finding? A. Blood urea nitrogen (BUN) 54 mg/dL B. Glomerular filtration rate (GRF) 20 mL/min C. Serum creatinine 1.2 mg/dL D. Serum potassium 5.0 mEq/L

B A. INCORRECT: A BUN of 180 to 200 mg/dL is indicative of stage 4 chronic kidney disease. B. CORRECT: The GRF is severely decreased to approximately 20 mL/min, which is indicative of stage 4 chronic kidney disease. C. INCORRECT: In stage 4 chronic kidney disease, a creatinine level can be as high as 15 to 30 mg/dL. D. INCORRECT: A client in stage 4 chronic kidney disease would have a potassium level greater than 5.0 mEq/L

44. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hypomagnesemia

B A. INCORRECT: An increase in calcium is not indicated with nasogastric losses due to suctioning. B. CORRECT: The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium. C. INCORRECT: An increase in phosphatemia is not indicated with nasogastric losses due to suctioning. D. INCORRECT: A decrease in magnesium is not indicated with nasogastric losses due to suctioning.

83. A nurse is preparing to administer a morning dose of aspart insulin (NovoLog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse? A. Check the client's blood glucose immediately after breakfast. B. Administer the insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

B A. INCORRECT: Blood glucose should be checked prior to insulin administration to prevent an episode of hypoglycemia. B. CORRECT: Administer aspart insulin when breakfast arrives to avoid a hypoglycemic episode. Aspart insulin is rapid-acting, and should be administered 5 to 10 min before breakfast. C. INCORRECT: Aspart insulin is rapid-acting and is administered 5 to 10 min before breakfast. Breakfast should be available at the time of the injection. D. INCORRECT: Aspart insulin is administered at breakfast time and may be prescribed for administration 2 to 3 times a day.

14. A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B A. INCORRECT: Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic, and adverse effects include electrolyte imbalances such as hyponatremia. C. INCORRECT: Hypovolemia is an adverse effect of mannitol, an osmotic diuretic, and should be monitored. D. INCORRECT: Polyuria is an adverse of mannitol, an osmotic diuretic, and should be monitored

56. A nurse is monitoring for postoperative complications in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client? A. Infection B. Hemorrhage C. Hematuria D. Kidney failure

B A. INCORRECT: Infection is not the most immediate risk following a kidney biopsy. However, if a hematoma develops, the kidney may become infected. B. CORRECT: Hemorrhage is the most immediate client risk following a kidney biopsy if clotting does not occur at the puncture site. C. INCORRECT: Hematuria is not the most immediate risk following a kidney biopsy, but it is a common complication the first 48 to 72 hr after the biopsy. D. INCORRECT: Kidney failure is not the most immediate risk following a kidney biopsy. However, the client should be monitored for hemorrhage, which can lead to kidney failure

33. A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C. "I will talk to my dentist about no longer needing antibiotics before dental exams." D. "I will continue to limit my intake of foods containing potassium."

B A. INCORRECT: The client will be on activity limitation for 6 weeks following surgery for a heart valve replacement. B. CORRECT: Anticoagulant therapy with warfarin (Coumadin) is necessary for the client following placement of a mechanical heart valve; the client's prothrombin time will be checked on a regular basis. C. INCORRECT: Antibiotic therapy is recommended prior to dental work following placement of a heart valve. D. INCORRECT: Dietary recommendations include limiting foods containing sodium.

2. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal puls

B A. INCORRECT: The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition. B. CORRECT: Using the priority-setting framework of urgent vs. nonurgent, the nurse should call the rapid response team because the signs indicate the beginning of a rapid decline in the client's condition. C. INCORRECT: This assessment does not indicate the beginning of a rapid decline in the client's condition at this time. The nurse should reassess the client and notify the provider if the bleeding increases. D. INCORRECT: The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition.

32. A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? A. "I will consume more white rice." B. "I will eat more baked potatoes." C. "I will drink more grape juice." D. " I will use more powdered cocoa mixes."

B A. INCORRECT: White rice is low in potassium. B. CORRECT: Baked potatoes are a good source of potassium, containing 854 mg. C. INCORRECT: Tomato and orange juices are good sources of potassium. D. INCORRECT: Powdered cocoa mixes contain high levels of sodium and minimal potassium.

28. A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

B A. incorrEcT: Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia. B. CoRRECT: A client who has bradycardia is a candidate for a pacemaker to increase his heart rate. C. incorrEcT: Synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with pulse. D. incorrEcT: The administration of IV lidocaine is used in clients with a pulseless ventricular dysrhythmia to stimulate cardiac electrical function.

15. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the client's bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the client's wheelchair on her left side.

B A. INCORRECT: A client who has left homonymous hemianopsia has lost the left visual ﬁeld of both eyes. Scanning to the right will decrease the client's ﬁeld of vision. B. CORRECT: The client is unable to visualize to the left midline of her body. Placing the client's bedside table on the right side of her bed will permit visualization of items on the table. C. INCORRECT: Using the clock method of food placement will be ineffective because only half of the plate can be seen. D. INCORRECT: The client's wheelchair should be placed to the client's right or unaffected side.

40. A nurse is instructing a client who is postoperative about the sequential compression device the provider has prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B A. INCORRECT: A sequential pressure device is a temporary intervention that remains in use only until the client is ambulatory. The device is not in place long enough to cause pressure ulcers. B. CoRRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation. C. INCORRECT: Continuous passive motion machines, not sequential pressure devices, provide some muscle movement that may assist in preserving some muscle strength. D. INCORRECT: Continuous passive motion machines, not sequential pressure devices, exercise the knee joint after arthroplasty.

33. A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area."

B A. INCORRECT: A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not improve blood flow in the coronary arteries. B. CORRECT: Surgery is indicated for older adult clients when clinical manifestations interfere with activities of daily living. C. INCORRECT: Surgical interventions can improve the client's quality of life, but they will not necessarily prolong life. D. INCORRECT: A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not reverse the damage that has already occurred to the valve.

79. A nurse in a provider's ofﬁce is reviewing the health record of a client who is being evaluated for Graves' disease. Which of the following is an expected laboratory ﬁnding for this client? A. Decreased thyrotropin receptor antibodies B. Decreased thyroid stimulating hormone C. Decreased free thyroxine index D. Decreased triiodothyronine

B A. INCORRECT: In the presence of Graves' disease, elevated thyrotropin receptor antibodies is an expected ﬁnding. B. CORRECT: In the presence of Graves' disease, low thyroid stimulating hormone (TSH) is an expected ﬁnding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. C. INCORRECT: In the presence of Graves' disease, elevated free thyroxine index is an expected ﬁnding. D. INCORRECT: In the presence of Graves' disease, elevated triiodothyronine is an expected ﬁnding.

16. A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/min. Which of the following actions should the nurse take ﬁrst? A. Notify the provider. B. Sit the client upright in bed. C. Check the client's urinary catheter for blockage. D. Administer antihypertensive medication.

B A. INCORRECT: Notifying the provider is important, but it is not the priority action for the nurse to take. B. CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure. The ﬁrst action by the nurse is to elevate the head of the bed until the client is in an upright position. This will lower the blood pressure secondary to postural hypotension. C. INCORRECT: Checking the client's catheter for blockage is important, but it is not the priority action the nurse should take. D. INCORRECT: Administering an antihypertensive medication may be indicated, but it is not the priority action the nurse should take.

32. A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take ﬁrst? A. Obtain the client's weight. B. Assist the client into high-Fowler's position. C. Auscultate lungs sounds. D. Check oxygen saturation with pulse oximeter.

B A. INCORRECT: Obtaining the client's weight is an appropriate action, but it does not improve the client's oxygenation. B. CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, the ﬁrst action is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion. C. INCORRECT: Auscultating lung sounds is an appropriate action, but it does not improve the client's oxygenation. D. INCORRECT: Checking oxygen saturation is an appropriate action, but it does not improve the client's oxygenation.

47. A nurse is providing care to a client who is 1 day postoperative paracentesis. The nurse observes clear, pale-yellow ﬂuid leaking from the operative site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site. B. Apply a dry, sterile dressing. C. Attach an ostomy bag. D. Place the client in a supine position.

B A. INCORRECT: Sterile dressings should be applied to the operative site to prevent infection and allow for assessment of drainage. B. CORRECT: Application of a sterile dressing will contain the drainage and allow continuous assessment of color and quantity. C. INCORRECT: Application of an ostomy bag is not appropriate and does not allow for assessment of ongoing drainage. D. INCORRECT: The client should be placed with the head of the bed elevated to promote lung expansion.

1. A nurse is caring for a client who was just told she has breast cancer and the nurse evaluates the client's response. Which of the following statements by the client reflects a lack of understanding of an illness perspective? A. "I have no family history of breast cancer." B. "I need a second opinion; there is no lump." C. "I am glad we live in the city near several large hospitals." D. "I will schedule surgery next week, over the holidays."

B A. INCORRECT: The client's lack of a family history of cancer may influence the client's response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective. B. CORRECT: The client's statement of denial reflects a lack of understanding of the illness perspective and may influence the client's acceptance of the diagnosis. C. INCORRECT: Access to health care resources may influence the client's response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective. D. INCORRECT: Time constraints may influence a client's response to the diagnosis, but it does not reflect a lack of understanding of an illness perspective.

30.A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia

B A. INCORRECT: Turning, coughing, and deep breathing should be performed every 2 hr to promote oxygenation and circulation. B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness. C. INCORRECT: This is not an adequate inspired air volume to promote effective oxygenation. D. INCORRECT: This intervention is non-therapeutic communication.

79. A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol (Inderal). Which of the following information should the nurse include? A. An adverse effect of this medication is jaundice. B. Take your pulse before each dose. C. The purpose of this medication is to decrease production of thyroid hormone. D. You should stop taking this medication if you have a sore throat.

B A. INCORRECT: Yellowing of the skin is an adverse effect of methimazole. B. CORRECT: Propranolol can cause bradycardia. The client should take his pulse before each dose. If there is a signiﬁcant change, he should withhold the dose and consult his provider. C. INCORRECT: The purpose of this medication is to suppress tachycardia, diaphoresis, and other effects of Graves' disease. D. INCORRECT: Sore throat is not an adverse effect of this medication. The client should not discontinue taking this medication because this action can result in tachycardia and dysrhythmias.

72. A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Gardner-Wells traction

B A. INCORRECT: Skeletal traction is an immobilization device applied surgically to a long bone fracture. B. CORRECT: Buck's traction is a temporary immobilization device applied to diminish muscle spasms and immobilize the affected extremity until surgery is performed. C. INCORRECT: Halo traction immobilizes the cervical spine when a cervical fracture occurs. D. INCORRECT: Gardner-Wells traction uses tongs to immobilize and realign the cervical spine when a cervical fracture occurs.

30. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client ﬁndings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary reﬁll of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb

B, C A. INCORRECT: A trace of bloody drainage on the dressing is an expected ﬁnding and does not require immediate concern. B. CORRECT: Capillary reﬁll greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider. C. CORRECT: Mottled appearance of the affected extremity is an unexpected ﬁnding and should be reported to the provider. D. INCORRECT: Pain that is decreased following IV bolus analgesia is an expected ﬁnding and does not require immediate concern. E. INCORRECT: Pulse of 2+ in the affected extremity is an expected ﬁnding and does not require immediate concern.

55. An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.) A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care

B, C A. INCORRECT: The client is not at either extreme of the age spectrum. B. CORRECT: Diabetes mellitus places this client at risk for impaired circulation. C. CORRECT: Diabetes mellitus places this client at risk for impaired immune system function. D. INCORRECT: There is no indication that the client is malnourished. E. INCORRECT: There is no indication that there have been any breaches in aseptic technique during wound care.

69. A nurse is assessing a client who is to undergo a right knee arthroplasty. Which of the following are expected findings? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

B, C, D, E A. INCORRECT: Skin over the knee that's red may indicate infection and is not an expected finding. B. CORRECT: Pain when bearing weight due to degeneration of the joint tissue is an expected finding. C. CORRECT: Joint crepitus due to degeneration of the joint tissue is an expected finding. D. CORRECT: Swelling of the affected joint due to degeneration of the joint tissue is an expected finding. E. CORRECT: Limited joint motion is due to degeneration of the joint tissue and is an expected finding

2. A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomiting. B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Complete a whole-bowel irrigation.

B, C, E A. INCORRECT: Vomiting places the client at risk for aspiration. B. CORRECT: This is an appropriate action by the nurse because activated charcoal adsorbs drugs and other chemicals, and the charcoal does not pass into the bloodstream. C. CORRECT: This is an appropriate action by the nurse because gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract. D. INCORRECT: Administering syrup of ipecac induces vomiting, which increases the client's risk for aspiration. E. CORRECT: This is an appropriate action by the nurse because a solution of polyethylene glycol with electrolytes is ingested or administered through an nasogastric tube, and the toxic agent and solution are eliminated from the bowels.

B, C, E A. INCORRECT: The client is not at either extreme of the age spectrum. B. CORRECT: Diabetes mellitus places this client at risk for impaired circulation. C. CORRECT: Diabetes mellitus places this client at risk for impaired immune system function. D. INCORRECT: There is no indication that the client is malnourished. E. INCORRECT: There is no indication that there have been any breaches in aseptic technique during

14. A nursing is caring for a client who has a closed-head injury with ICP readings range from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube. B. Hyperventilate the client. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

B, D A. INCORRECT: Suctioning increases ICP and should be done only when indicated. B. CORRECT: Hyperventilation of the client will prevent hypercarbia, which can cause vasodilation with a secondary increase in ICP. C. INCORRECT: Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. INCORRECT: Overhydration carries the risk of increasing ICP and should be avoided.

79. A nurse is reviewing the clinical manifestations of hyperthyroidism with a client. Which of the following ﬁndings should the nurse include? (Select all that apply.) A. Dry skin B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

B, D, E A. INCORRECT: Moist skin is an expected ﬁnding for the client who has hyperthyroidism. B. CORRECT: Hyperthyroidism increases the client's metabolism. Therefore, heat intolerance is an expected ﬁnding. C. INCORRECT: Diarrhea is an expected ﬁnding for the client who has hyperthyroidism. D. CORRECT: Hyperthyroidism increases the client's metabolism. Therefore, palpitations are an expected ﬁnding for the client who has hyperthyroidism. E. CORRECT: Hyperthyroidism increases the client's metabolism. Therefore, weight loss is an expected ﬁnding for the client who has hyperthyroidism. F. INCORRECT: Hyperthyroidism increases the client's metabolism. Therefore, tachycardia is an expected ﬁnding for the client who has hyperthyroidism.

40. A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to use the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change position often.

B, E A. INCORRECT: The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation. B. CoRRECT: Elastic stockings promote venous return and prevent thrombus formation. C. INCORRECT: A review of the client's total protein level is important for evaluating his ability to heal and prevent skin breakdown. D. INCORRECT: Placing pillows under the knees and lower extremities further impairs circulation of the lower extremities. E. CoRRECT: Frequent position changes prevent venous stasis.

2. A nurse is reviewing the common emergency management protocol for clients during a cardiac emergency. Which of the following is an appropriate action by the nurse? A. Administer IV dobutamine (Dobutrex). B. Administer IV dopamine (Intropin). C. Administer IV epinephrine (Adrenaline). D. Administer IV atropine (Atropair

C A. INCORRECT: Administering dobutamine during a cardiac emergency is not an appropriate action by the nurse because this medication is administered during the postresuscitation phase. B. INCORRECT: Administering dopamine during a cardiac emergency is not an appropriate action by the nurse because this medication is administered during the postresuscitation phase. C. CORRECT: Administering epinephrine during a cardiac emergency is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation. D. INCORRECT: Administering atropine during a cardiac emergency is not appropriate action by the nurse because the medication is no longer used during the crisis period

83. A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 4 oz grape juice. D. Report findings to the provider

C A. INCORRECT: Blood glucose is rechecked in 15 min after a rapidly absorbed carbohydrate is ingested, but is not the priority nursing action. B. INCORRECT: A carbohydrate and protein food is given to the client if the next meal is more than 1 hr away after the blood glucose returns to a normal range. This is not the priority nursing action. C. CORRECT: The client's acute need for a rapidly absorbed carbohydrate, such as grape juice, takes priority when treating the blood glucose of 52 mg/dL. D. INCORRECT: Reporting the findings to the provider is not the priority action.

33. A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following is an expected finding? A. Hoarseness B. Petechiae C. Crackles in lung bases D. Splenomegaly

C A. INCORRECT: Hoarseness is an expected finding in a client who has mitral valve stenosis. B. INCORRECT: Petechiae is an expected finding in a client who has infective endocarditis. C. CORRECT: Crackles in the lung bases is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency. D. INCORRECT: Hepatomegaly, not splenomegaly, is an expected finding in a client who has left-sided heart valve damage.

56. A nurse is reviewing a client's laboratory findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrites. Which of the following is an appropriate nursing action? A. Repeat the test early the next morning. B. Start a 24-hr urine collection for creatinine clearance. C. Obtain a clean-catch urine specimen for culture and sensitivity. D. Insert a urinary catheter to collect a urine specimen.

C A. INCORRECT: Repeating the test early the next morning is not an appropriate nursing action because leukoesterase and nitrites in the urine indicate the client has a urinary tract infection. B. INCORRECT: Starting a 24-hr urine collection for creatinine clearance is not an appropriate nursing action because leukoesterase and nitrites in the urine indicate the client has a urinary tract infection. C. CORRECT: Obtaining a clean-catch urine specimen for culture and sensitivity is an appropriate nursing action because this determines the antibiotic that will be most effective for treatment of the urinary tract infection. D. INCORRECT: Inserting a urinary catheter to collect a urine specimen is not an appropriate nursing action because leukoesterase and nitrites in the urine indicate the client has a urinary tract infection.

14. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

C A. INCORRECT: The Glasgow Coma Scale is important but not the priority assessment at this time. B. INCORRECT: Assessment of cranial nerve function is important but not the priority assessment at this time. C. CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. INCORRECT: Assessment of pupillary response is important but not the priority assessment at this time. NCLEX® Connection: Physiological Adaptations, Unexpected Response to Therapies

83. A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C A. INCORRECT: These insulins are not compatible. They should not be drawn up in the same syringe. B. INCORRECT: These insulins are not compatible. They should not be drawn up in the same syringe. C. CORRECT: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe. D. INCORRECT: These insulins should be administered at the same time. Regular insulin is short-acting and should lower the blood glucose level in a short period of time. Glargine insulin is long-acting and administered once a day.

56. A nurse administered captopril (Capoten) to a client during renography (kidney scan). Which of the following is an appropriate action by the nurse? A. Assess the client for hypertension. B. Limit the client's fluid intake. C. Monitor for orthostatic hypotension. D. Encourage early ambulation.

C A. INCORRECT: This is not an appropriate action by the nurse because captopril is an antihypertensive medication, and the client should be assessed for hypotensive effects. B. INCORRECT: This is not an appropriate action by the nurse. Increasing the client's fluids can help to resolve any hypotensive effects following the administration of captopril, an antihypertensive medication. C. CORRECT: The appropriate action by the nurse is to monitor for orthostatic hypotension because the antihypertensive effect of captopril results in a change in blood flow to the kidneys when an initial dose is administered. D. INCORRECT: This is not an appropriate action by the nurse because the client may be at risk for a fall when ambulating due to the hypotensive effects of captopril, an antihypertensive medication.

44. A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower his chin to his chest.

C A. INCORRECT: This is performed to assess for Trousseau's sign. B. INCORRECT: This is performed to auscultate a carotid bruit. C. CORRECT: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of his face. D. INCORRECT: This is performed to assess for range of motion of the neck.

49. A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori (H. pylori). Which of the following statements by the client indicates understanding of the teaching? A. "I will continue my prescription for corticosteroids." B. "I will schedule a CT scan to monitor improvement." C. "I will take a combination of medications for treatment." D. "I will have my throat swabbed to recheck for this bacteria."

C A. iNCORRECT: Corticosteroid use is a contributing factor to an infection caused by H. pylori. B. iNCORRECT: An esophagogastroduodenoscopy (EGD) is done to evaluate for the presence of H. pylori and to evaluate effectiveness of treatment. C. CORRECT: A combination of antibiotics and a histamine2 receptor antagonist is used to treat an infection caused by H. pylori. D. iNCORRECT: H. pylori is evaluated by obtaining gastric samples, not a throat swab.

28. A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? (Review the data below for additional client information.) MAR ViTAl SignS HiSToRy And PHySiCAl › Ferrous Sulfate (Feosol) 200 mg Po 0800 and 2000 › Diazepam (Valium) 2 mg Po 0800 and 2000 › isosorbide (isordil) 2.5 mg Po 4 times a day Ac and HS 0800 › T 99° F (37.2° c) › Blood pressure 142/86 mm Hg › Heart rate 88/min and irregular › respirations 20/min › Bariatric surgery 10 years ago › Dyspnea with exertion for 3 years › Atrial fibrillation began 3 years ago › client reports taking the following medications for the past 6 weeks: iron supplement, multivitamin, antilipemic, and nitroglycerin A. Respiratory history B. Vital signs C. Medication history D. Medications to be administered

C A. incorrEcT: A client who has a dysrhythmia often has a history of lung disease, which can make him a candidate for cardioversion. B. incorrEcT: A client who has a dysrhythmia may have an irregular pulse, which can make him a candidate for cardioversion. C. CoRRECT: A client who is to undergo cardioversion needs to be on anticoagulant therapy for 4 to 6 weeks prior to the procedure. D. incorrEcT: A client who has a dysthymia often has a history of cardiac disease and angina, which can make him a candidate for cardioversion.

15. A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected ﬁnding? A. Impulse control difﬁculty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

C A. INCORRECT: A client who has experienced a right-hemispheric stroke will experience difﬁculty with impulse control. B. INCORRECT: A client who has experienced a right-hemispheric stroke will experience poor judgment. C. CORRECT: A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects. This is also known as agnosia. D. INCORRECT: A client who experienced a right-hemispheric stroke will experience a loss of depth perception.

47. A nurse is completing discharge teaching with a client who is 3 days postoperative for a transverse colostomy. Which of the following should be included in the teaching? A. Mucus will be present in stool for 5 to 7 days after surgery. B. Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks. C. Stoma should be moist and pink. D. Change the ostomy bag when it is ¾ full.

C A. INCORRECT: Mucus and blood may be present for 2 to 3 days after surgery. B. INCORRECT: Output should become stool-like, semi-formed, or formed within days to weeks. C. CORRECT: A pink, moist stoma is an expected ﬁnding with a transverse colostomy. D. INCORRECT: The ostomy bag should be changed when it is ¼ to ½ full.

30. A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure.

C A. INCORRECT: Retroperitoneal bleeding is internal bleeding. B. INCORRECT: Cardiac tamponade includes manifestations of bleeding in the pericardial sac, which is internal. C. CORRECT: Bleeding is occurring from the incision site and then draining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider. D. INCORRECT: Heart failure does not including ﬁndings of blood underneath the client's lower back.

40. A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction

C A. INCORRECT: Sitting up in a chair will help prevent stasis of secretions. B. INCORRECT: Muscle atrophy is a complication for a client on prolonged bed rest, not for one who is sitting in a chair. C. CoRRECT: Unrelieved pressure over a bony prominence for too long increases the risk for skin breakdown. D. INCORRECT: Fecal impaction is a complication for a client on prolonged bed rest, not for one who is sitting in a chair.

6. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should the nurse include in the teaching? A. The use of a microwave to heat food is permitted. B. Inform a provider to order only a MRI when a scan is needed. C. Place a magnet over the implantable device when an aura occurs. D. The use of ultrasound diathermy for pain management is recommended

C A. INCORRECT: The client should be instructed to avoid using a microwave, which may affect the stimulator. B. INCORRECT: The client should be instructed to inform his providers about the stimulator, which would be affected if an MRI were performed. C. CORRECT: The client should be instructed to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. INCORRECT: The client should be instructed to avoid the use of ultrasound diathermy for pain management because of its effect on the stimulator.

6. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication

C A. INCORRECT: The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. INCORRECT: The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. INCORRECT: The nurse should instruct the client to have period blood tests to determine the therapeutic level of phenytoin.

60. A nurse is planning care for a client who has prerenal acute kidney injury following abdominal aortic aneurysm repair. The client's urinary output is 80 mL in the past 4 hr, and blood pressure is 92/58 mm Hg. Which of the following should be included in the plan of care? A. Prepare the client for a CAT scan with contrast dye. B. Anticipate urine specific gravity to be 1.010. C. Plan to administer a fluid challenge. D. Place client in Trendelenburg position

C A. INCORRECT: The nurse should not plan for a CAT scan as an intervention in the care of the client. Contrast dye is also contraindicated in a client who has possible acute kidney injury. B. INCORRECT: The nurse should expect a specific gravity of 1.030 for a client who has prerenal acute kidney injury. C. CORRECT: The nurse should plan to administer a fluid challenge for hypovolemia, which is indicated by the client's low urinary output and blood pressure. D. INCORRECT: The nurse should position the client in reverse Trendelenburg, with the head down and feet up to treat hypotension.

56. A charge nurse is discussing the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should obtain a specimen for culture and sensitivity after the ﬁrst dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."

C A. INCORRECT: The nurse should obtain a specimen for culture and sensitivity prior to the initiation of antimicrobial therapy. B. INCORRECT: MRSA is resistant to all antibiotics, except vancomycin. C. CORRECT: Monitoring antimicrobial levels ensures that therapeutic levels are maintained. D. INCORRECT: Discontinuing antimicrobial therapy prior to completing a full course of treatment increases the risk of producing resistant pathogens

65. A nurse is preparing to discharge a client who has had an anterior and posterior colporrhaphy. Which of the following instructions should the nurse provide? A. "Do not bend over for at least 6 weeks." B. "You can lift objects as heavy as 10 pounds." C. "Do not engage in intercourse for at least 6 weeks." D. "You may have foul-smelling draining within the first week after surgery."

C A. incorrEct: The client does not have a restriction regarding bending over. B. incorrEct: The client should not lift an object that weighs more than 5 lb. C. CORRECT: The client should refrain from intercourse to allow time for the surgical site to heal, which is typically about 6 weeks. D. incorrEct: Foul-smelling draining is a sign of infection, which should be reported to the provider.

65. A client is admitted to the gynecology unit for an anterior colporrhaphy. Which of the following client statements is consistent with the physiological alteration that necessitates this type of surgery? A. "I have to push the feces out of a pouch in my vagina with my fingers." B. "I have pain and bleeding when I have a bowel movement." C. "I have had frequent urinary tract infections." D. "I am embarrassed by uncontrollable flatus.

C REMEMBER Cyst=ANERIOR Recta=POSTERIOR (Backside) A. incorrEct: Pouching of feces is a physiological alteration associated with a rectocele. The surgical procedure for a rectocele is posterior colporrhaphy. B. incorrEct: Pain and bleeding with a bowel movement is a physiological alteration associated with a rectocele. The surgery for a rectocele is a posterior colporrhaphy. C. CORRECT: Due to urinary stasis associated with a cystocele, this finding is consistent with a cystocele. The surgery for a cystocele is an anterior colporrhaphy. D. incorrEct: Uncontrollable flatus is a physiological alteration associated with a rectocele. The surgery for a rectocele is a posterior colporrhaphy.

28. A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting. B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time-out is being called to verify correct protocols

C A. incorrEcT: The cardioverter is charged prior to the delivery of the shock during cardioversion. B. incorrEcT: The team leader calls out "Initiate CPR" when members of the team are to begin CPR. C. CoRRECT: A safety concern for personnel performing cardioversion is to "stand clear" of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock. D. incorrEcT: A "time-out" is called by personnel during a procedure to verify that proper protocols are being followed.

C, D A. CORRECT: Slight elevation reduces shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. INCORRECT: Massaging the skin over bony prominences can traumatize deep tissues. C. INCORRECT: Cornstarch can create gritty particles that can abrade sensitive skin. D. CORRECT: The client should sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. INCORRECT: Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr.

83. A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

C, D, E A. INCORRECT: A podiatrist should remove calluses or corns. Commercial over-the-counter remedies may increase the risk for tissue injury and an infection. B. INCORRECT: Applying lotion between the toes increases moisture for growth of micro-organisms, which can lead to infection. C. CORRECT: Perform nail care after bathing, when toenails are soft and easier to trim. D. CORRECT: Trim toenails straight across to prevent injury to soft tissue of the toes. E. CORRECT: Wear closed-toe shoes to prevent injury to soft tissue of the toes and feet.

79. A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following ﬁndings are indicative of thyroid crisis? (Select all that apply.) A. Bradycardia B. Hypothermia C. Tremors D. Abdominal pain E. Mental confusion

C, D, E A. INCORRECT: When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in tachycardia. B. INCORRECT: When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in a high fever. C. CORRECT: Excessive levels of thyroid hormone can cause the client to experience tremors. D. CORRECT: When thyroid crisis occurs, the client can experience gastrointestinal conditions, such as vomiting, diarrhea, and abdominal pain. E. CORRECT: Excessive thyroid hormone levels can cause the client to experience mental confusion.

49. A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following are expected findings? (Select all that apply.) A. Client reports pain relieved by eating. B. Client states that pain often occurs at night. C. Client reports a sensation of bloating. D. Client states that pain occurs ½ to 1 hr after a meal. E. Client experiences pain upon palpation of the epigastric region.

C, D, E A. iNCORRECT: A client who has a duodenal ulcer will report that pain is relieved by eating. B. iNCORRECT: Pain that rarely occurs at night is an expected finding. C. CORRECT: A client report of a bloating sensation is an expected finding. D. CORRECT: A client who has a gastric ulcer will often report pain 30 to 60 min after a meal. E. CORRECT: Pain in the epigastric region upon palpation is an expected finding.

69. A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age of 78 B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago

D A. INCORRECT: Age greater than 70 is not a contraindication for a total joint arthroplasty unless there are comorbidity factors. B. INCORRECT: History of cancer is not a contraindication for a total joint arthroplasty unless there are comorbidity factors. C. INCORRECT: Previous joint arthroplasty surgery is not contraindicated for total joint arthroplasty unless there are comorbidity factors. D. CORRECT: A recent infection can cause micro-organisms to migrate to the surgical area and cause the prosthesis to fail.

30. A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected ﬁnding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg

D A. INCORRECT: Reddening (rubor) of a leg affected by peripheral artery disease occurs when it is placed in a dependent position. B. INCORRECT: Pulses are decreased or absent in the feet in cases of peripheral artery disease. C. INCORRECT: Toenails are thickened in cases of peripheral artery disease. D. CORRECT: A client who has peripheral artery disease may report that numbness or burning pain in the extremity ceases with rest (intermittent claudication).

43. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake. B. Observe for signs of hypertension. C. Encourage the client to ambulate to promote oxygenation. D. Monitor respirations for shortness of breath.

D A. INCORRECT: The nurse should not initiate fluid restrictions to limit intake. This would be an appropriate action for a client who has fluid volume excess. The client is dehydrated, and fluids should be encouraged. B. INCORRECT: The nurse should not be monitoring for signs of hypertension. This would be an appropriate action for a client who has fluid volume excess. The client is hypotensive due to fluid volume depletion. The nurse should monitor the client for hypotension. C. INCORRECT: The nurse should not encourage the client to ambulate to promote oxygenation. This would be an appropriate action for a client who has fluid volume excess. The client is experiencing dizziness due to dehydration and is at risk for falling. The nurse should keep the client in bed and assist him to the bathroom as needed. D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right lower lobe. This client is dehydrated and has fluid volume deficit.

97. A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses. B. Apply a warm blanket. C. Assess the client's dressings. D. Place the client in a lateral position

D A. IncOrrEct: Comparing and contrasting the client's peripheral pulses is important but is not the first nursing action. B. IncOrrEct: Applying warm blankets to prevent hypothermia is important but is not the first nursing action. C. IncOrrEct: Assessing the client's dressings for drainage is important but is not the first nursing action. D. CORRECT: The greatest risk to the client is injury from aspiration. The first action is to position the client laterally.

49. A nurse is providing teaching for a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following should be included in the teaching? A. Eat three moderate-sized meals a day. B. Drink at least one glass of water with each meal. C. Eat a bedtime snack that contains a milk product. D. Increase protein in the diet.

D A. iNCORRECT: The client should consume small, frequent meals rather than moderate-sized meals. B. iNCORRECT: The client should eliminate liquids with meals and for 1 hr prior to and following meals. C. iNCORRECT: The client should avoid milk products. D. CORRECT: The client should eat a high-protein, high-fat, low-fiber, and moderate- to low-carbohydrate diet.

56. A nurse is providing teaching to a client who is to have an x-ray of the kidneys, ureters, and bladder (KUB). Which of the following statements should the nurse include in the teaching? A. "Contrast dye is given during the procedure." B. "An enema is necessary before the procedure." C. "You will need to lie in a prone position during the procedure." D. "The procedure determines whether a kidney stone is present."

D 1. A. INCORRECT: No contrast dye is injected for this procedure. B. INCORRECT: An enema is not administered before this procedure. C. INCORRECT: The client will be asked to lie supine, not prone. D. CORRECT: A KUB can identify renal calculi, strictures, calcium deposits, or obstructions

16. A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

D A. CORRECT: A client who has a cervical spinal cord injury will also have an upper motor neuron injury, which is manifested by a spastic bladder. Because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive. B. INCORRECT: Intermittent urinary catheterization is an appropriate method for a client who has a ﬂaccid bladder. C. INCORRECT: Credé's method is appropriate for a client who has a ﬂaccid bladder. D. INCORRECT: An indwelling urinary catheter is invasive and another bladder management method should be used

47. A nurse is caring for a client who had a paracentesis. Which of the following ﬁndings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation

D A. INCORRECT: A report of sharp, constant abdominal pain is associated with bowel perforation. B. INCORRECT: Decreased urine output is associated with bladder perforation during a paracentesis. C. INCORRECT: Pallor is not a ﬁnding indicating bowel perforation. D. CORRECT: Fever is an indication of bowel perforation during a paracentesis.

16. A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D A. INCORRECT: Glucocorticoids are appropriate medications to administer at this time. B. INCORRECT: Plasma expanders are appropriate medications to administer at this time. C. INCORRECT: H2 antagonists are appropriate medications to administer at this time. D. CORRECT: The client will still be in spinal shock 24 hr following the injury. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

56. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following ﬁndings suggests the client is experiencing postherpetic neuralgia? A. Linear clusters of vesicles present on the client's right shoulder B. Purulent drainage from both of the client's eyes C. Decreased white blood cell count D. Report of continued pain following resolution of rash

D A. INCORRECT: Localized linear clusters of vesicles are an expected ﬁnding of herpes zoster rather than postherpetic neuralgia. B. INCORRECT: Eye infection is a potential complication of herpes zoster but does not suggest postherpetic neuralgia. C. INCORRECT: Immunosuppression increases the client's risk for herpes zoster but does not suggest postherpetic neuralgia. D. CORRECT: Pain that persists following resolution of the vesicular rash is an indication of postherpetic neuralgia.

43. A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D A. INCORRECT: Moist skin is a clinical manifestation indicative of fluid volume excess. B. INCORRECT: Distended neck veins is a clinical manifestation indicative of fluid volume excess. C. INCORRECT: Increased urinary output is a clinical manifestation indicative of fluid volume excess. D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of fluid volume deficit.

16. A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D A. INCORRECT: Neurogenic shock is a complication, but it is not the greatest risk to the client at this time. B. INCORRECT: A paralytic ileus is a complication, but it is not the greatest risk to the client at this time. C. INCORRECT: A stress ulcer is a complication, but it is not the greatest risk to the client at this time. D. CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, the greatest risk to the client with an SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

40. A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A. Encourage isometric exercises. B. Suction every 8 hr. C. Give low-dose heparin. D. Promote incentive spirometer use.

D A. INCORRECT: Performing isometric exercises strengthens skeletal muscles. B. INCORRECT: The nurse should not suction the client's airway routinely. C. INCORRECT: Low-dose heparin helps prevent thrombus formation. D. CoRRECT: Using an incentive spirometer helps keep the airways open and prevents atelectasis.

1. A nurse in a health care clinic is evaluating the level of wellness for clients using the health/wellness/ illness continuum tool. Which of the following clients is measured at the center of the continuum? A. A college student who has influenza B. An older adult who is newly diagnosed with type 2 diabetes mellitus C. A new mother who has a urinary tract infection D. A young male who has a long history of well-controlled rheumatoid arthritis

D A. INCORRECT: The client who has influenza is measured on the continuum by the level of health to illness in comparison to the norm for the client. B. INCORRECT: The client who is newly diagnosed with type 2 diabetes mellitus is measured by the level of health to illness in comparison to the norm for the client. C. INCORRECT: The client who has a urinary tract infection is measured on the continuum by the level of health to illness in comparison to the norm for the client. D. CORRECT: The client with well-controlled rheumatoid arthritis is measured at the center of the continuum, which is the client's normal state of health.

Staging Pressure Ulcers

Suspected deep tissue injury - Discolored but intact skin from damage to underlying tissue. ◯ Stage I - Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. ◯ Stage II - Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superﬁcial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. ◯ Stage III - Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. ◯ Stage IV - Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). ◯ Unstageable - No determination of stage because eschar or slough obscures the wound.

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