COMPREHENSIVE - MED SURG SUCCESS

101. According to the nursing process, which interventions should the nurse implement when caring for a client diagnosed with a right-sided cerebrovascular accident (stroke) and who has difficulty swallowing? List the interventions in order of the nursing process. 1. Write the client problem of "altered tissue perfusion." 2. Assess the client's level of consciousness and speech. 3. Request dietary to send a full liquid tray with Thick-It. 4. Instruct the UAP to elevate the head of the bed 30 degrees. 5. Note the amount of food consumed on the dinner tray.

In order of the nursing process: 2, 1, 3, 4, 5. 2. This is the assessment step, the first step of the nursing process. 1. Diagnosis is the second step in the nursing process. In this case, it is "altered tissue perfusion." 3. Planning is the third step of the nursing process. 4. Implementation is the fourth step in the nursing process. 5. Evaluation is the last step of the nursing process.

51. The nurse is initiating a blood transfusion. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250 mL of D5W at a keep-open rate. 5. Check the chart for the HCP's order.

1,2,5 rationales: 1. The nurse must make a decision on the amount of blood to infuse per hour. If the client is showing any sign of heart or lung compromise, the nurse would infuse the blood at the slowest possible rate. 2. Blood products require the client to give specific consent to receive blood. 3. The IV should be started with an 18-gauge catheter if possible; the smallest possible catheter is a 20-gauge. Smaller gauge catheters break down the blood cells. 4. Blood is not compatible with D5W; the nurse should hang 0.9% normal saline (NS) to keep open. 5. The nurse should verify the HCP's order before having the client sign the consent form.

87. The client diagnosed with chronic renal failure is receiving peritoneal dialysis. Which assessment by the nurse warrants immediate intervention? 1. The dialysate return is cloudy. 2. There is a greater dialysate return than input. 3. The client complains of abdominal fullness. 4. The client voided 50 mL during the day.

1. A cloudy dialysate indicates an infection and must be reported immediately to prevent peritonitis.

99. The client is eight (8) hours postoperative small bowel resection. Which data indicate the client has had a complication from the surgery? 1. A hard, rigid, boardlike abdomen. 2. High-pitched tinkling bowel sounds. 3. Absent bowel sounds. 4. Complaints of pain at "6" on the pain scale.

1. A hard, rigid, boardlike abdomen is the hallmark sign of peritonitis, which is a life-threatening complication of abdominal surgery.

48. The client comes to the emergency department complaining of pain in the right forearm. The nurse notes a large area of redness and edema over the forearm, and the client has an elevated temperature. Which condition should the nurse suspect? 1. Cellulitis. 2. Intravenous drug abuse. 3. Raynaud's phenomenon. 4. Thromboangiitis obliterans.

1. Cellulitis is the most common infectious cause of limb edema as a result of bacterial invasion of the subcutaneous tissue. This assessment would make the nurse suspect this condition.

17. The client comes to the clinic complaining of itching on the left wrist near a wristwatch. The nurse notes an erythematous area along with pruritic vesicles around the left wrist. Which condition should the nurse suspect? 1. Contact dermatitis. 2. Herpes simplex 1. 3. Impetigo. 4. Seborrheic dermatitis.

1. Contact dermatitis is a type of dermatitis caused by a hypersensitivity response. In this case, it is a hypersensitivity reaction to metal salts in the watch the client is wearing. Anytime the nurse assesses redness or irritation in areas where jewelry (such as rings, watches, necklaces) or clothing (such as socks, shoes, or gloves) are worn, the nurse should suspect contact dermatitis.

65. The nurse is assessing the client with a pneumothorax who has a closed-chest drainage system. Which data indicate the client's condition is stable? 1. There is fluctuation in the water-seal compartment. 2. There is blood in the drainage compartment. 3. The trachea deviates slightly to the left. 4. There is bubbling in the suction compartment.

1. Fluctuation in the water-seal compartment with respirations indicates the system is working properly and the client is stable.

42. The client diagnosed with stomach cancer has developed disseminated intravascular coagulopathy (DIC). Which collaborative intervention should the nurse expect to implement? 1. Prepare to administer intravenous heparin. 2. Assess for frank hemorrhage from venipuncture sites. 3. Monitor for decreased level of consciousness. 4. Prepare to administer total parenteral nutrition.

1. Heparin interferes with the clotting cascade and may prevent further clotting factor consumption resulting from uncontrolled thromboses formation.

69. Which information should the nurse discuss with the client to prevent an acute exacerbation of diverticulosis? 1. Increase the fiber in the diet. 2. Drink at least 1,000 mL of water a day. 3. Encourage sedentary activities. 4. Take cathartic laxatives daily.

1. Increasing fiber will help prevent constipation, the number-one reason for an acute exacerbation of diverticulosis, which results in diverticulitis.

47. Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Paralytic ileus. 4. Atelectasis.

1. Medical client problems indicate the nurse and the HCP must collaborate to care for the client; the client must have medications for heart failure.

52. The nurse is assessing the client with psoriasis. Which data support this diagnosis? 1. Appearance of red, elevated plaques with silvery white scales. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen.

1. Most clients with psoriasis have red, raised plaques with silvery white scales.

53. Which comment by the client diagnosed with rule-out Guillain-Barré (GB) syndrome is most significant when completing the admission interview? 1. "I had a bad case of gastroenteritis a few weeks ago." 2. "I never use sunblock and I use a tanning bed often." 3. "I started smoking cigarettes about 20 years ago." 4. "I was out of the United States for the last 2 months."

1. The cause of GB syndrome is unknown, but a precipitating event usually occurs one (1) to three (3) weeks prior to the onset. The precipitating event may be a respiratory or gastrointestinal viral or bacterial infection.

57. The client reports a twisting motion of the knee during a basketball game. The client is scheduled for arthroscopic surgery to repair the injury. Which information should the nurse teach the client about postoperative care? 1. The client should begin strengthening the surgical leg. 2. The client should take pain medication routinely. 3. The client should remain on bedrest for two (2) weeks. 4. The client should return to the doctor in six (6) months.

1. The client should begin exercises that will strengthen the surgical leg as soon as the surgery is completed.

60. The 85-year-old client diagnosed with severe end-stage chronic obstructive pulmonary disease has a chest x-ray incidentally revealing an eight (8)-cm abdominal aortic aneurysm (AAA). Which intervention should the nurse implement? 1. Discuss possible end-of-life care issues. 2. Prepare the client for abdominal surgery. 3. Teach the client how to do pursed-lip breathing. 4. Talk with the family about the client's condition.

1. The client with end-stage COPD would not be a candidate for an AAA repair, although the size of the aneurysm places the client at risk for rupture. Although many nurses do not like to address end of life issues, this would be an important and timely intervention.

80. The client with type 2 diabetes mellitus asks the nurse, "What does it matter if my glucose level is high? I don't feel bad." Which statement by the nurse is most appropriate? 1. "The high glucose level can damage your eyes and kidneys over time." 2. "The glucose level causes microvascular and macrovascular problems." 3. "As long as you don't feel bad, everything will probably be all right." 4. "A high blood glucose level will cause you to get metabolic acidosis."

1. The long-term complications of increased blood glucose levels to organs are the primary reasons for keeping the blood glucose level controlled.

96. The client is admitted to the medical unit complaining of severe abdominal pain. Which intervention should the nurse implement first? 1. Assess for complications. 2. Medicate for pain. 3. Turn the television on. 4. Teach relaxation techniques.

1. The nurse must rule out any complication requiring immediate intervention before masking the pain with medication. Pain indicates a problem in some instances; pain is expected after surgery, but complications should always be ruled out.

45. The nurse is at home preparing for the 7 a.m. to 7 p.m. shift and has the flu with a temperature of 100.4˚F. Which action should the nurse take? 1. Notify the hospital the nurse will not be coming into work. 2. Go to work and wear an isolation mask when caring for the clients. 3. Request an alternative assignment not involving direct client care. 4. Take over-the-counter cold medication and report to work on time.

1. The nurse should stay at home because the nurse will expose all other personnel and clients to the illness. Flu, especially with a fever, places the nurse at risk for a secondary pneumonia.

6. Which diagnostic procedure does the nurse anticipate being ordered for the 27-year-old female client who is reporting irregular menses and complaining of lower left abdominal pain during menses? 1. Pelvic sonogram. 2. Complete blood count (CBC). 3. Kidney, ureter, bladder (KUB) x-ray. 4. Computed tomography (CT) of abdomen.

1. The pelvic sonogram, which visualizes the ovary using sound waves, is a diagnostic test for an ovarian cyst, which would be suspected with the client's signs/symptoms.

74. The nurse is discussing funeral arrangements with the family of a deceased client whose organs and tissues are being donated today. Which information should the nurse discuss with family? 1. The family can request an open casket funeral. 2. Your loved one must wear a long-sleeved shirt. 3. You might want to have a private viewing only. 4. This will not delay the timing of the funeral.

1. The procurement of organs/tissues from the client will not be noticeable if there is an open casket funeral

66. The client is admitted to the intensive care unit diagnosed with rule-out adult respiratory distress syndrome (ARDS). The client is receiving 10 L/min of oxygen via nasal cannula. Which arterial blood gases indicate the client does not have ARDS? 1. pH 7.38, Pao2 82, Paco2 45, HCO3 26. 2. pH 7.35, Pao2 74, Paco2 43, HCO3 24. 3. pH 7.45, Pao2 60, Paco2 45, HCO3 28. 4. pH 7.32, Pao2 50, Paco2 55, HCO3 28.

1. These are normal ABGs, which would not be expected if the client has ARDS.

83. Which signs/symptoms should the nurse expect to assess in the client diagnosed with Addison's disease? 1. Hypotension and bronze skin pigmentation. 2. Water retention and osteoporosis. 3. Hirsutism and abdominal striae. 4. Truncal obesity and thin, wasted extremities.

1. These are signs/symptoms of Addison's disease, which is adrenal cortex insufficiency.

30. The nurse is teaching the client in a cardiac rehabilitation unit. Which dietary information should the nurse discuss with the client? 1. No more than 30% of daily food intake should be fats. 2. Eighty percent of calories should come from carbohydrates. 3. Red meat should comprise at least 50% of daily intake. 4. Monounsaturated fat in the daily diet should be increased.

1. This is a correct statement. The recommended proportions of food are 50% carbohydrates, 30% or less from fat, and 20% protein.

91. Which assessment data would make the nurse suspect the client has cancer of the bladder? 1. Gross painless hematuria. 2. Burning on urination. 3. Terminal dribbling. 4. Difficulty initiating the stream.

1. This is the most common presenting symptom of bladder cancer.

21. The client is newly diagnosed with epilepsy. Which statement indicates the client needs clarification of the discharge teaching? 1. "I can drive as soon as I see my HCP for my follow-up visit." 2. "I should get at least eight (8) hours of sleep at night." 3. "I should take my medication every day even if I am sick." 4. "I will take showers instead of taking tub baths."

1. This statement indicates the client does not understand the discharge teaching. The client will not be able to drive until the client is seizure free for a certain period of time. The laws in each state differ.

3. The 28-year-old client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which intervention should have priority in the client's plan of care? 1. Encourage the client to bank his sperm. 2. Discuss completing an advance directive. 3. Explain follow-up chemotherapy and radiation. 4. Allow the client to express his feelings regarding having cancer.

1. With a remaining testicle, the client will be able to maintain sexual potency, but radiation and chemotherapy may cause the client to become sterile. Therefore, banking his sperm will allow him to father a child later in life.

43. The nurse is administering 250 mL of packed red blood cells with 50 mL of preservative. The client has no jugular vein distention and has clear breath sounds. After the first 15 minutes, at what rate should the nurse set the IV infusion pump? _______

150 mL/hr. The nurse should infuse the blood in two (2) hours because the client does not have signs/ symptoms of fluid volume overload.

98. Which interventions should the emergency department nurse implement for a client who has an AP of 122 and a BP of 80/50? Select all that apply. 1. Put the client in reverse Trendelenburg position. 2. Start an intravenous line with an 18-gauge catheter. 3. Have the client complete the admission process. 4. Cover the client with blankets and keep warm. 5. Request the laboratory draw a type and crossmatch.

2,4,5 RATIONALES: 1. The client would be placed in the Trendelenburg position, which is with the head lower than the feet. 2. The client is in shock and may need blood transfusions; therefore, a large-bore catheter should be started to infuse fluids, plasma expanders, and possible blood. 3. The admission process cannot be completed by the client because the condition is life threatening. 4. The client will be cold as a result of vasoconstriction of the periphery resulting from a low pulse and blood pressure. 5. The client will more than likely need blood transfusions that require a type and crossmatch.

78. Which priority problem should the clinic nurse identify for the client who is greater than ideal body weight and weighs 87 kg? 1. Risk for complications. 2. Altered nutrition. 3. Body image disturbance. 4. Activity intolerance.

2. "Altered nutrition: more than body requirements" is an appropriate client problem for a client who weighs 175 pounds.

50. Which assessment information is the most critical indicator of a neurological deficit? 1. Changes in pupil size. 2. Level of consciousness. 3. A decrease in motor function. 4. Numbness of the extremities.

2. A change in level of consciousness is the first and most critical indicator of any neurological deficit.

94. The student nurse accidentally punctured her finger with a contaminated needle. Which action should the student nurse take first? 1. Notify the infection control nurse. 2. Allow the puncture site to bleed. 3. Report to the emergency department. 4. Cleanse the site with Betadine.

2. Allowing the site to bleed allows any pathogen to bleed out; the student nurse should not apply pressure or attempt to stop the flow of blood.

26. The client diagnosed with a transient ischemic attack (TIA) is being discharged from the hospital. Which medication should the nurse expect the HCP to prescribe? 1. The oral anticoagulant warfarin (Coumadin). 2. The antiplatelet medication, a baby aspirin. 3. The beta blocker propranolol (Inderal). 4. The anticonvulsant valproic acid (Depakote).

2. Atherosclerosis is the most common cause of a TIA or stroke, and taking a baby aspirin every day helps prevent clot formation around plaques.

33. The client who has just received a permanent pacemaker is admitted to the telemetry floor. The nurse writes the problem "knowledge deficit." Which interventions should be included in the plan of care? Select all that apply. 1. Take tub baths instead of showers the rest of his or her life. 2. Do not hold electrical devices near the pacemaker. 3. Carry the pacemaker identification card at all times. 4. Count the radial pulse one (1) full minute every morning. 5. Notify the HCP if the pulse is 12 beats slower than the preset rate.

2. Electrical devices may interfere with the functioning of the pacemaker. 3. This alerts any HCP as to the presence of a pacemaker. 4. The client should be taught to take the radial pulse for one (1) full minute before getting out of bed. If the count is more than five (5) bpm less than the preset rate, the HCP should be notified immediately because this may indicate the pacemaker is malfunctioning.

38. The client with venous insufficiency tells the nurse, "The doctor just told me about my disease and walked out of the room. What am I supposed to do?" Which statement is the nurse's best response? 1. "I will have your HCP come back and discuss this with you." 2. "One thing you can do is elevate your legs above your heart while watching TV." 3. "You will probably need to have surgery within a few months." 4. "This will go away after you lose about 20 pounds and start walking."

2. Elevating the legs above the heart as much as possible will help decrease edema.

75. The public health nurse is discussing hepatitis with a client who is traveling to a third world country in one (1) month. Which recommendation should the nurse discuss with the client? 1. A gamma globulin injection. 2. A hepatitis A vaccination. 3. A PPD skin test on the left arm. 4. A hepatitis B vaccination.

2. Hepatitis A is contracted through the fecal-oral route of transmission; poor sanitary practices in third world countries place the client at risk for hepatitis A.

5. The nurse has taught Kegel exercises to the client who is para 5, gravida 5. Which information indicates the exercises have been effective? 1. The client reports no SOB when walking up stairs. 2. The client has no complaints of stress incontinence. 3. The client denies being pregnant at this time. 4. The client has lost 10 lb in the last two (2) months.

2. Kegel exercises are exercises that strengthen the perineal muscles. Multiple pregnancies weaken the pelvic muscles, resulting in bladder incontinence; a report of no stress incontinence indicates the Kegel exercises are effective.

85. The client is admitted into the medical unit diagnosed with heart failure and is prescribed the thyroid hormone levothyroxine (Synthroid) orally. Which intervention should the nurse implement? 1. Call the pharmacist to clarify the order. 2. Administer the medication as ordered. 3. Ask the client why he or she takes Synthroid. 4. Request serum thyroid function levels.

2. Many elderly clients have comorbid conditions requiring daily medications, which are not the primary reason for admission into the hospital.

62. Which psychosocial client problem should the nurse write for the client diagnosed with cancer of the lung and metastasis to the brain? 1. Altered role performance. 2. Grieving. 3. Body image disturbance. 4. Anger.

2. Metastasis indicates advanced disease, and the client should be allowed to express feelings of loss and grieving; the client is dying.

2. Which problem is priority for the 24-year-old client diagnosed with endometriosis who is admitted to the gynecological unit? 1. Hemorrhage. 2. Pain. 3. Constipation. 4. Dyspareunia.

2. Pain is the primary complaint of the client; the pain occurs as a result of ectopic tissue bleeding into

67. The client has gastroesophageal reflux disease. Which HCP order should the nurse question? 1. Elevate the head of the client's bed with blocks. 2. Administer pantoprazole (Protonix) four (4) times a day. 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals.

2. Proton pump inhibitors are only administered once or twice a day; they should not be given four (4) times a day because the medication decreases gastric acidity and the stomach needs some gastric acid to digest foods. The nurse would question this order.

100. Which intervention will help prevent the nurse from being sued for malpractice throughout his or her professional practice? 1. Keep accurate and legible documentation of client care. 2. A kind, caring, and compassionate bedside manner at all times. 3. Maintain knowledge of medications for disease processes. 4. Follow all health-care provider orders explicitly.

2. Research indicates nurses who form a trusting nurse-client relationship are less likely to be sued; if the nurse were to make an error, the client and family are often more forgiving.

16. The nurse is planning the care for the client with multiple stage IV pressure ulcers. Which complication results from these pressure ulcers? 1. Wasting syndrome. 2. Osteomyelitis. 3. Renal calculi. 4. Cellulitis.

2. Stage IV pressure ulcers frequently extend to the bone tissue, predisposing the client to developing a bone infection— osteomyelitis—which can rarely be treated effectively.

22. The nurse observes the unlicensed assistive personnel (UAP) taking vital signs on an unconscious client. Which action by the UAP warrants intervention by the nurse? 1. The UAP uses a vital sign machine to check the BP. 2. The UAP takes the client's temperature orally. 3. The UAP verifies the blood pressure manually. 4. The UAP counts the respirations for 30 seconds.

2. The body temperature of an unconscious client should never be taken by mouth because the client is unable to safely hold the thermometer.

59. Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg? 1. A negative Homans' sign of the left leg. 2. Increased left-leg calf circumference. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg.

2. The calf with deep vein thrombosis becomes edematous, so there is an increase in the size of the calf when compared to the other leg.

27. The nurse has just received the shift assessment. Which client should the nurse assess first? 1. The client with encephalitis who has myalgia. 2. The client who is complaining of chest pain. 3. The client who refuses to eat hospital food. 4. The client who is scheduled to go to the whirlpool.

2. The client complaining of chest pain is priority. Remember Maslow's hierarchy of needs.

81. The client with type 1 diabetes asks the nurse, "What causes me to get dehydrated when my glucose level is elevated?" Which statement would be the nurse's best response? 1. "The kidneys are damaged and cannot filter out the urine." 2. "The glucose causes fluid to be pulled from the tissues." 3. "The sweating as a result of the high glucose level causes dehydration." 4. "You get dehydrated with a high glucose because you are so thirsty."

2. The glucose in the bloodstream is hyperosmolar, which causes water from the extracellular space to be pulled into the vessels, resulting in dehydration.

97. The female client is admitted to the orthopedic floor with a spiral fracture of the arm and multiple contusions and abrasions covering the trunk of the body. Her husband accompanies her. During the admission interview, which intervention is priority? 1. Notify the local police department of the client's admission. 2. Provide privacy to discuss how the injuries occurred to the client. 3. Refer the client to the social worker for names of women's shelters. 4. Ask the client if she prefers the husband to stay in the room.

2. The nurse must ensure the husband cannot hear the client discussing how she was injured. The client needs to feel safe when answering these questions because a spiral fracture indicates a twisting motion and the bruises are on areas covered with clothing. The nurse should suspect abuse with these types of injuries.

12. The 33-year-old client had a traumatic amputation of the right forearm as a result of a work-related injury. Which referral by the rehabilitation nurse is most appropriate? 1. Physical therapist. 2. Occupational therapist. 3. Workers' compensation. 4. State rehabilitation commission.

2. The occupational therapist focuses on evaluating and improving functional abilities to optimize independence and address activities of daily living, which would be an appropriate referral.

84. The client diagnosed with neurogenic diabetes insipidus (DI) asks the nurse, "What is wrong with me? Why do I urinate so much?" Which statement by the nurse is most appropriate? 1. "The islet cells in your pancreas are not functioning properly." 2. "Your pituitary gland is not secreting a necessary hormone." 3. "Your kidneys are in failure and you are overproducing urine." 4. "The thyroid gland is speeding up all your metabolism."

2. The pituitary gland secretes vasopressin, the antidiuretic hormone (ADH) causing the body to conserve water, and if the pituitary is not secreting ADH, the body will produce large volumes of dilute urine.

46. The client is being admitted into the hospital with a diagnosis of pneumonia. Which HCP order should the nurse implement first? 1. Initiate intravenous antibiotics. 2. Collect a sputum specimen for culture. 3. Obtain a clean voided midstream urinalysis. 4. Request a chest x-ray to confirm the diagnosis.

2. The sputum must be collected first to identify the infectious organism so appropriate antibiotics can be prescribed. Administering broad-spectrum antibiotics prior to collecting sputum could alter the C&S results.

93. The elderly client from the long-term care facility is admitted into the hospital diagnosed with septicemia. Which area of the body is the most appropriate place for the nurse to assess the hydration status of the client? 1. A (eyeball) 2. B (chest) 3. C (hand) 4. D (thigh)

2. The tissue on the chest is protected from sun exposure and has adequate subcutaneous tissue to provide a more accurate assessment of hydration status.

70. The client diagnosed with peptic ulcer disease is being discharged. Which nursing task can be delegated to a trained unlicensed assistive personnel (UAP)? 1. Complete the discharge instructions sheet. 2. Remove the client's saline lock. 3. Clean the client's room after discharge. 4. Check the client's hemoglobin and hematocrit.

2. The trained UAP can remove a saline lock from a stable client.

18. Which diagnostic test should the nurse expect to be ordered for the client who has a nevus which is purple and brown with irregular borders? 1. Bone scan. 2. Skin biopsy. 3. Carcinoembryonic antigen (CEA). 4. Sonogram.

2. This is an abnormal-appearing mole on the skin, and the HCP would order a biopsy to confirm skin cancer.

34. Which question should the nurse ask the client who is being admitted to rule out infective endocarditis? 1. "Do you have a history of a heart attack?" 2. "Have you had a cardiac valve replacement?" 3. "Is there a family history of rheumatic heart disease?" 4. "Do you take nonsteroidal anti-inflammatory medications?"

2. This is why clients must receive prophylactic antibiotic treatment before dental work and invasive procedures.

31. The client diagnosed with end-stage congestive heart failure is being cared for by the home health nurse. Which intervention should the nurse teach the caregiver? 1. Report any time the client starts having difficulty breathing. 2. Notify the HCP if the client gains more than 3 lb in a week. 3. Teach how to take the client's apical pulse for one (1) full minute. 4. Encourage the client to participate in 30 minutes of exercise a day.

2. Two (2) to three (3) pounds of weight gain reflects fluid retention as a result of heart failure, which warrants notifying the HCP.

11. The 54-year-old female client is diagnosed with osteoporosis. Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to swim 30 minutes every day. 2. Encourage drinking milk with added vitamin D. 3. Determine if the client smokes cigarettes. 4. Recommend the client not go outside. 5. Teach about safety and fall precautions.

2. Vitamin D helps the body absorb calcium. 3. Smoking interferes with estrogen's protective effects on bones, promoting bone loss. 5. The client is at risk for fractures; therefore, a fall could result in serious complications.

86. Which client should the nurse consider at risk for developing acute renal failure? 1. The client diagnosed with essential hypertension. 2. The client diagnosed with type 2 diabetes. 3. The client who had an anaphylactic reaction. 4. The client who had an autologous blood transfusion.

3. Anaphylaxis leads to circulatory collapse, which decreases perfusion of the kidneys and can lead to acute renal failure.

13. The client has a fractured right tibia. Which assessment data warrant immediate intervention? 1. The client complains of right calf pain. 2. The nurse cannot palpate the radial pulse. 3. The client's right foot is cold to touch. 4. The nurse notes ecchymosis on the right leg.

3. Any abnormal neurovascular assessment data, such as coldness, paralysis, or paresthesia, warrant immediate intervention by the nurse.

63. The client diagnosed with cancer of the larynx has had a partial laryngectomy. Which client problem has the highest priority? 1. Impaired communication. 2. Ineffective coping. 3. Risk for aspiration. 4. Social isolation.

3. As a result of the injury to the musculature of the throat area, this client is at high risk for aspirating.

72. The home health nurse must see all of the following clients. Which client should the nurse assess first? 1. The client who is postoperative from an open cholecystectomy who has green drainage coming from the T-tube. 2. The client diagnosed with congestive heart failure who complains of shortness of breath while fixing meals. 3. The client diagnosed with AIDS dementia whose family called and reported that the client is vomiting "coffee grounds stuff." 4. The client diagnosed with end-stage liver failure who has gained three (3) pounds and is not able to wear house shoes.

3. Coffee-ground emesis indicates gastrointestinal bleeding, and this client should be seen first.

1. The 44-year-old female client calls the clinic and tells the nurse she felt a lump while performing breast self-examination (BSE). Which question should the nurse ask the client? 1. "Are you taking birth control pills?" 2. "Do you eat a lot of chocolate?" 3. "When was your last period?" 4. "Are you sexually active?"

3. During the menstrual cycle, pregnancy, and menopause, variations in breast tissue occur and must be distinguished from pathological disease. BSE is best performed on days five (5) to seven (7) after menses, counting the first day of menses as day one (1).

76. The client with chronic pancreatitis is admitted with an acute exacerbation of the disease. Which laboratory result warrants immediate intervention by the nurse? 1. The client's amylase is elevated. 2. The client's WBC count is WNL. 3. The client's blood glucose is elevated. 4. The client's lipase is within normal limits.

3. In clients with chronic pancreatitis, the beta cells of the pancreas are affected and, therefore, insulin production is affected. An elevated glucose level would warrant the nurse assessing the client.

29. The telemetry nurse is monitoring the following clients. Which client should the telemetry nurse instruct the primary nurse to assess first? 1. The client who has occasional premature ventricular contractions (PVCs). 2. The client post-cardiac surgery who has three (3) unifocal PVCs in a minute. 3. The client with a myocardial infarction who had two (2) multifocal PVCs. 4. The client diagnosed with atrial fibrillation who has an AP of 116 and no P wave.

3. Multifocal PVCs indicate the ventricle is irritable, and this client is at risk for a cardiac event such as ventricular fibrillation.

39. The client is admitted with rule-out leukemia. Which assessment data support the diagnosis of leukemia? 1. Cervical lymph node enlargement. 2. An asymmetrical dark-purple nevus. 3. Petechiae covering the trunk and legs. 4. Brownish-purple nodules on the face.

3. Petechiae covering the trunk and legs is one of the indicators of bone marrow problems, which could be leukemia.

32. The client is diagnosed with aortic stenosis. Which assessment data indicate a complication is occurring? 1. Barrel chest and clubbing of the fingers. 2. Intermittent claudication and rest pain. 3. Pink, frothy sputum and dyspnea on exertion. 4. Bilateral wheezing and friction rub.

3. Pink, frothy sputum and dyspnea on exertion are signs of congestive heart failure, which occurs when the heart can no longer compensate for the strain of an incompetent valve. rationales: 1. Barrel chest and clubbing of the fingers are signs of chronic lung disease. 2. Intermittent claudication and rest pain are signs of peripheral arterial disease. 4. Friction rub occurs with pericarditis, and bilateral wheezing occurs with asthma.

23. The client diagnosed with a brain tumor who had radiation treatment and developed alopecia asks, "When will my hair grow back?" Which statement is the nurse's best response? 1. "Your hair should start growing back within three (3) weeks." 2. "Are you concerned your hair will not grow back?" 3. "It may take months, if your hair grows back at all." 4. "It may take a couple of years for the hair to grow back."

3. Radiation therapy can cause permanent damage to the hair follicles and the hair may not grow back at all; the nurse should answer the client's question honestly.

44. The 24-year-old African American female client tells the nurse she has a brother with sickle cell disease. She is engaged to be married and is concerned about giving this disease to her future children. Which information is most important to provide to the client? 1. Tell the client that she won't pass this on if she has never had symptoms. 2. Encourage the client to discuss this concern with her fiancé. 3. Recommend that she and her fiancé see a genetic counselor. 4. Discuss the possibility of adopting children after she gets married.

3. Referral to a genetic counselor is the most important information to give the client. If she and her fiancé both have the sickle cell trait, there is a 25% chance of a child having sickle cell disease with each pregnancy.

79. Which assessment data indicate to the nurse the client with diarrhea is experiencing a complication? 1. Moist buccal mucosa. 2. A 3.6-mEq/L potassium level. 3. Tented tissue turgor. 4. Hyperactive bowel sounds.

3. Tented tissue turgor indicates dehydration, which is a complication of diarrhea.

7. The client diagnosed with Stage IV prostate cancer is receiving chemotherapy. Which laboratory value should the nurse assess prior to administering the chemotherapy? 1. Prostate-specific antigen (PSA). 2. Serum calcium level. 3. Complete blood count (CBC). 4. Alpha-fetoprotein (AFP).

3. The CBC is monitored to determine if the client is at risk for developing an infection or bleeding as a result of side effects of the chemotherapy medications. The chemotherapy could be held or decreased based on these results.

37. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task could be delegated to the UAP? 1. Retake the BP on a client who received a STAT nitroglycerin sublingual. 2. Notify the health-care provider of the client's elevated blood pressure. 3. Obtain and document the routine vital signs on all the clients on the floor. 4. Call the laboratory technician and discuss a hemolyzed blood specimen.

3. The UAP can take routine vital signs. The nurse must evaluate the vital signs and take action if needed. The nurse should not delegate teaching, assessing, evaluating, or any client who is unstable.

56. Which assessment data indicate to the nurse the client has a conductive hearing loss? 1. The Rinne test results in air-conducted sound being louder than bone-conducted. 2. The client is unable to hear accurately when conducting the whisper test. 3. The Weber test results in the sound being heard better in the affected ear. 4. The tympanogram results in the ticking watch heard better in the unaffected ear.

3. The Weber test uses bone conduction to test lateralization of sound by placing a tuning fork in the middle of the skull or forehead. A normal test results in the client hearing the sound equally in both ears.

89. The unlicensed assistive personnel (UAP) empties the indwelling urinary catheter for a client who is four (4) hours postoperative transurethral resection of the prostate and informs the nurse the urine is red with some clots. Which intervention should the nurse implement first? 1. Assess the client's urine output immediately. 2. Notify the HCP that the client has gross hematuria. 3. Explain this is expected with this surgery. 4. Medicate for bladder spasms to decrease bleeding.

3. The client has a three (3)-way indwelling 30-mL catheter inserted in surgery. This type of catheter instills an irrigant into the bladder to flush the clots and blood from the bladder; bloody urine is expected after this surgery.

19. The client with a closed head injury is admitted to the neurointensive care department following a motor-vehicle accident. Which goal is an appropriate short-term goal for the client? 1. The client will maintain optimal level of functioning. 2. The client will not develop extremity contractures. 3. The client's intracranial pressure will not be greater than 15 mm Hg. 4. The client will be able to verbalize feelings of anger.

3. The worse-case scenario with a closed head injury is increased intracranial pressure resulting in death. An appropriate short-term goal would be the ICP remaining within normal limits, which is 5 to 15 mm Hg.

10. The primary nurse is applying antiembolism hose to the client who had a total hip replacement. Which situation warrants immediate intervention by the charge nurse? 1. Two fingers can be placed under the top of the band. 2. The peripheral capillary refill time is less than three (3) seconds. 3. There are wrinkles in the hose behind the knees. 4. The nurse does not place a hose on the foot with a venous ulcer.

3. There should be no wrinkles in the hose after application. Wrinkles could cause constriction in the area, resulting in clot formation or skin breakdown; therefore, this would warrant immediate intervention by the charge nurse.

35. The client diagnosed with arterial occlusive disease is prescribed an antiplatelet medication, clopidogrel (Plavix). Which assessment data indicate the medication is effective? 1. The client's pedal pulse is bounding. 2. The client's blood pressure has decreased. 3. The client does not exhibit signs of a stroke. 4. The client has decreased pain when ambulating.

3. This medication inhibits platelet aggregation and is considered effective when there is a decrease in atherosclerotic events, an example of which is a stroke.

68. The client is diagnosed with an acute exacerbation of Crohn's disease. Which assessment data warrant immediate attention? 1. The client's WBC count is 10 (× 103)/mm3. 2. The client's serum amylase is 100 units/dL. 3. The client's potassium level is 3.3 mEq/L. 4. The client's blood glucose is 148 mg/dL.

3. This potassium level is low as a result of excessive diarrhea and puts the client at risk for cardiac dysrhythmias. Therefore, these assessment data warrant immediate intervention.

82. The client calls the clinic first thing in the morning and tells the nurse, "I have been vomiting and having diarrhea since last night." Which response is appropriate for the nurse to make? 1. Encourage the client to eat dairy products. 2. Have the client go to the emergency department. 3. Request the client obtain a stool specimen. 4. Tell the client to stay on a clear liquid diet.

4. A clear liquid diet is recommended because it maintains hydration without stimulating the gastrointestinal tract; diarrhea/ vomiting lasting longer than 24 hours, along with dehydration and weakness, would warrant the client being evaluated.

73. Which data indicate to the nurse the client with end-stage liver failure is improving? 1. The client has a tympanic wave. 2. The client is able to perform asterixis. 3. The client is confused and lethargic. 4. The client's abdominal girth has decreased.

4. A decrease in the abdominal girth indicates an improvement in the ascitic fluid.

8. Which client should the charge nurse of the day surgery unit assign to a new graduate nurse in orientation? 1. The client who had an arthroscopy with an AP of 110 and BP of 94/60. 2. The client with open reduction of the ankle who is confused. 3. The client with a total hip replacement who is being transferred to the ICU. 4. The client diagnosed with low back pain who has had a myelogram.

4. A myelogram is a routine diagnostic test. With minimal instruction, an inexperienced nurse could care for this client.

4. The nurse is teaching a class on sexually transmitted diseases to high school sophomores. Which information should be included in the discussion? 1. Oral sex decreases the chance of transmitting a sexual disease. 2. Sexual activity during menses decreases transmission of diseases. 3. Frequent sexual activity is necessary to transmit a sexual disease. 4. Unprotected sex puts the individual at risk for many diseases.

4. According to developmental theories, adolescents think they are invincible and nothing will happen to them. This attitude leads adolescents to participate in high-risk behaviors without regard to consequences.

95. Which psychosocial problem should the nurse identify as priority for a client diagnosed with rheumatoid arthritis? 1. Alteration in comfort. 2. Ineffective coping. 3. Anxiety. 4. Altered body image.

4. Altered body image is an expected psychosocial problem for all clients with rheumatoid arthritis because of the joint deformities.

77. The client had abdominal surgery and is receiving bag #5 of total parenteral nutrition (TPN) via a subclavian line infusing at 126 mL/hr. The nurse realizes bag #6 is not on the unit and TPN bag #5 has 50 mL left to infuse. Which intervention should the nurse implement? 1. Decrease the rate of bag #5 to a keep-open rate. 2. Prepare to hang a 1,000-mL bag of normal saline. 3. When bag #5 is empty, convert to a heparin lock. 4. Infuse D10W at 126 mL/hr via the subclavian line.

4. Dextrose 10% has enough glucose to prevent hypoglycemia and should be administerd until bag #6 arrives to the unit.

41. The nurse writes the goal "the client will list three (3) food sources of vitamin B12" for the client diagnosed with pernicious anemia. Which foods listed by the client indicate the goal has been met? 1. Brown rice, dried fruits, and oatmeal. 2. Beef, chicken, and pork. 3. Broccoli, asparagus, and kidney beans. 4. Liver, cheese, and eggs.

4. Liver, cheese, and eggs are sources of vitamin B12.

25. The client is being evaluated to rule out Parkinson's disease. Which diagnostic test confirms this diagnosis? 1. A positive magnetic resonance imaging (MRI) scan. 2. A biopsy of the substantia nigra. 3. A stereotactic pallidotomy. 4. There is no test that confirms this diagnosis.

4. Many diagnostic tests are completed to rule out other diagnoses, but Parkinson's disease is diagnosed based on the clinical presentation of the client and the presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia.

36. The client diagnosed with atherosclerosis has coronary artery disease. The client experiences sudden chest pain when walking to the nurse's station. Which intervention should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Apply oxygen via nasal cannula. 3. Obtain a STAT electrocardiogram. 4. Have the client sit in a chair.

4. Stopping the client from whatever activity the client is doing is the first intervention because this decreases the oxygen demands of the heart muscle and may decrease or eliminate the chest pain.

9. The client in the long-term care facility has severe osteoarthritis. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Feed the client the breakfast meal. 2. Give the client Maalox, an antacid. 3. Monitor the client's INR results. 4. Assist the client to the shower room.

4. The UAP could assist the client to ambulate to the shower room and assist with morning care.

88. Which action by the unlicensed assistive personnel (UAP) requires intervention by the nurse? 1. The UAP used two (2) washcloths when washing the perineal area. 2. The UAP emptied the indwelling catheter and documented the amount. 3. The UAP applied moisture barrier cream to the anal area. 4. The UAP is wiping the client's perineal area from back to front.

4. The UAP should wipe the area from front to back to prevent fecal contamination of the urinary meatus, which could result in a urinary tract infection.

24. Which assessment data indicate the treatment for the client diagnosed with bacterial meningitis is effective? 1. There is a positive Brudzinski's sign and photophobia. 2. The client tolerates meals without nausea. 3. There is a positive Kernig's sign and an elevated temperature. 4. The client is able to flex the neck without pain.

4. The client does not have nuchal rigidity, which indicates the client's treatment is effective.

28. Which client should the charge nurse on the substance abuse unit assign to the licensed practical nurse (LPN)? 1. The client with chronic alcoholism who has been on the unit three (3) days. 2. The client who is complaining of palpitations and has a history of cocaine abuse. 3. The client diagnosed with amphetamine abuse who tried to commit suicide. 4. The client diagnosed with cannabinoid abusewho is threatening to leave AMA.

4. The client has a right to leave against medical advice (AMA), and marijuana abuse is not life threatening to him or to others. Therefore, the LPN could be assigned to this client.

14. The nurse identifies the problem "high risk for complications" for the client with a right total hip replacement who is being discharged from the hospital. Which problem would have the highest priority? 1. Self-care deficit. 2. Impaired skin integrity. 3. Abnormal bleeding. 4. Prosthetic infection.

4. The client must inform all HCPs, especially the dentist, of the hip prosthesis because the client should be taking prophylactic antibiotics prior to any invasive procedure. Any bacteria invading the body may cause an infection in the joint, and this may result in the client having the prosthesis removed.

64. The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, "Something is really wrong with me." Which intervention should the nurse implement first? 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula.

4. The client probably has a pulmonary embolus, and the priority is to provide additional oxygen so oxygenation of tissues can be maintained.

90. The client with a history of substance abuse presents to the emergency department complaining of right flank pain, and the urinalysis indicates microscopic blood. Which intervention should the nurse implement? 1. Determine the last illegal drug use. 2. Insert a #22 French indwelling catheter. 3. Give the client a back massage. 4. Medicate the client for pain.

4. The client should be medicated for pain, which is excruciating, and the client's history of substance abuse should not be an issue.

54. Which laboratory result warrants immediate intervention by the nurse for the female client diagnosed with systemic lupus erythematosus (SLE)? 1. A hemoglobin and hematocrit of 13 g/dL and 40%. 2. An erythrocyte sedimentation rate of 9 mm/hr. 3. A serum albumin level of 4.5 g/dL. 4. A white blood cell count of 15,000/mm3.

4. The client with SLE is at an increased risk for infection, and this WBC count indicates an

49. The client is performing breast self-examination (BSE) by the American Cancer Society's recommended steps and has completed palpating the breast. Which step is next when completing the BSE? 1. Stand before the mirror and examine the breast. 2. Lean forward and look for dimpling or retractions. 3. Examine the breast using a circular motion. 4. Pinch the nipple to see if any fluid can be expressed.

4. The last step of BSE after palpation is to express the nipple by gently squeezing the nipple. Any discharge should be brought to the attention of an HCP. Nipple discharge can be caused by many factors such as carcinoma, papilloma, pituitary adenoma, cystic breasts, and some medications. RATIONALES: 1. This step is the first step in BSE. 2. This is step three (3) in the BSE process. 3. This is included in steps four (4) and five (5) and is described as using a systematic process of examining the breast. Using circular motions and dividing the breast into wedges or vertical strips to palpate the entire breast is encouraged. This step was described in the stem as having been completed.

61. The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement? 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone.

4. The oxygen level for a client with COPD must remain between two (2) and three (3) L/min because the client's stimulus for breathing is low blood oxygen levels. If the client receives increased oxygen, the stimulus for breathing will be removed and the client will stop breathing.

20. The 25-year-old client who has a C6 spinal cord injury is crying and asks the nurse, "Why did I have to survive? I wish I was dead." Which statement is the nurse's best response? 1. "Don't talk like that. At least you are alive and able to talk." 2. "God must have something planned for your life. Pray about it." 3. "You survived because the people at the accident saved your life." 4. "This must be difficult to cope with. Would you like to talk?"

4. This is a therapeutic response which allows the client to ventilate feelings.

40. The client diagnosed with non-Hodgkin's lymphoma tells the nurse, "I am so tired. I just wish I could die." Which stage of the grieving process does this statement represent? 1. Anger. 2. Denial. 3. Bargaining. 4. Acceptance.

4. This statement indicates the client is ready to die and is in the acceptance stage of the grieving process.

58. The nurse is preparing the client newly diagnosed with asthma for discharge. Which data indicate the teaching about the peak flowmeter has been effective? 1. "I can continue my usual activities without medication if I am in the yellow zone." 2. "It takes one (1) to two (2) days to establish my personal best." 3. "When I can't talk while walking, I need to take my quick-relief medicine." 4. "When I am in the red zone, I must take my quick-relief medication and not exercise."

4. When the client is in the red zone, the client should take the quick-relief medication and should not exercise or follow regular routines.