med-surg final EAQ
What is the reason for the development of erythema, heat, edema, and pain with inflammation? 1 Increase in the flow of blood elements 2 Production of a thin and watery serum portion of blood 3 Production of thin and red fluid exudates from the wound 4 Overgrowth of collagenous scar tissue at the site of the wound
Correct1 Increase in the flow of blood elements
An adolescent with a history of type 1 diabetes is admitted in ketoacidosis. What does the nurse suspect as a precipitating cause of this episode of ketoacidosis? 1 Infection 2 Increased exercise 3 Recent weight loss 4 Overdose of insulin
Correct1 Infection
A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client? 1 Intravenous (IV) fluids 2 Potassium 3 NPH insulin 4 Sodium polystyrene sulfonate
Correct1 Intravenous (IV) fluids
On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse whether she has any special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply. 1 Iron 2 Calcium 3 Folic acid 4 Vitamin C 5 Vitamin B12
Correct1 Iron Correct3 Folic acid
Which statement regarding rheumatoid arthritis is true? 1 It is a systemic condition. 2 It affects the hips and knees. 3 It involves bone spur formation. 4 It affects males and females equally.
Correct1 It is a systemic condition
The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does the nurse determine whether the desired effect of therapy has been achieved? 1 Mobility increases 2 Fewer muscle spasms occur 3 The heartbeat is more regular 4 There are fewer bruises than before therapy
Correct1 Mobility increases
Thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? 1 Neuronal activity 2 Bowel elimination 3 Efficient circulation 4 Prothrombin development
Correct1 Neuronal activity
Which musculoskeletal condition occurs in part as a result of deficiencies in vitamin D and calcium? 1 Osteoporosis 2 Osteoarthritis 3 Ankylosing spondylitis 4 Fibromyalgia syndrome
Correct1 Osteoporosis
A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? 1 Preventing falls 2 Monitoring electrolytes 3 Administering antiemetics 4 Adjusting the diuretic therapy
Correct1 Preventing falls
A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply. 1 Providing mechanical ventilation 2 Administering sodium bicarbonate 3 Helping the client breathe into a paper bag 4 Using intermittent positive pressure breathing 5 Using continuous positive airway pressure (CPAP)
Correct1 Providing mechanical ventilation Correct2 Administering sodium bicarbonate
Which parts of the skeleton are categorized as axial? Select all that apply. 1 Skull 2 Sternum 3 Vertebrae 4 Pelvic girdle 5 Shoulder girdle
Correct1 Skull Correct2 Sternum Correct3 Vertebrae
A client understands that an increase in both vitamin E and beta-carotene is important for healthier skin. What foods should the nurse include in her teaching that are excellent sources of both? 1 Spinach and mangoes 2 Fish and peanut butter 3 Oranges and grapefruit 4 Carrots and sweet potatoes
Correct1 Spinach and mangoes
When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain a nothing-by-mouth (NPO) status.
Correct2 Employ breathing exercises and controlled coughing.
What is the score in the Glasgow Coma Scale when the client has no eye response after a head injury?
1
Arrange the events that occur in respiratory acidosis.
1.The level of carbonic acid in the blood is increased. 2.The blood pH falls and ratio of bicarbonate-to-carbonic acid ratio is upset. 3.The partial pressure of carbon dioxide increases. 4.Respiration must increase to eliminate carbon dioxide.
A healthcare provider's prescription for a client in ketoacidosis is 60 units of insulin IV in the next 30 minutes. The pharmacy dispensed 500 units regular insulin in 500 mL lactated Ringer solution. At how many milliliters per hour should the nurse set the IV infusion device to administer the correct amount of medication? Record your answer using a whole number. _____ mL/hr
120
A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? 1 Digoxin 2 Furosemide 3 Propranolol 4 Spironolactone
Correct1 Digoxin
Acetaminophen 15 mg/kg is prescribed for a child with a temperature of 102° F (38.9° C). How much will the nurse tell the parent to administer if the child weighs 9.6 kg and the acetaminophen strength is 160 mg/5 mL? Record your answer using one decimal place. ___ mL
4.5
A physician orders guaifenesin 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. ____ mL
7.5
A client with cardiac dysrhythmia is taking several medications. During a follow-up visit, the client reports fatigue to the primary health-care provider. Which medication does the nurse suspect the client is taking? 1 Digoxin 2 Lidocaine 3 Procainamide 4 Disopyramide
Correct1 Digoxin
Which laboratory finding indicates metabolic alkalosis? 1 A pH value of more than 7.45 2 Potassium ions (K+) more than 5 mEq/L 3 Bicarbonate ion ( HCO3- ) levels less than 21 4 Partial pressure of carbon dioxide (PaCO2) more than 45 mm Hg
Correct1 A pH value of more than 7.45
Which is a clinical manifestation of metabolic alkalosis? 1 Atrial tachycardia 2 Occipital headache 3 Kussmaul respirations 4 Warm and flushed skin
Correct1 Atrial tachycardia
Which fact is true about male rather than female clients? 1 Gonorrhea is more common among men. 2 Chlamydia is more common among men. 3 Men experience more frequent and serious complications related to sexuality transmitted infections. 4 Syphilis is more common among men.
Correct4 Syphilis is more common among men.
An adolescent is admitted to the hospital in respiratory distress, and the health care provider orders oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Mark where the ball of the flow meter should be raised to deliver the percentage of oxygen ordered by the health care provider.
The ball of the oxygen flowmeter should be set at 8 L/min to deliver 40% oxygen through the Venturi mask.
A nurse must obtain a client's apical pulse. Mark where the nurse should place the stethoscope.
The heart's apex is between the fifth and sixth ribs at the midclavicular line. It is closest to the chest wall here, so auscultation is easier.
A 9-year-old child with type 1 diabetes is hospitalized for insulin dosage regulation. A nurse observes the child sneaking food and trying to talk family members into bringing candy. What action should the nurse take when the child complains of feeling hypoglycemic? 1 Test the urine for ketones 2 Obtain a blood glucose level 3 Offer orange juice with sugar 4 Determine when the child ate last
Correct2 Obtain a blood glucose level
A healthcare provider prescribes 0.2 mg of cyanocobalamin (vitamin B12) intramuscularly for a client with pernicious anemia. A vial of the drug labeled 100 mcg = 1 mL is available. How much solution should the nurse administer? Record your answer using a whole number. ___ mL
2
Which self-care behavior would benefit a client with gastroesophageal reflux disease? 1 Limiting alcohol intake 2 Avoiding protein-rich foods 3 Eating two small meals a day 4 Consuming small evening snacks
Correct1 Limiting alcohol intake
Which classic signs are observed in peripheral vascular disease? Select all that apply. 1 Pain 2 Pallor 3 Pruritus 4 Paresthesia 5 Purulent discharge
Correct1 Pain Correct2 Pallor Correct4 Paresthesia
Which test is used to diagnose sleep apnea? 1 Sonography 2 Polysomnography 3 Echocardiography 4 Plethysmography
Correct2 Polysomnography
The nurse is counseling a pregnant client with type 1 diabetes regarding medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? 1 Insulin 2 Antihypertensives 3 Pancreatic enzymes 4 Estrogenic hormones
Correct1 Insulin
The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit levels
Correct4 Improved hemoglobin and hematocrit levels
What is the function of the biceps brachii muscle? 1 Flexes the lower arm 2 Abducts the upper arm 3 Compresses the abdomen 4 Rotates and extends the head
Correct1 Flexes the lower arm
Which herbal product is contraindicated when a client is receiving anticoagulant therapy? 1 Garlic 2 Flaxseed oil 3 Red yeast rice 4 Horse chestnut seed extract
Correct1 Garlic
A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply. 1 Dry skin 2 Abdominal pain 3 Kussmaul respirations 4 Absence of ketones in the urine 5 Blood glucose level of less than 100 mg/dL
Correct1 Dry skin Correct2 Abdominal pain Correct3 Kussmaul respirations
A nurse is planning to teach facts about hyperglycemia to a client with diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis? 1 Breakdown of fat stores for energy 2 Ingestion of too many highly acidic foods 3 Excessive secretion of endogenous insulin 4 Increased amounts of cholesterol in the extracellular compartment
Correct1 Breakdown of fat stores for energy
Which foods rich in vitamin C act as dietary supplement for wound healing? Select all that apply. 1 Broccoli 2 Cabbage 3 Legumes 4 Red meat 5 Strawberries 6 Riboflavin-enriched cereals
Correct1 Broccoli Correct2 Cabbage Correct5 Strawberries
nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. What statement by the client indicates that teaching was understood? 1 "I must take this monthly for the rest of my life." 2 "I should take this vitamin, as needed, when feeling fatigued." 3 "Once my symptoms subside, I can stop taking this vitamin." 4 "I need to have this available for use during exacerbations of anemia."
Correct1 "I must take this monthly for the rest of my life."
A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What is the origin of the metabolic acidosis caused by aspirin toxicity? 1 Deep rapid breathing 2 Higher pH of gastric contents 3 Rapid absorption of salicylate 4 Increased renal excretion of bicarbonate
Correct3 Rapid absorption of salicylate
Which statement regarding sexual identity is true? 1 The nurse should always have a single belief about sexual ethics. 2 The nurse may judge sexual decisions as immoral on the basis of religious standards. 3 The nurse should view any private sexual act between consenting adults as immoral. 4 The nurse should maintain a nonjudgmental attitude about sexuality while caring for all clients.
Correct4 The nurse should maintain a nonjudgmental attitude about sexuality while caring for all clients
The laboratory data of four clients are shown below. Which client may have respiratory alkalosis?
In respiratory alkalosis, the blood pH value is more than 7.45, and the partial pressure of carbon dioxide (PaCO2) is below 35 mm Hg. Therefore, client A may have respiratory alkalosis. In respiratory acidosis, the blood pH value is less than 7.35, and the PaCO2 is more than 45 mm Hg; client B may have respiratory acidosis. In metabolic acidosis, the blood pH value is less than 7.35, and the PaCO2 is normal or less than 35 mm Hg; client C may have metabolic acidosis. In metabolic alkalosis, the blood pH value is more than 7.45, and PaCO2 is normal or more than 45 mm Hg; client D may have metabolic alkalosis.
What is the manifestation of Cushing syndrome? 1 "Moon face" 2 Weight loss 3 Short stature 4 Skin hyperpigmentation
Correct1 "Moon face"
The laboratory data of four clients are shown below. Which client may have metabolic acidosis?
In metabolic acidosis, the blood pH value less is than 7.35, the bicarbonate ion level is less than 22 mEq/L, and the potassium ion level is greater than 5 mEq/L; client C may have metabolic acidosis. In respiratory alkalosis, the blood pH value is more than 7.45, the bicarbonate ion level is normal (or below 21), and the potassium ion level is less than 3.5 mEq/L; client A may have respiratory alkalosis. In respiratory acidosis, the blood pH value is less than 7.35, the bicarbonate ion level is normal, and the potassium ion level is less than 5 mEq/L; client B may have respiratory acidosis. In metabolic alkalosis, the blood pH value is more than 7.45, the bicarbonate ion level is more than 26 mEq/L, and the potassium ion level is less than 3.5 mEq/L; client D may have metabolic alkalosis.
A client with a spinal cord injury tends to assume the low-Fowler position excessively. Mark the area of the body that is most vulnerable to the development of a pressure ulcer in this client.
The sacrum bears the most pressure because it is the focal point of the weight of the body when in the low-Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low-Fowler position.
The registered nurse is delegating a task for unlicensed assistive personnel l (UAP). Which client's care would be suitable for delegation to the UAP?
The unlicensed assistive personnel (UAP) can monitor the temperature of client B every hour. Discharges from the surgical site of client A should be monitored, but the UAP may not have appropriate knowledge. Abdominal pain should be monitored in client C, but the UAP is not qualified to understand the condition of the client. Respiratory rate cannot be monitored by the UAP as it is the responsibility of the more qualified UNP.
What can be a cause of metabolic acidosis? 1 Severe diarrhea 2 Cushing disease 3 Hyperaldosteronism 4 Consumption of too much baking soda
Correct1 Severe diarrhea
Which type of movement results in the palm facing upward or forward? 1 Abduction 2 Supination 3 Dorsiflexion 4 Plantar flexion
Correct2 Supination
During assessment, the nurse finds that a client with Alzheimer's disease is having difficulty in communicating by writing. What does the nurse document in the medical chart of the client? 1 Apraxia 2 Agnosia 3 Dysgraphia 4 Sundowning
Correct3 Dysgraphia
What can cause metabolic alkalosis? 1 Shock 2 Anemia 3 Pneumonia 4 Cushing disease
Correct4 Cushing disease
A client's laboratory report indicates a cardiac output of 3 L/min. Which symptom may be associated with the client's condition? 1 Fatigue 2 Polyuria 3 Hot skin 4 Weight loss
Correct1 Fatigue
A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 1 7.2 2 7.35 3 7.45 4 7.48
Correct1 7.2
Which precaution will help a client on warfarin therapy to reduce the risk of further clot formation? 1 Avoid broccoli 2 Avoid flaxseed oil 3 Reduce the intake of garlic 4 Reduce the intake of aspirin
Correct1 Avoid broccoli
The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent? 1 "Give your child orange juice." 2 "Call the Poison Control Center." 3 "Iron-fortified multivitamins are safe for your child." 4 "Administer an emetic - syrup of ipecac, if you have it.
Correct2 "Call the Poison Control Center."
The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply. 1 "The client's Chvostek sign would be negative." 2 "The client's Trousseau sign would be positive." 3 "The client would be experiencing paresthesias." 4 "The client would show signs of anxiety and irritability." 5 "The client's central nervous system should have a decrease activity in case alkalosis."
Correct2 "The client's Trousseau sign would be positive." Correct3 "The client would be experiencing paresthesias." Correct4 "The client would show signs of anxiety and irritability."
To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? 1 A change in the respiratory rate 2 A tingling sensation in the hands 3 Periodic changes in the fetal heart rate 4 A pulse oximetry reading of less than 98%
Correct2 A tingling sensation in the hands
Which statement is true regarding fatigue? 1 Fatigue is usually preceded by a sensation of lightheadedness. 2 Exhaustion and activity intolerance are associated with decreased cardiac output. 3 Fatigue may result from a sudden decrease in cardiac output to the brain as a result of dysrhythmia. 4 Fatigue can manifest as discoloration of skin caused by an excess of deoxygenated hemoglobin in the blood.
Correct2 Exhaustion and activity intolerance are associated with decreased cardiac output.
Which organization established the Department of Practical Nursing Programs and developed the accreditation service called the Council of Practical Nursing Programs? 1 Frontier Nursing Service 2 National League for Nursing 3 Association of Practical Nurse Schools 4 National Federation of Licensed Practical Nurses
Correct2 National League for Nursing
A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply. 1 Lettuce Correct2 Oranges Correct3 Broccoli Incorrect4 Apricots Correct5 Strawberries
Correct2 Oranges Correct3 Broccoli Correct5 Strawberries
A client experiences fatigue, chest pain, and dyspnea caused by low tissue perfusion after exercise. Which symptom might also occur in this client? 1 Edema 2 Syncope 3 Orthopnea 4 Increased body temperature
Correct2 Syncope
How does the body compensate for metabolic alkalosis? 1 The kidneys retain bicarbonate to raise pH levels. 2 The lungs retain carbon dioxide to lower pH levels. 3 The lungs excrete carbon dioxide to raise pH levels. 4 The kidneys excrete increased amounts of bicarbonate to lower pH levels.
Correct2 The lungs retain carbon dioxide to lower pH levels.
Which is a clinical manifestation of respiratory acidosis? 1 Tetany 2 Tremors 3 Bradycardia 4 Hypertension
Correct2 Tremors
A child who is receiving methotrexate and undergoing cranial radiation is very weak. Her mother asks the nurse whether she may give her daughter vitamins. How does the nurse respond? 1 "That's an excellent idea. I'll try to get a prescription for her." 2 "Unfortunately, vitamins won't make her feel any better now." 3 "Although I can understand this idea, vitamins interfere with the action of methotrexate." 4 "After we receive the laboratory reports, your daughter will be getting vitamins."
Correct3 "Although I can understand this idea, vitamins interfere with the action of methotrexate."
After the birth of her child, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. Why is this necessary?" How should the nurse respond? 1 "Your baby needs the injection to promote development of red blood cells." 2 "An injection of vitamin K will help keep your baby from becoming jaundiced." 3 "Newborns are deficient in vitamin K. This treatment will ensure adequate levels." 4 "A newborn's blood clots extremely rapidly. This injection will help decrease the clotting time."
Correct3 "Newborns are deficient in vitamin K. This treatment will ensure adequate levels."
When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, what teaching does the nurse provide? 1 Weekly Z-track injections provide needed control. 2 Daily intramuscular injections are required for control. 3 Intramuscular injections once a month will maintain control. 4 Oral vitamin B12 tablets taken daily will provide symptom control.
Correct3 Intramuscular injections once a month will maintain control.
The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. Which type of respirations does the nurse expect the client to exhibit? 1 Dyspnea 2 Hyperpnea 3 Kussmaul's breathing 4 Cheyne-Stokes breathing
Correct3 Kussmaul's breathing
A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? 1 Deltoid muscle 2 Rectus femoris 3 Vastus lateralis 4 Gluteus maximus
Correct3 Vastus lateralis
A thin 24-year-old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend? 1 Vitamin E and ginseng tea 2 Vitamin B and ginkgo biloba 3 Vitamin D and calcium citrate 4 Vitamin C and glucosamine/chondroitin
Correct3 Vitamin D and calcium citrate
A client reports frequent awakening at night, insomnia, and excessive daytime sleepiness. The client adds that his bed partner also complains about his loud snoring. What does the nurse anticipate including in the patient's teaching plan? 1 "Take a warm shower before bedtime." 2 "Take a sedative three or four hours before bedtime." 3 "Avoid alcoholic beverages for five to six hours before bedtime." 4 "Get fitted for an oral appliance that will bring the lower jaw and tongue forward."
Correct4 "Get fitted for an oral appliance that will bring the lower jaw and tongue forward."
A nurse prepares to administer vitamin K to a newborn. What rationale explains why newborns are deficient in this vitamin? 1 Alterations in blood coagulation interfere with vitamin K production. 2 A newborn's liver does not produce it immediately after birth. 3 Increased bilirubin levels interfere with vitamin K synthesis during the neonatal period. 4 A newborn's intestinal tract does not synthesize it for several days after birth.
Correct4 A newborn's intestinal tract does not synthesize it for several days after birth.
A client on the psychiatric unit who is receiving high-dosage risperidone is exhibiting tremors of the hands. What will be the nurse's first intervention? 1 Withholding the medication 2 Telling the client it is transitory 3 Giving the client finger exercises 4 Contacting the primary healthcare provider
Correct4 Contacting the primary healthcare provider
The chemotherapy protocol prescribed for a client with tuberculosis includes vitamin B6 and isoniazid. What does the nurse identify as the reason for prescribing vitamin B6? 1 Improve the nutritional status of the client 2 Enhance the tuberculostatic effect of isoniazid 3 Accelerate the destruction of dormant tubercular bacilli 4 Counteract the peripheral neuritis that isoniazid may cause
Correct4 Counteract the peripheral neuritis that isoniazid may cause
An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its antioxidant effects on the structure of cell walls. I wonder whether it is wise to take it." Which vitamin does the nurse conclude the client is describing? 1 K 2 B 1 3 C 4 E
Correct4 E
A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection? 1 It promotes formation of red blood cells. 2 It prevents destruction of red blood cells. 3 It promotes conjugation of bilirubin. 4 It provides protection from hemorrhage.
Correct4 It provides protection from hemorrhage.
A nurse administers several vitamins as part of a client's medical regimen. Which prescribed vitamin is essential for the synthesis of prothrombin by the liver? 1 B12 2 C 3 D 4 K
Correct4 K
A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.
Correct4 Vitamin C is required for collagen production by fibroblasts
Which statements about sleep are correct? Select all that apply. A Sleep involves three phases. B Sleep is associated with healing. C Sleep is a state of rest that occurs for a sustained period. D Sleep restores a person's energy and feeling of well-being. E Sleep is a cyclic physiologic process that alternates with shorter periods of wakefulness
CorrectB Sleep is associated with healing. CorrectC Sleep is a state of rest that occurs for a sustained period. CorrectD Sleep restores a person's energy and feeling of well-bein
A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for an aneurysm in the left femoral artery. Place an X over the site of the pulse that should be assessed to determine maximum arterial perfusion distal to the operative site.
The pedal pulse is located on the top of the foot and is the most distal peripheral pulse.
The nurse is performing a neurologic assessment on a client and notices Battle sign. Place a mark on what part of the client's skull the nurse would view this sign?
https://drive.google.com/file/d/1-hPMmtcIvjzQkfHjvhusbQ82NpY7abU7/view?usp=sharing
Which part of the male reproductive system produces sperm cells? 1 Epididymis 2 Prostate gland 3 Ductus deferens 4 Seminiferous tubules
Correct4 Seminiferous tubules
Which signs and symptoms indicate recurrent infection? Select all that apply. 1 Chills 2 Fatigue 3 Headache 4 Weight gain 5 Increased body temperature
Correct1 Chills Correct2 Fatigue Correct5 Increased body temperature
A client with asthma was taught about self-management with long-acting medication. Which action performed by the client indicates a need for correction? 1 Practicing yoga daily 2 Minimum intake of eight ounces of water daily 3 Taking the medication when an attack is triggered 4 Performing deep breathing exercise whenever possible
Correct3 Taking the medication when an attack is triggered
Which intervention will help a client prevent dental plaque and caries? 1 Performing hand hygiene 2 Drinking fluoridated water 3 Avoiding hot, cold, and spicy foods 4 Eating four to six small meals daily
Correct2 Drinking fluoridated water
Which is a clinical manifestation of osteoarthritis? 1 Inflammation of the joints 2 Pain and stiffness of the joints 3 Tophi around the rim of the ear 4 Generalized achiness in the lower back
Correct2 Pain and stiffness of the joints
What is the most common warning symptom of myocardial infarction in women? 1 Fatigue 2 Nausea 3 Dyspnea 4 Diaphoresis
Correct1 Fatigue
Which condition is associated with fatigue? 1 Pain related to ischemia 2 Dry mouth related to cardiac dysrhythmia 3 Blurred vision related to cardiac dysrhythmia 4 Decreased cardiac output related to cardiac insufficiency
Correct4 Decreased cardiac output related to cardiac insufficiency
Which diagnostic test is beneficial in identifying prostate cancer in men? 1 Mammography 2 Ultrasonography 3 Endometrial biopsy 4 Radiographic examination
Correct2 Ultrasonography
What is the result of increased dental caries in an older adult? 1 Decreased digestion 2 Decreased nutritional status 3 Increased incidence of pyrosis 4 Increased incidence of choking
Correct2 Decreased nutritional status
Which phase produces an irregular purplish immature scar? 1 Maturation 2 Hemostasis 3 Reconstruction 4 Inflammatory phase
Correct3 Reconstruction
Which ethnic group of women has the highest incidence of osteoporosis? 1 Hispanic 2 Asian American 3 Native American 4 African American
Correct2 Asian American
The primary healthcare team is caring for four different groups of clients who were affected by a mass casualty burn event. Which group of clients is considered the lowest priority for care?
Black tags are given to the clients who are dead or about to die. In a mass casualty scene, the healthcare team tries to save the lives of as many people as they can instead of caring for clients who are almost dead. In group B, clients with 90 percent third degree burns have the need for immediate surgical intervention, which may not be possible in a mass casualty event. First priority of care is given to clients with life-threatening conditions. They receive a red tag and are provided immediate attention. Clients with moderate shortness of breath may receive a green tag and can be treated even after few hours. Clients with bleeding bruises may receive yellow tags and should be treated after the treatment of red tagged clients.
Which physiologic characteristics of newborns affect drug dosage considerations? Select all that apply. 1 A newborn's less regulated body temperature 2 Immature liver and kidneys 3 Thick and less permeable skin 4 Lungs with weaker mucous barriers 5 Bacteria-killing acid in the stomach
Correct1 A newborn's less regulated body temperature Correct2 Immature liver and kidneys Correct4 Lungs with weaker mucous barriers
A nurse advises a client to use a firm mattress for sleep and to refrain from sleeping on the abdomen. Which condition does the client most likely have? 1 Back sprain 2 Fibromyalgia 3 Rheumatoid arthritis 4 Ankylosing spondylitis
Correct1 Back sprain
The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes mellitus. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. 1 Confusion 2 Hyperactivity 3 Excessive thirst 4 Fruity-scented breath 5 Decreased urinary output
Correct1 Confusion Correct3 Excessive thirst Correct4 Fruity-scented breath
A client with cardiac dysrhythmia on medication for it. During a follow-up visit, the primary health-care provider learns that the client is experiencing fatigue, anorexia, headache, and visual disturbances. Which medication is likely responsible for the client's condition? 1 Digoxin 2 Adenosine 3 Dobutamine 4 Disopyramide
Correct1 Digoxin
A client with cardiac dysrhythmia reports fatigue, dizziness, and headache. The primary health-care provider finds peripheral edema. What may be causing the client's symptoms? 1 Diltiazem 2 Dopamine 3 Dobutamine 4 Disopyramide
Correct1 Diltiazem
What are the clinical signs of generalized tonic-clonic seizure? Select all that apply. 1 Excessive salivation 2 Partial loss of vision 3 Loss of consciousness 4 Complex hallucinations 5 Cease in the motor activity
Correct1 Excessive salivation Correct2 Partial loss of vision Correct3 Loss of consciousness
A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse suspect is causing these clinical findings? 1 Hypokalemia 2 Hyponatremia 3 Hyperglycemia 4 Hypercalcemia
Correct1 Hypokalemia
A client with inflammation of the membranous sac surrounding the heart has muscle aches, fatigue, and dyspnea. The client reports chest pain that radiates to the shoulder and neck. Which condition does the client have? 1 Pericarditis 2 Endocarditis 3 Hypertension 4 Arteriosclerosis
Correct1 Pericarditis
Which nursing action would be appropriate for treating a client with respiratory alkalosis caused by hyperventilation secondary to anxiety? Select all that apply. 1 Sedating the client 2 Providing mechanical ventilation 3 Administering sodium bicarbonate 4 Helping the client breath into a paper bag 5 Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body
Correct1 Sedating the client Correct4 Helping the client breath into a paper bag Correct5 Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body
A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. 1 Tremors 2 Bradycardia 3 Somnolence 4 Heat intolerance 5 Decreased blood pressure
Correct1 Tremors Correct4 Heat intolerance
Which statement is true regarding ulcerative colitis? 1 Ulcerative colitis may cause rectal bleeding and abdominal cramping. 2 Ulcerative colitis may occur anywhere along the gastrointestinal tract. 3 The stool of a client with ulcerative colitis contains an excess amount of fats. 4 Inflammation in clients with ulcerative colitis may extend through all layers of the bowel.
Correct1 Ulcerative colitis may cause rectal bleeding and abdominal cramping.
A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dosage. For what clinical manifestations should the nurse monitor the client? 1 Constipation and lack of interest in surroundings 2 Agitation and attempts to escape from the hospital 3 Skin dryness and scratching under the incision dressing 4 Lethargy and refusal to participate in therapeutic exercises
Correct2 Agitation and attempts to escape from the hospital
A nurse collecting data from a client with atherosclerosis finds syncope, fatigue, pulse deficit, palpitations, and pulmonary edema. Which disease condition might the nurse suspect? 1 Angina pectoris 2 Atrial fibrillation 3 Myocardial infarction 4 Ventricular tachycardia
Correct2 Atrial fibrillation
A client who visited the hospital reports sneezing, excessive nasal secretions, and itching eyes. On assessment, the condition is diagnosed as anaphylactic hypersensitivity. Which cells act against this reaction? 1 T-cells 2 B-cells 3 Neutrophils 4 Macrophages
Correct2 B-cells
An adolescent with type 1 diabetes is brought to the emergency department in ketoacidosis. The adolescent admits to not adhering to the diabetic regimen. What can the nurse do to help the adolescent become more accepting of the diabetic regimen? 1 Determine what the adolescent has been taught about diabetes 2 Encourage the adolescent to express feelings about having diabetes 3 Explain to the parents that it is their responsibility to demonstrate their acceptance 4 Provide the family with printed materials about the consequences of ineffectively controlled diabetes
Correct2 Encourage the adolescent to express feelings about having diabetes
A client with respiratory disorder complains of fatigue. Which nursing intervention will be beneficial for this client? 1 Assessing the degree of dyspnea 2 Encouraging adequate periods of rest 3 Instruction in effective breathing techniques 4 Monitoring for nasal flaring and sternal retractions
Correct2 Encouraging adequate periods of rest
What are the clinical manifestations of myocardial infarction in women? Select all that apply. 1 Anoxia 2 Indigestion 3 Unusual fatigue 4 Sleep disturbances 5 Tightness of the chest
Correct2 Indigestion Correct3 Unusual fatigue Correct4 Sleep disturbances
A nurse is caring for a postoperative client who has diabetes. Which is the most common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client? 1 Emotional stress 2 Presence of infection 3 Increased insulin dose 4 Inadequate food intake
Correct2 Presence of infection
Status epilepticus develops in an adolescent with a seizure disorder who is taking antiseizure medication. The nurse remembers that the most common reason for the development of status epilepticus is that the prescribed dosage of medication is what? 1 Insufficient to cover activities 2 Probably not taken consistently 3 Ineffective in preventing seizures 4 Did not account for a growth spurt
Correct2 Probably not taken consistently
Which nursing intervention would be beneficial to a client with human immunodeficiency virus (HIV) infection who is experiencing fatigue? 1 Recommending high-fiber foods 2 Scheduling ample periods of rest 3 Recommending dry and salty foods 4 Encouraging fluid intake of more than 2,500 mL/day
Correct2 Scheduling ample periods of rest
A client who recently started receiving oral corticosteroids for a severe allergic reaction is instructed that the dosage will be reduced gradually until all medication is stopped at the end of two weeks. What reason does the nurse provide for this gradual reduction in dosage? 1 Discontinuing the drug too fast will cause the allergic reaction to reappear. 2 Slow reduction of the drug will prevent a physiologic crisis because the adrenal glands are suppressed. 3 The healthcare provider is attempting to determine the minimal dose that will be effective for the allergy. 4 Sudden cessation of the drug will cause development of serious side effects, such as moon face and fluid retention.
Correct2 Slow reduction of the drug will prevent a physiologic crisis because the adrenal glands are suppressed.
A client with anemia undergoing blood transfusion is experiencing dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. What is the priority nursing intervention in this situation? 1 Administering diuretics 2 Stopping the transfusion 3 Administering saline and steroids 4 Notifying the health-care provider
Correct2 Stopping the transfusion
A client reports non-refreshing sleep, cognitive difficulties, anxiety, depression, and a sensation of numbness or tingling in the upper extremities. Which intervention does the nurse anticipate will help manage the client's condition? 1 Administering colchicine and advising the client to get adequate sleep 2 Teaching relaxation techniques and the basic principles of good sleep hygiene 3 Teaching relaxation techniques and encouraging intake of a diet rich in milk and dairy products 4 Promoting correct posture and encouraging sleeping without a pillow and the use of a firm mattress
Correct2 Teaching relaxation techniques and the basic principles of good sleep hygiene
A nurse tells a 71-year-old client with dyspnea, orthopnea, pulmonary crackles, wheezing, and frothy, pink sputum upon coughing to avoid isometric exercise. What is the rationale behind this suggestion? 1 To reduce pain 2 To prevent fatigue 3 To improve coping 4 To strengthen the body
Correct2 To prevent fatigue
A client with diabetes is self-administering insulin. Which action performed by the client indicates a need for correction? 1 Inspecting the vial for crystals 2 Washing the hands with hot water 3 Inspecting the barrel for air bubbles 4 Bringing the insulin to room temperature
Correct2 Washing the hands with hot water
An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the primary healthcare provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive? 1 Administer the dose and monitor the client. 2 Withhold the dose and notify the nurse manager. 3 Administer the dose and document it on the client's record. 4 Withhold the dose and notify the director of the obstetric department.
Correct2 Withhold the dose and notify the nurse manager.
Which client is most likely to report experiencing fatigue? 1 A client with peripheral edema 2 A client limiting vigorous activity 3 A client with increased oxygen demand 4 A client with increased body temperature
Correct3 A client with increased oxygen demand
A client who takes high-dose aspirin for arthritis has an acute episode of right ventricular heart failure. The healthcare provider prescribes furosemide and lowers the client's usual dosage of aspirin. The client asks the nurse the reason for the lower dose. On what principle does the nurse base a response? 1 Aspirin accelerates metabolism of furosemide and decreases the diuretic effect. 2 Aspirin in large doses after an acute stress episode increases the bleeding potential. 3 Competition for renal excretion sites by the drugs causes increased serum levels of aspirin. 4 Use of furosemide and aspirin concomitantly increases formation of uric acid crystals in the nephron.
Correct3 Competition for renal excretion sites by the drugs causes increased serum levels of aspirin
A primary health-care provider asks a nurse to encourage bed rest and to plan care to prevent fatigue in a client. What condition might the client have? 1 Pain related to ischemia 2 Respiratory distress related to cardiac dysrhythmia 3 Decreased cardiac output related to cardiac insufficiency 4 Gastrointestinal complaints related to cardiac dysrhythmia
Correct3 Decreased cardiac output related to cardiac insufficiency
Which statement regarding menopause is true? 1 Hot flashes are a result of an increase in estrogen 2 Menopause usually occurs in women between 18 and 22 years of age 3 During menopause, menstrual flow ceases and hormone levels decrease 4 Cigarette smoking, family history, and surgical interventions are all associated with delayed menopause
Correct3 During menopause, menstrual flow ceases and hormone levels decrease
An adolescent who was admitted to the hospital with ketoacidosis is stable and receiving Novolin R subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. What is the nurse's priority intervention? 1 Delaying the client's lunch tray 2 Providing a glass of low fat milk 3 Obtaining a blood glucose reading 4 Covering the client with a light blanket
Correct3 Obtaining a blood glucose reading
A client has clinical manifestations of rigidity, tremor, bradykinesia, and impaired postural reflexes. Which condition can be suspected in the client? 1 Myasthenia gravis 2 Alzheimer's disease 3 Parkinson's disease 4 Trigeminal neuralgia
Correct3 Parkinson's disease
A client at 38 weeks gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity? 1 Pulse rate 2 Daily weight 3 Patellar reflex 4 Blood pressure
Correct3 Patellar reflex
A client's echocardiogram report indicates decreased cardiac output. Which nursing intervention is most appropriate for this client? 1 Supplying emotional support 2 Teaching relaxation techniques 3 Restricting activity to avoid fatigue 4 Assessing the coping ability of the client
Correct3 Restricting activity to avoid fatigue
The hepatitis B positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine? 1 1.0 mL subcutaneously before discharge 2 0.5 mL subcutaneously within 24 hours of birth 3 1.0 mL intramuscularly within 24 hours of birth 4 0.5 mL intramuscularly within 12 hours of birth
Correct4 0.5 mL intramuscularly within 12 hours of birth
Which action may cause lipohypertrophy in a client who is receiving insulin injections? 1 Injecting insulin subcutaneously 2 Storing insulin in the refrigerator 3 Using buffered regular insulin injections 4 Administering insulin into the same site each time
Correct4 Administering insulin into the same site each time
Which individual is referred to as transgendered? 1 An individual who cross-dresses as an entertainment performance 2 An individual who periodically dresses like a woman 3 An individual who is persistently attracted to people of the same sex 4 An individual whose inward sexuality does not match the sex of his or her body
Correct4 An individual whose inward sexuality does not match the sex of his or her body
A client is to receive donepezil for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed? 1 Nausea 2 Dizziness 3 Headache 4 Constipation
Correct4 Constipation
A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, what action does the nurse perform? 1 Administer the medication after meals. 2 Administer the medication on an empty stomach. 3 Evaluate the client's psychological responses between medication doses. 4 Evaluate the client's muscle strength every hour after the medication is given.
Correct4 Evaluate the client's muscle strength every hour after the medication is given.
A nurse is assisting a health-care provider in providing palliative care to a client with lung cancer who has just undergone surgery. The provider instructs the nurse to assist the client with frequent position changes. Which complication is this intervention intended to prevent? 1 Fever and nausea 2 Fear related to prognosis 3 Fear related to treatment 4 Ineffective airway clearance
Correct4 Ineffective airway clearance
A client with a head injury has been receiving dexamethasone. The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client? 1 Builds glycogen stores in the muscles 2 Produces antibodies by the immune system 3 Allows the increased intracranial pressure to return to normal 4 Promotes return of cortisone production by the adrenal glands
Correct4 Promotes return of cortisone production by the adrenal glands
What is a clinical sign of thrombophlebitis? 1 Cutaneous cyanosis 2 Cramping of the muscles 3 Toes that have necrotic tissue 4 Redness and warmth of the calves
Correct4 Redness and warmth of the calves
A nurse administers the prescribed regular insulin to a client in diabetic ketoacidosis. In addition, an intravenous (IV) solution with potassium is prescribed even though the serum potassium level is within normal limits. What does the nurse recognize as the reason for potassium administration? 1 Potassium loss occurs rapidly from diaphoresis present during coma. 2 Potassium is carried with glucose to the kidneys to be excreted in the urine in increased amounts. 3 Potassium is quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose. 4 Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment.
Correct4 Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment.
Which nursing action would be appropriate to decrease carbon dioxide for a client with respiratory acidosis? 1 Administering sodium bicarbonate 2 Sedating the client to slow the breathing 3 Helping the client breathe into a paper bag 4 Using continuous positive airway pressure (CPAP)
Correct4 Using continuous positive airway pressure (CPAP)
