MED SURG FINAL

Multiple Choice 27. The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A. Decreased ejection fraction B. Decreased heart rate C. Ventricular hypertrophy D. Mitral valve regurgitation

A Rationale: DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in clients with DCM. PTS: 1 REF: p. 776 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 15. A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A. Vigilant monitoring of fluid balance B. Continuous BP monitoring C. Serial arterial blood gases (ABGs) D. Monitoring of the client's airway for patency

A Rationale: Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus. PTS: 1 REF: p. 2010 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. A nurse is working with a client who will undergo invasive urologic testing. The nurse has informed the client that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria? A. Increased fluid intake following the test B. Use of an over-the-counter (OTC) diuretic after the test C. Gentle massage of the lower abdomen D. Activity limitation for the first 12 hours after the test

A Rationale: Drinking fluids can help to clear hematuria. Diuretics are not used for this purpose. Activity limitation and massage are unlikely to resolve this expected consequence of testing. PTS: 1 REF: p. 1546 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure? A. Colonoscopy B. Barium enema C. ERCP D. Upper gastrointestinal fibroscopy

A Rationale: During colonoscopy, tissue biopsies can be obtained, as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy. PTS: 1 REF: p. 1222 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube. D. Topical anesthetics will be used to reduce discomfort during insertion.

A Rationale: Insertion may cause gagging until the tube has passed beyond the throat. Insertion is often unpleasant, but not normally painful. Anesthetic is not usually applied and there is no initial need for a small-gauge tube. PTS: 1 REF: p. 1255 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? A. Atrial fibrillation B. Infective endocarditis C. Recurrent pneumonia D. Recent surgery

A Rationale: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation. PTS: 1 REF: p. 811 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? A. Smoking cessation B. Reduction of alcohol intake C. Maintenance of a diet high in vitamins and nutrients D. Vitamin D supplementation

A Rationale: People who smoke are significantly more likely to develop bladder cancer than those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer. PTS: 1 REF: p. 1626 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

A Rationale: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer. PTS: 1 REF: p. 1277 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply. A. "Are you exposed to any toxins or chemicals at work?" B. "How would you describe your ability to cope with stress?" C. "What medications are you currently taking?" D. "When was the last time you were hospitalized?" E. "Does anyone else in your family struggle with headaches?"

A, B, C, E Rationale: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches. PTS: 1 REF: p. 2025 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 31. The nurse is evaluating a client's diagnosis of arterial insufficiency with reference to the adequacy of the client's blood flow. On what physiologic variables does adequate blood flow depend? Select all that apply. A. Efficiency of heart as a pump B. Adequacy of circulating blood volume C. Ratio of platelets to red blood cells D. Size of red blood cells E. Patency and responsiveness of the blood vessels

A, B, E Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets. PTS: 1 REF: p. 818 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 20. The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A. Improve functional status B. Prevent endocarditis. C. Extend survival. D. Limit physical activity. E. Relieve client symptoms.

A, C, E Rationale: The overall goals of management of heart failure are to relieve the client's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care. PTS: 1 REF: p. 799 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. A. Confusion B. Shortness of breath C. Numbness and tingling in the extremities D. Chest pain E. Bradycardia F. Diuresis

A, E Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity. PTS: 1 REF: p. 809 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is screening a number of adults for hypertension. Which range of blood pressure is considered normal? A. Less than 110/80 mm Hg B. Less than 120/80 mm Hg C. Less than 130/90 mm Hg D. Less than 140/90 mm Hg

B Rationale: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension. PTS: 1 REF: p. 866 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 26. A nurse is caring for a client who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the client's appetite? A. Encourage the family to bring in the client's favorite foods. B. Limit visitors at mealtimes so that the client is not distracted. C. Avoid offering food unless the client initiates. D. Provide thorough oral care immediately after the client eats.

A Rationale: Family involvement and home-cooked favorite foods may help the client to eat. Having visitors at mealtimes may make eating more pleasant and increase the client's appetite. The nurse should not place the complete onus for initiating meals on the client. Oral care after meals is necessary, but does not influence appetite. PTS: 1 REF: p. 1241 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedure care? A. Strain the client's urine following the procedure. B. Administer a bolus of 500 mL normal saline following the procedure. C. Monitor the client for fluid overload following the procedure. D. Insert a urinary catheter for 24 to 48 hours after the procedure.

A Rationale: Following ESWL, the nurse should strain the client's urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL. PTS: 1 REF: p. 1622 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse is caring for a client who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? A. Cardiac monitoring B. Monitoring the implanted device signal C. Pain assessment D. Monitoring the client's level of consciousness (LOC)

A Rationale: Following catheter ablation therapy, the client is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? A. Early ambulation B. Increased dietary intake of protein C. Maintaining the client in a supine position D. Administering aspirin with warfarin

A Rationale: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding. PTS: 1 REF: p. 535 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is caring for a client with a history of endocarditis. Which topic would the nurse prioritize during health promotion education? A. Oral hygiene B. Physical activity C. Dietary guidelines D. Fluid intake

A Rationale: For clients with endocarditis, regular professional oral care combined with personal oral care may reduce the risk of bacteremia. In most cases, diet and fluid intake do not need to be altered. Physical activity has broad benefits, but it does not directly prevent complications of endocarditis. PTS: 1 REF: p. 786 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. Which intervention is the most effective way to prevent rheumatic heart disease? A. Recognizing and promptly treating streptococcal infections B. Prophylactic use of calcium channel blockers in high-risk populations C. Adhering closely to the recommended child immunization schedule D. Promoting smoking cessation in all clients who smoke

A Rationale: Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease. PTS: 1 REF: p. 784 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 8. A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

A Rationale: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acid-base imbalances do not cause peptic ulcer disease. PTS: 1 REF: p. 1278 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for clients on airborne precautions

A Rationale: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV. PTS: 1 REF: p. 1391 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A clinic nurse is caring for a client admitted with acquired immunodeficiency syndrome (AIDS). The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of which complication? A. Human immunodeficiency virus (HIV) encephalopathy B. B-cell lymphoma C. Kaposi sarcoma D. Wasting syndrome

A Rationale: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. B-cell lymphoma is a type of non-Hodgkin lymphoma, and fatigue and weight loss are some typical signs and symptoms. Kaposi sarcoma is a malignancy that impacts clients with HIV/AIDS and involves epithelial layers of blood and lymphatic vessels. Lesions on the skin and lymphedema can cause pain and infections. Wasting syndrome is related to HIV/AIDS and involves involuntary loss of 10% of total weight with diarrhea and fevers. None of the other listed complications normally have cognitive and behavioral manifestations. PTS: 1 REF: p. 1023 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 18: Management of Patients with Upper Respiratory Tract Disorders 1. The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season? A. Wash hands frequently. B. Gargle with warm salt water regularly. C. Dress self and infant warmly. D. Take preventative antibiotics as prescribed.

A Rationale: Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. In addition, antibiotics are not prescribed for a cold. PTS: 1 REF: p. 498 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. A client with diabetic nephropathy has end-stage renal disease and is starting dialysis. What should the nurse teach the client about hemodialysis? A. "Hemodialysis is a treatment option that is usually required three times a week." B. "Hemodialysis is a program that will require you to commit to daily treatment." C. "This will require you to have surgery and a catheter will need to be inserted into your abdomen." D. "Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again."

A Rationale: Hemodialysis is the most commonly used method of dialysis. Clients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatment usually occurs three times a week for at least 3 to 4 hours per treatment. Peritoneal dialysis, not hemodialysis, requires placement of a catheter inserted into the abdomen. PTS: 1 REF: p. 1577 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? A. Increased eosinophils B. Increased neutrophils C. Increased serum albumin D. Decreased blood glucose

A Rationale: Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in clients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing. Which symptom is most closely associated with the early stages of laryngeal cancer? A. Hoarseness B. Dyspnea C. Dysphagia D. Frequent nosebleeds

A Rationale: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Nosebleeds are not associated with a diagnosis of laryngeal cancer. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. Which classification of clients would be at greatest risk for hospital-acquired endocarditis? A. Hemodialysis clients B. Clients on immunoglobulins C. Clients who undergo intermittent urinary catheterization D. Children under the age of 12

A Rationale: Hospital-acquired infective endocarditis occurs most often in clients with debilitating disease or indwelling catheters and in clients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Clients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Clients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis. PTS: 1 REF: p. 785 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.

A Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak. PTS: 1 REF: p. 285 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 23. A school nurse is caring for a 10-year-old who appears to be having an allergic response. Which intervention should be the initial action of the school nurse? A. Assess for signs and symptoms of anaphylaxis. B. Assess for erythema and urticaria. C. Administer an over-the-counter (OTC) antihistamine. D. Administer epinephrine.

A Rationale: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction. PTS: 1 REF: p. 1047 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: A. total gastrectomy. B. bariatric surgery. C. diverticulitis. D. gastroesophageal reflux disease (GERD).

A Rationale: If a total gastrectomy is performed, injection of vitamin B12 will be required for life, because intrinsic factor, secreted by parietal cells in the stomach, binds to vitamin B12 so that it may be absorbed in the ileum. Bariatric surgery, diverticulitis and GERD do not necessitate total gastrectomy and subsequent vitamin B12 supplementation. PTS: 1 REF: p. 1278 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 30. A nurse is conducting a class on how to self-manage insulin regimens. A client asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer? A. "If you are going to use up the vial within 1 month, it can be kept at room temperature." B. "If a vial of insulin will be used up within 21 days, it may be kept at room temperature." C. "If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature." D. "If a vial of insulin will be used up within 1 week, it may be kept at room temperature."

A Rationale: If a vial of insulin will be used up within 1 month, it may be kept at room temperature. PTS: 1 REF: p. 1508 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. The nurse is caring for a client who is in the recovery room following the implantation of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse assess and document? A. ECG to compare time of onset of VT and onset of device's shock B. ECG so health care provider can see what type of dysrhythmia the client has C. Client's level of consciousness (LOC) at the time of the dysrhythmia D. Client's activity at time of dysrhythmia

A Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset. PTS: 1 REF: p. 721 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities? A. Ensure that the client's heels are protected and supported. B. Closely monitor the client's serum albumin and prealbumin levels. C. Perform gentle massage of the client's lower legs, as tolerated. D. Perform passive range-of-motion exercises once per shift.

A Rationale: If the client is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown. PTS: 1 REF: p. 857 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubin B. Decreased serum cholesterol C. Increased blood urea nitrogen (BUN) D. Decreased serum alkaline phosphatase level

A Rationale: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected. PTS: 1 REF: p. 1419 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

A Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration. PTS: 1 REF: p. 594 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A. The client's swallowing ability B. The client's ability to speak C. The client's management of secretions D. The client's airway patency

A Rationale: If the superior laryngeal nerve is damaged, the client may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only indirectly affects management of secretions and airway patency. PTS: 1 REF: p. 1243 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A client is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what issue? A. Hydronephrosis B. Nephritic syndrome C. Pyelonephritis D. Nephrotoxicity

A Rationale: If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. This problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity results from chemical causes. PTS: 1 REF: p. 1611 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A. A tourniquet B. A syringe preloaded with vitamin K C. A unit of packed red blood cells, placed on ice D. A dose of protamine sulfate

A Rationale: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the client's bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not given to treat active postsurgical bleeding. PTS: 1 REF: p. 1200 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. After the completion of testing, a 7-year-old client's allergies have been attributed to the family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote which action? A. Removing the cat from the family's home B. Administering over-the-counter antihistamines to the client regularly C. Keeping the cat restricted from the client's bedroom D. Maximizing airflow in the house

A Rationale: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the client's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines. PTS: 1 REF: p. 1049 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client? A. Insertion of an implantable cardioverter defibrillator (ICD) B. Insertion of an implantable pacemaker C. Administration of a calcium channel blocker D. Administration of a beta-blocker

A Rationale: In clients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an ICD can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the client with left ventricular dysfunction. PTS: 1 REF: p. 804 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 27. A client has been brought to the emergency department by paramedics after being found unconscious. The client's MedicAlert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A. IV administration of 50% dextrose in water B. Subcutaneous administration of 10 units of Humalog C. Subcutaneous administration of 12 to 15 units of regular insulin D. IV bolus of 5% dextrose in 0.45% NaCl

A Rationale: In hospitals and emergency departments, for clients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate, and insulin would exacerbate the client's condition. PTS: 1 REF: p. 1513 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV? A. Male-to-male sexual contact B. Heterosexual contact C. Male-to-male sexual contact with injection drug use D. People 25 to 29 years of age

A Rationale: In the United States from 2012 to 2016, male-to-male sexual contact accounted for approximately 67% of new cases, male-to-male contact with injection use 3%, heterosexual contact 24%, and people 25 to 29 years of age 32.9%. PTS: 1 REF: p. 1008 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 5. The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax? A. Diminished or absent breath sounds on the affected side B. Paradoxical chest wall movement with respirations C. Sudden loss of consciousness D. Muffled heart sounds

A Rationale: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade. PTS: 1 REF: p. 581 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside.

A Rationale: In the client with Barrett esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer, necessitating close monitoring. H2 receptor antagonists are commonly prescribed for clients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for clients with GERD, they should be taken as prescribed whether or not the client is symptomatic. PTS: 1 REF: p. 1257 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion? A. The client is in the compensatory stage of shock. B. The client is in the progressive stage of shock. C. The client will stabilize and be released by tomorrow. D. The client is in the irreversible stage of shock.

A Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described "fight or flight" response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing. PTS: 1 REF: p. 276 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? A. Inform the care team and assess for further signs of possible increased ICP. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Administer a bolus of normal saline as prescribed.

A Rationale: Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the client and administering bronchodilators are insufficient responses, even though these actions may later be prescribed. PTS: 1 REF: p. 2009 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the client's psychosocial status D. Administration of antiretroviral medications

A Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated. PTS: 1 REF: p. 1410 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogenesis D. Risk for contamination related to accumulation of ammonia

A Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure. PTS: 1 REF: p. 1410 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 33. Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization

A Rationale: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid ICP, and handle secretions to avoid aspiration. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has passed. PTS: 1 REF: p. 2039 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client is involved in a motorcycle accident and injures an arm. The health care provider diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A. Posttraumatic arthritis B. Fat embolism syndrome (FES) C. Osteomyelitis D. Compartment syndrome

A Rationale: Intra-articular fractures often lead to posttraumatic arthritis. Research does not indicate a correlation between intra-articular fractures and FES, osteomyelitis, or compartment syndrome. PTS: 1 REF: p. 1159 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela? A. Stroke B. Myocardial infarction (MI) C. Hemorrhage D. Peripheral edema

A Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema. PTS: 1 REF: p. 811 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A nurse is preparing to administer a client's intravenous fat emulsion simultaneously with parenteral nutrition (PN). What principle should guide the nurse's action? A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

A Rationale: Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The client does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing. PTS: 1 REF: p. 1314 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for: A. jaundice. B. bleeding. C. malnutrition. D. hypokalemia.

A Rationale: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0 mg/dL (34 mmol/L). Elevated bilirubin levels are not associated with hypokalemia, malnutrition or bleeding, though these complications may result from the underlying liver disorder. PTS: 1 REF: p. 1371 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A. Knots in the rope should not be resting against pulleys. B. Weights should rest against the bed rails. C. The end of the limb in traction should be braced by the footboard of the bed. D. Skeletal traction may be removed for brief periods to facilitate the client's independence.

A Rationale: Knots in the rope should not rest against pulleys because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted. PTS: 1 REF: p. 1174 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 15. A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to three soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool

A Rationale: Lactulose is given to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the client's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool. PTS: 1 REF: p. 1383 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 6. The nurse is caring for a client who is seeking care for signs and symptoms of lymphedema. The nurse's plan of care should prioritize which nursing diagnosis? A. Risk for infection related to lower extremity swelling secondary to lymphedema B. Disturbed body image related to lower extremity swelling secondary to lymphedema C. Ineffective health maintenance related to lower extremity swelling secondary to lymphedema D. Risk for deficient fluid volume related to lower extremity swelling secondary to lymphedema

A Rationale: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The client's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the client's physiologic well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk. PTS: 1 REF: p. 861 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

A Rationale: MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known, and the disease affects twice as many women as men. PTS: 1 REF: p. 2094 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 38. A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? A. Maintaining a patent airway B. Preventing the need for suctioning C. Maintaining the sterility of the client's airway D. Increasing the client's lung compliance

A Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent. PTS: 1 REF: p. 566 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. A nurse is creating an education plan for a client with venous insufficiency. Which measure should the nurse include in the plan? A. Avoid normal stockings that are tight. B. Limit activities, including walking. C. Sleep with legs below heart level. D. Refrain from using graduated compression stockings.

A Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking; sleeping with legs elevated; and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency. PTS: 1 REF: p. 853 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

A Rationale: Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprazole are proton pump inhibitors that reduce gastric acid secretion. Calcium carbonate does not affect gastric emptying. PTS: 1 REF: p. 1258 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. A client is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the client's pacemaker? A. Monitoring for pacemaker malfunction or battery failure B. Determining when it is appropriate to remove the pacemaker C. Making necessary changes to the pacemaker settings D. Selecting alternatives to future pacemaker use

A Rationale: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are health care provider responsibilities. PTS: 1 REF: p. 715 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? A. Laparoscopic cholecystectomy B. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsy D. Extracorporeal shock wave therapy (ESWL)

A Rationale: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used. Cholecystectomy is the preferred treatment. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

A Rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the client's concerns by wholly deferring to the health care provider. PTS: 1 REF: p. 2103 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 7. A nurse is caring for a 6-year-old client with cystic fibrosis. To enhance the child's nutritional status, which priority intervention should be included in the plan of care? A. Pancreatic enzyme supplementation with meals B. Provision of five to six small meals per day rather than three larger meals C. Total parenteral nutrition (TPN) D. Magnesium, thiamine, and iron supplementation

A Rationale: Nearly 90% of clients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical. PTS: 1 REF: p. 645 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse is performing a respiratory assessment of an adult client and is distinguishing between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. How should the nurse distinguish between these normal breath sounds? A. Their location over a specific area of the lung B. The volume of the sounds C. Whether they are heard on inspiration or expiration D. Whether or not they are continuous breath sounds

A Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Breath sounds are not distinguished solely on the basis of volume. Normal breath sounds are heard on both inspiration and expiration, and are continuous. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. A client with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This client's nursing care should involve which of the following? A. Protection of the affected limb from injury B. Passive and active ROM exercises for the affected limb C. Education about improvements to glycemic control D. Interventions to prevent contractures

A Rationale: Nursing care involves protection of the affected limb or area from injury, as well as appropriate client teaching about mononeuropathy and its treatment. Nursing care for this client does not likely involve exercises or assistive devices, since these are unrelated to the etiology of the disease. Improvements to diabetes management may or may not be necessary. PTS: 1 REF: p. 2110 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated? A. Performing frequent oral care B. Maintaining the client in a supine position C. Suctioning the client every 15 minutes unless contraindicated D. Administering prophylactic antibiotics, as prescribed

A Rationale: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated. PTS: 1 REF: p. 280 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 26. A nurse is planning the care of a client with bronchiectasis. What goal of care should the nurse prioritize? A. The client will successfully mobilize pulmonary secretions. B. The client will maintain an oxygen saturation level of 98%. C. The client's pulmonary blood pressure will decrease to within reference ranges. D. The client will resume prediagnosis level of function within 72 hours.

A Rationale: Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Pulmonary pressures are not a central focus in the care of the client with bronchiectasis. Rapid resumption of prediagnosis function and oxygen saturation above 98% are unrealistic goals. PTS: 1 REF: p. 632 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. While reviewing a client's medical record, the nurse notes that the client has hypothyroidism resulting from dysfunction of the thyroid gland itself. The nurse identifies this as which type of hypothyroidism? A. primary B. central C. secondary D. tertiary

A Rationale: Often clients with hypothyroidism may have primary (thyroidal) hypothyroidism, which refers to dysfunction of the thyroid gland itself. If the cause of the thyroid dysfunction is failure of the pituitary gland, the hypothalamus, or both, then the hypothyroidism is known as central hypothyroidism. If the cause is entirely a pituitary disorder, then it may be referred to as pituitary, or secondary, hypothyroidism. If the cause is a disorder of the hypothalamus resulting in inadequate secretion of TSH due to decreased stimulation by TRH, then it is referred to as hypothalamic, or tertiary, hypothyroidism. PTS: 1 REF: p. 1461 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C. A laparoscopic approach allows for the removal of the entire gallbladder. D. A laparoscopic approach can be performed under conscious sedation.

A Rationale: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthesia in an operating theater. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 6. A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client most likely faces the highest immediate risk of oral cancer? A. A 65-year-old man with alcoholism who smokes B. A 45-year-old woman who has type 1 diabetes and who wears dentures C. A 32-year-old man who is obese and uses smokeless tobacco D. A 57-year-old man with GERD and dental caries

A Rationale: Oral cancers are often associated with the use of alcohol and tobacco, which when used together have a synergistic carcinogenic effect. Most cases of oral cancers occur in people over the age of 60 and a disproportionate number of cases occur in men. Diabetes, dentures, dental caries, and GERD are not risk factors for oral cancer. PTS: 1 REF: p. 1235 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the client takes oral contraceptives. The nurse's postoperative plan of care should include what intervention? A. Early ambulation and leg exercises B. Cessation of the oral contraceptives until 3 weeks' postoperative C. Doppler ultrasound of peripheral circulation twice daily D. Dependent positioning of the client's extremities when at rest

A Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the client may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term. PTS: 1 REF: p. 847 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is preparing a client for cardiac surgery. During the procedure, the client's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this client undergo? A. Orthotopic transplant B. Xenograft C. Heterotopic transplant D. Homograft

A Rationale: Orthotopic transplantation is the most common surgical procedure for cardiac transplantation. The recipient's heart is removed, and the donor heart is implanted at the vena cava and pulmonary veins. Some surgeons still prefer to remove the recipient's heart, leaving a portion of the recipient's atria (with the vena cava and pulmonary veins) in place. Homografts, or allografts (i.e., human valves), are obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement. Xenografts and heterotopic transplantation are not terms used to describe heart transplantation. PTS: 1 REF: p. 779 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? A. "A PFT measures how much air moves in and out of your lungs when you breathe." B. "A PFT measures how much energy you get from the oxygen you breathe." C. "A PFT measures how elastic your lungs are." D. "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood."

A Rationale: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly. PTS: 1 REF: p. 486 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. The nurse is caring for a client who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A. Increase in the size of the artery's lumen B. Decrease in arterial blood flow in relation to venous flow C. Increase in the client's resting heart rate D. Increase in the client's level of consciousness (LOC)

A Rationale: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the client's LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures. PTS: 1 REF: p. 746 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A. Constricted pupils B. Dilated bronchioles C. Decreased peristaltic movement D. Relaxed muscular walls of the urinary bladder

A Rationale: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder. PTS: 1 REF: p. 1975 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client has been living with type 2 diabetes for several years, and the nurse realizes that the client is likely to have minimal contact with the health care system. In order to ensure that the client maintains adequate blood sugar control over the long term, what should the nurse recommend? A. Participation in a support group for persons with diabetes B. Regular consultation of websites that address diabetes management C. Weekly telephone "check-ins" with an endocrinologist D. Participation in clinical trials relating to antihyperglycemics

A Rationale: Participation in support groups is encouraged for clients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on clients' circumstances. PTS: 1 REF: p. 1512 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV fluids. B. Administer broad-spectrum antibiotics. C. Administer IV potassium chloride. D. Administer packed red blood cells.

A Rationale: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally given. Potassium chloride would exacerbate the client's hyperkalemia. PTS: 1 REF: p. 1871 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. An advanced practice nurse is assessing the size and density of a client's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? A. Percussion B. Auscultation C. Inspection D. Rectal examination

A Rationale: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings. PTS: 1 REF: p. 1216 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A. The client may chronically produce excess red blood cells. B. The client may frequently experience a low relative plasma volume. C. The client may have impaired stem cell function. D. The client may previously have undergone bone marrow biopsy.

A Rationale: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy. PTS: 1 REF: p. 896 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. A client with difficulty voiding and elevated BUN and creatinine values has been referred by the health care provider for further evaluation. The nurse should anticipate the use of what initial diagnostic test? A. Portable bladder ultrasound B. X-ray C. Computed tomography (CT) D. Nuclear scan

A Rationale: Portable bladder ultrasound is a method of detecting urinary retention. These devices provide a three-dimensional image of the bladder and should be used after voiding to detect urine retention. Researchers have reported a decrease in urinary tract infections and a shorter hospital stay when this device is used. A portable bladder ultrasound can be done quickly and frequently at the bedside by the nurse to detect urinary retention. There is no ionizing radiation exposure with a portable ultrasound. X-ray, CT and nuclear scans all use a certain amount of ionizing radiation. PTS: 1 REF: p. 1545 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 3. The nurse is providing care for a client who has recently been diagnosed with chronic obstructive pulmonary disease. When educating the client about exacerbations, the nurse should prioritize which topic? A. Identifying specific causes of exacerbations B. Prompt administration of corticosteroids during exacerbations C. The importance of prone positioning during exacerbations D. The relationship between activity level and exacerbations

A Rationale: Prevention is key in the management of exacerbations, and it is important for the client to identify which factors cause exacerbations. Corticosteroids are not normally used as a "rescue" medication, and prone positioning does not enhance oxygenation. Activity in the morning may need to be delayed for an hour or two for bronchial secretions that have collected overnight in the lungs to clear. Therefore, the right amount of activity, at the right time, can impact exacerbations, but prevention is the priority. PTS: 1 REF: p. 616 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client's absolute neutrophil count (ANC) is 440/mm3 but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client? A. Meticulous hand hygiene B. Timely administration of antibiotics C. Provision of a nutrient-dense diet D. Maintaining a sterile care environment

A Rationale: Providing care for a client with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care. PTS: 1 REF: p. 930 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The critical care nurse is caring for a client with a pulmonary artery pressure monitoring system. In addition to assessing left ventricular function, what is an additional function of a pulmonary artery pressure monitoring system? A. To assess the client's response to fluid and drug administration B. To obtain specimens for arterial blood gas measurements C. To dislodge pulmonary emboli D. To diagnose the etiology of chronic obstructive pulmonary disease

A Rationale: Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the client's response to medical interventions, such as fluid administration and vasoactive medications. Pulmonary artery monitoring is preferred over central venous pressure monitoring for the client with heart failure. Arterial catheters are useful when arterial blood gas measurements and blood samples need to be obtained frequently. Neither intervention is used to clear pulmonary emboli. PTS: 1 REF: p. 685 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A. Hot or cold packs B. Analgesics C. Anti-inflammatory medications D. Whirlpool baths

A Rationale: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older client may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in older adults, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment prescribed for older adults. PTS: 1 REF: p. 1985 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes? A. Pathologic B. Superficial C. Deep tendon D. Brachioradialis

A Rationale: Reflexes are classified either as pathological, superficial, or deep tendon. Pathological reflexes often represent the emergence of earlier reflexes that disappeared with the maturity of the nervous system. The palmar reflex is associated with assessing for a pathologic reflex. Superficial and deep tendon reflexes are not assessed using this type of test. Brachioradialis is a type of deep tendon reflex. Reflex tests are performed as a part of neurological assessment to quickly determine an intact spinal cord. PTS: 1 REF: p. 1984 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 19. The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

A Rationale: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress

A Rationale: Risk factors include high alcohol intake; cigarette smoking; and high-fat, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer. PTS: 1 REF: p. 1325 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? A. "The younger you are when you start smoking, the higher your risk of lung cancer." B. "The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays." C. "The risk for lung cancer is determined mostly by what type of cigarettes you smoke." D. "The risk for lung cancer depends primarily on the other risk factors for cancer that you have."

A Rationale: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor. PTS: 1 REF: p. 578 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 16. A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension: A. has a specific cause. B. has a more gradual onset than primary hypertension. C. does not normally cause target organ damage. D. does not normally respond to antihypertensive drug therapy.

A Rationale: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated. PTS: 1 REF: p. 867 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 22. The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client? A. A beta-adrenergic blocker B. An antiplatelet aggregator C. A calcium channel blocker D. A nonsteroidal anti-inflammatory drug (NSAID)

A Rationale: Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed. PTS: 1 REF: p. 800 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem? A. Severe pancreatitis with possible peritonitis B. Acute cholecystitis C. Chronic pancreatitis D. Acute appendicitis with possible perforation

A Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis. PTS: 1 REF: p. 1430 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 8. The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale-appearing calf

A Rationale: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the health care provider for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf. PTS: 1 REF: p. 1175 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 6. A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. "How many alcoholic drinks do you typically consume in a week?" B. "To the best of your knowledge, are your immunizations up to date?" C. "Have you ever worked in an occupation where you might have been exposed to toxins?" D. "Has anyone in your family ever experienced symptoms similar to yours?"

A Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease. PTS: 1 REF: p. 1367 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. A nurse has been asked to give a workshop on chronic obstructive pulmonary disease for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has which pathophysiologic effect? A. Increases the amount of mucus produced B. Destabilizes hemoglobin C. Shrinks the alveoli in the lungs D. Collapses the alveoli in the lungs

A Rationale: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung. Smoking is not known to destabilize hemoglobin, shrink the alveoli in the lungs, or collapse the alveoli in the lungs. PTS: 1 REF: p. 605 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 22. A client is admitted to the critical care unit with a diagnosis of cardiomyopathy. When reviewing the client's most recent laboratory results, the nurse would prioritize assessment of which value? A. Sodium B. Aspartate aminotransferase, alanine aminotransferase, and bilirubin C. White blood cell differential D. Blood urea nitrogen (BUN)

A Rationale: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests. PTS: 1 REF: p. 776 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's level of consciousness (LOC) is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Recognize that this may represent the peak of postsurgical cerebral edema. B. Alert the surgeon to the possibility of an intracranial hemorrhage. C. Understand that the surgery may have been unsuccessful. D. Recognize the need to refer the client to the palliative care team.

A Rationale: Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the client to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage. Any change in the client's LOC should be reported to the healthcare provider. PTS: 1 REF: p. 2012 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client has been diagnosed with a valvular disorder. The client tells the nurse that the client has read about numerous treatment options, including valvuloplasty. Which statement would be most appropriate for the nurse to make regarding valvuloplasty? A. "For some clients, valvuloplasty can be done in a cardiac catheterization laboratory." B. "Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well." C. "Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an overnight hospital stay." D. "It's prudent to get a second opinion before deciding to have valvuloplasty."

A Rationale: Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and the procedure does not carry exceptional risks that would designate it as being dangerous. Normally there is no need for the nurse to advocate for a second opinion. PTS: 1 REF: p. 771 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? A. Incentive spirometry B. Intermittent positive-pressure breathing (IPPB) C. Positive end-expiratory pressure (PEEP) D. Bronchoscopy

A Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used. PTS: 1 REF: p. 530 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A 42-year-old woman comes to the clinic reporting occasional urinary incontinence when sneezing. The clinic nurse should recognize what type of incontinence? A. Stress incontinence B. Reflex incontinence C. Overflow incontinence D. Functional incontinence

A Rationale: Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure, such as a result of exertion, sneezing, coughing, or changing positions. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors (outside the urinary system) make it difficult or impossible for the client to reach the toilet in time for voiding. PTS: 1 REF: p. 1611 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 9. A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize? A. The importance of adhering closely to the prescribed medication regimen B. The disease being a lifelong, chronic condition that will affect activities of daily living (ADLs) C. TB being self-limiting but taking up to 2 years to resolve D. The need to work closely with the occupational and physical therapists

A Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable. PTS: 1 REF: p. 550 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 7. A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

A Rationale: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Clients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis. PTS: 1 REF: p. 1276 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 13. The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor? A. Hypothermia B. Bradycardia C. Coffee ground emesis D. Pain

A Rationale: Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the client for cardiovascular overload and pulmonary edema when large volumes of IV solution are given. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock. PTS: 1 REF: p. 287 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. Begin ECG monitoring. B. Obtain information about family history of heart disease. C. Auscultate lung fields. D. Determine if the client smokes.

A Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the client smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met. PTS: 1 REF: p. 738 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

A Rationale: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 40. The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 3. A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond? A. "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." B. "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." C. "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." D. "Your small intestine will adapt over time to the absence of your appendix."

A Rationale: The appendix is an appendage of the cecum (not the small intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption. PTS: 1 REF: p. 1209 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 36. A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation? A. Teach the client strategies for promoting diaphragmatic breathing. B. Administer supplementary oxygen by simple face mask. C. Teach the client to perform airway suctioning. D. Assist the client in developing an appropriate exercise program.

A Rationale: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in clients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate. PTS: 1 REF: p. 627 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for infection B. Risk for ineffective role performance C. Risk for perioperative positioning injury D. Risk for powerlessness

A Rationale: The client has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated. PTS: 1 REF: p. 1164 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A. Slow the infusion rate and monitor the client closely. B. Discontinue the transfusion and begin resuscitation. C. Pause the transfusion and administer a 250 mL bolus of normal saline. D. Discontinue the transfusion and administer a beta-blocker, as prescribed.

A Rationale: The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload. PTS: 1 REF: p. 904 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 27. A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A. Administer morphine sulfate as prescribed. B. Reposition the client in a prone position. C. Apply a hot pack to the client's scalp. D. Implement distraction techniques.

A Rationale: The client usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in clients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain. PTS: 1 REF: p. 2012 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A client presents at the walk-in clinic reporting diarrhea and vomiting. The client has a documented history of adrenal insufficiency. Considering the client's history and current symptoms, the nurse should anticipate that the client will be instructed to increase intake of: A. sodium. B. potassium. C. simple carbohydrates. D. calcium.

A Rationale: The client will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis. While the client may experience the loss of other electrolytes, the major concern is the replacement of lost sodium. PTS: 1 REF: p. 1478 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever walking several blocks. The client has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The health care provider diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client? A. "Be sure to practice meticulous foot care." B. "Consider cutting down on your smoking." C. "Reduce your activity level to accommodate your limitations." D. "Try to make sure you eat enough protein."

A Rationale: The client with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The client should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. Increased protein intake will not alleviate the client's symptoms. PTS: 1 REF: p. 832 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. A client with gastric cancer has been scheduled for a total gastrectomy. During the preoperative assessment, the client confides in the nurse feeling the surgery will "mutilate" the client's body. The nurse should plan interventions that address what nursing diagnosis? A. Disturbed body image B. Deficient knowledge related to the risks of surgery C. Anxiety about the surgery D. Low self-esteem

A Rationale: The client's choice of words ("mutilate") suggests a change in body image. This may or may not be rooted in anxiety or a lack of knowledge. It may cause an eventual reduction in self-esteem but the essence of the statement is the client's body image. PTS: 1 REF: p. 1281 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding

A Rationale: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. A nurse is promoting increased protein intake to enhance a client's wound healing. What is the enzyme that will initiate the digestion of the protein that the client consumes? A. Pepsin B. Intrinsic factor C. Lipase D. Amylase

A Rationale: The enzyme that initiates the digestion of protein is pepsin. Intrinsic factor combines with vitamin B12 for absorption by the ileum. Lipase aids in the digestion of fats and amylase aids in the digestion of starch. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. The nurse is monitoring blood pressure for a client with unstable readings. How often should the nurse check the client's blood pressure? A. Every 5 minutes B. Every 30 minutes C. Every 30 minutes until stable D. Every 2 minutes

A Rationale: The exact frequency of monitoring is a matter of clinical judgment and varies with the client's condition. Taking vital signs every 5 minutes is appropriate if the blood pressure is changing rapidly; taking vital signs at 15- or 30-minute intervals in a more stable situation may be sufficient. A precipitous drop in blood pressure can occur that would require immediate action to restore blood pressure to an acceptable level. PTS: 1 REF: p. 880 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse is planning client teaching for a client with end-stage kidney disease who is scheduled for the creation of a fistula. The nurse should teach the client what information about the fistula? A. "A vein and an artery in your arm will be attached surgically." B. "The arm should be immobilized for 4 to 6 days." C. "One needle will be inserted into the fistula for each dialysis treatment." D. "The fistula can be used 5 to 7 days after the surgery for dialysis treatment."

A Rationale: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need several weeks to "mature" before it can be used. The client is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment. PTS: 1 REF: p. 1580 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A. The causative agent B. The client's pre-injury health status C. The client's prognosis for recovery D. The circumstances of the accident

A Rationale: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn. PTS: 1 REF: p. 1868 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A. Always carry a form of fast-acting sugar. B. Perform exercise prior to eating whenever possible. C. Eat a meal or snack every 8 hours. D. Check blood sugar at least every 24 hours.

A Rationale: The following teaching points should be included in information provided to the client on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly. PTS: 1 REF: p. 1513 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 34. A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A. A client-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics

A Rationale: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of client-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required. PTS: 1 REF: p. 1878 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 25. The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Decreased pain C. Improved GI function D. Improved cognition

A Rationale: The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue. The drug is not intended to treat pain, or cognitive or GI functions. PTS: 1 REF: p. 2101 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Response 24. The critical care nurse is caring for a client who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located? A. SA node B. AV node C. Bundle of His D. Purkinje cells

A Rationale: The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute). PTS: 1 REF: p. 653 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 21. The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? A. Risk for disturbed body image related to skin lesions B. Risk for disuse syndrome related to dermatitis C. Risk for ineffective role performance related to dermatitis D. Risk for self-care deficit related to skin lesions

A Rationale: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit. PTS: 1 REF: p. 1057 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client? A. Place a pillow between the legs. B. Turn the client on the surgical side. C. Avoid flexion of the right hip. D. Keep the right hip adducted at all times.

A Rationale: The hips should be kept in abduction by a pillow placed between the legs. When positioning the client in bed, the nurse should avoid placing the client on the operated hip. The right hip should not be flexed more than 90 degrees to avoid dislocation. The right hip should be maintained in an abducted position. PTS: 1 REF: p. 1185 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing? A. Function of the hypoglossal nerve B. Function of the vagus nerve C. Function of the spinal nerve D. Function of the trochlear nerve

A Rationale: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue. PTS: 1 REF: p. 1972 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client the nurse is caring for has a permanent pacemaker implanted, with the identification code beginning with VVI. What does this indicate? A. Ventricular paced, ventricular sensed, inhibited B. Variable paced, ventricular sensed, inhibited C. Ventricular sensed, ventricular situated, implanted D. Variable sensed, variable paced, inhibited

A Rationale: The identification of VVI indicates ventricular paced, ventricular sensed, inhibited. PTS: 1 REF: p. 717 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 11. The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

A Rationale: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages. PTS: 1 REF: p. 2045 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 21. A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Hemodynamic instability B. Gastrointestinal hypermotility C. Respiratory arrest D. Hypokalemia

A Rationale: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery. PTS: 1 REF: p. 1871 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care? A. Administer an analgesic before coughing and deep breathing. B. Ambulate the client at least three times daily. C. Arrange for a soft-textured diet and increased fluid intake. D. Encourage the client to speak as little as possible.

A Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Because deep breathing and coughing prevent atelectasis, the client should be given an analgesic prior to performing these respiratory exercises. A soft diet is not necessarily indicated, and there is no need for the client to avoid speaking. Ambulation has multiple benefits, but pain management is not among them. PTS: 1 REF: p. 554 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse identifies a nursing diagnosis of Ineffective Health Maintenance related to nonadherence to therapeutic regimen in a client with hypertension who has not been taking their medication as prescribed. When planning this client's care, which outcome would be appropriate? A. Client takes medication as prescribed and reports any adverse effects. B. Client's BP remains consistently below 140/90 mm Hg. C. Client denies signs and symptoms of hypertensive urgency. D. Client is able to describe modifiable risk factors for hypertension.

A Rationale: The most appropriate expected outcome for a client who is given the nursing diagnosis of risk for ineffective health maintenance is that the client takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the client's role in the treatment regimen. PTS: 1 REF: p. 879 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment? A. "Lately, I have this cough that just never seems to go away." B. "I find that I don't have nearly the stamina that I used to." C. "I seem to get nearly every cold and flu that goes around my workplace." D. "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."

A Rationale: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections, and fatigue are not characteristic early signs of lung cancer. PTS: 1 REF: p. 579 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? A. Do not eliminate insulin when nauseated and vomiting. B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). C. Eat three substantial meals a day, if possible. D. Reduce food intake and insulin doses in times of illness.

A Rationale: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L). PTS: 1 REF: p. 1514 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. An office worker eats a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger, and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed-type (type IV)

A Rationale: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 21. The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

A Rationale: The nurse administers antidiarrheal medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease. PTS: 1 REF: p. 1311 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. A 5-year-old client has been diagnosed with a severe food allergy. Which instruction should the nurse include when educating the parents about this client's allergy and care? A. Wear a medical identification bracelet. B. Know how to use the antihistamine pen. C. Know how to give injections of lidocaine. D. Avoid live attenuated vaccinations.

A Rationale: The nurse also advises the parents to have the client wear a medical identification bracelet and to be able to identify symptoms of food allergy. Clients and their families do not carry antihistamine pens, they carry epinephrine pens. Lidocaine is not self-administered to treat allergies. The client may safely be vaccinated. PTS: 1 REF: p. 1047 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

A Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary. PTS: 1 REF: p. 2001 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? A. Encouraging the client to turn from side to side and to assume a prone position B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C. Minimizing movement of the flexor muscles of the hip D. Encouraging the client to sit in a chair for at least 8 hours a day

A Rationale: The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time. PTS: 1 REF: p. 1197 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The nurse is working on the renal transplant unit. To reduce the risk of infection in a client with a transplanted kidney, it is imperative for the nurse to take what action? A. Wash hands carefully and frequently. B. Ensure immediate function of the donated kidney. C. Instruct the client to wear a face mask. D. Bar visitors from the client's room.

A Rationale: The nurse ensures that the client is protected from exposure to infection by hospital staff, visitors, and other clients with active infections. Careful handwashing is imperative; face masks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the client is receiving high doses of immunosuppressants. Visitors may be limited, but are not normally barred outright. Ensuring kidney function is vital, but does not prevent infection. PTS: 1 REF: p. 1598 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what? A. "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." B. "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." C. "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea." D. "I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I have ketones in my urine."

A Rationale: The nurse must explain the "sick day rules" again to the client who plans to stop taking insulin when sick. The nurse should emphasize that the client should take insulin agents as usual and test the blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring clients may need supplemental doses of regular insulin every 3 to 4 hours. The client should report elevated glucose levels (greater than 300 mg/dL or 16.6 mmol/L, or as otherwise instructed) or urine ketones to the health care provider. If the client is not able to eat normally, the client should be instructed to substitute with soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the client should have an intake of liquids every 30 to 60 minutes to prevent dehydration. PTS: 1 REF: p. 1514 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice Chapter 39: Management of Patients with Oral and Esophageal Disorders 1. The nurse determines that a client who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the nurse's priority when suctioning this client? A. Avoid applying suction on or near the suture line. B. Position client on the non-operative side with the head of the bed down. C. Assess the client's ability to perform self-suctioning. D. Evaluate the client's ability to swallow saliva and clear fluids.

A Rationale: The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Self-sectioning may be unsafe because the client may damage the suture line. Following a modified radical neck dissection with graft, the client is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing the viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the client's ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the client's need for suctioning. PTS: 1 REF: p. 1240 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? A. Increase oral fluids unless contraindicated. B. Call the nurse for oral suctioning, as needed. C. Lie in a low Fowler or supine position. D. Increase activity.

A Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms. PTS: 1 REF: p. 539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? A. Administer the platelets as rapidly as the client can tolerate. B. Establish IV access as soon as the platelets arrive from the blood bank. C. Ensure that the client has a patent central venous catheter. D. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.

A Rationale: The nurse should infuse each unit of platelets as fast as client can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion. PTS: 1 REF: p. 902 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 33. A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A. Perianal region and oral mucosa B. Sacral region and lower abdomen C. Scalp and skin over the scapulae D. Axillae and upper thorax

A Rationale: The nurse should inspect all the client's skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A. Establish fall-prevention measures. B. Encourage bed rest whenever possible. C. Encourage the use of assistive devices. D. Provide constant supervision.

A Rationale: The nurse should take action to limit the client's risk for falls. However, bed rest has too many harmful effects, and assistive devices may or may not be necessary. Constant supervision is not normally required or practicable. PTS: 1 REF: p. 1481 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngectomy. The nurse should encourage the client to use which appliance during recovery at home? A. A room humidifier B. An air conditioner C. A water purifier D. A radiant heater

A Rationale: The nurse stresses the importance of humidification at home and instructs the family to obtain a humidifier before the client returns home. Air conditioning may be too cool and drying for the client. A water purifier or radiant heater is not necessary. PTS: 1 REF: p. 519 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fetor hepaticus D. Palmar erythema

A Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor. PTS: 1 REF: p. 1381 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Choice 8. The nurse is developing a care plan for a client with Cushing syndrome. What nursing diagnosis should the nurse prioritize? A. Risk for injury related to weakness B. Ineffective breathing pattern related to muscle weakness C. Risk for loneliness related to disturbed body image D. Autonomic dysreflexia related to neurologic changes

A Rationale: The nursing priority is to decrease the risk of injury by establishing a protective environment. The client who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners of furniture. The client's breathing will not be affected, and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the client, but safety is a priority. PTS: 1 REF: p. 1480 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries? A. Older adults B. Women more than men C. Adults 35-40 years of age D. School-aged teenagers

A Rationale: The population that is most at risk for hospitalization are older adults. Statistically men have a higher incidence of burns over women. Adults from 35 to 40 years of age are not shown to have a high prevalence. School-aged teenagers do not have a higher prevalence of burns with hospitalization than the aging population. PTS: 1 REF: p. 1866 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 16. A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A. Assess pulse of affected extremity every 15 minutes at first. B. Palpate the affected leg for pain during every assessment. C. Assess the client for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

A Rationale: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery. PTS: 1 REF: p. 836 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 48: Management of Patients with Kidney Disorders 1. The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A. Hematuria B. Precipitous decrease in serum creatinine levels C. Hypotension unresolved by fluid administration D. Glucosuria

A Rationale: The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Glucosuria does not normally accompany glomerulonephritis, and hypertension is much more likely than hypotension. PTS: 1 REF: p. 1558 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 32. A client asks the nurse why kidney problems can cause gastrointestinal disturbances. What relationship should the nurse describe? A. The right kidney's proximity to the pancreas, liver, and gallbladder B. The indirect impact of digestive enzymes on renal function C. That the peritoneum encapsulates the GI system and the kidneys D. The left kidney's connection to the common bile duct

A Rationale: The proximity of the right kidney to the colon, duodenum, head of the pancreas, common bile duct, liver, and gallbladder may cause GI disturbances. The proximity of the left kidney to the colon (splenic flexure), stomach, pancreas, and spleen may also result in intestinal symptoms. Digestive enzymes do not affect renal function, and the left kidney is not connected to the common bile duct. PTS: 1 REF: p. 1544 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 32. The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A Rationale: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications. PTS: 1 REF: p. 1314 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client? A. "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." B. "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." C. "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." D. "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."

A Rationale: The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid, and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. The nurse is caring for a client who has been diagnosed with renal calculi. Prompt management of renal calculi is most important when the stone is located where? A. In the ureteropelvic junction B. In the ureteral segment near the sacroiliac junction C. In the ureterovesical junction D. In the urethra

A Rationale: The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovesical junction. These three areas of the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of the ureteropelvic junction is most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The urethra is not part of the ureter. PTS: 1 REF: p. 1536 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select Chapter 38: Assessment of Digestive and Gastrointestinal Function 1. A nurse is caring for a client who is scheduled for a colonoscopy and whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A. Inflammatory bowel disease B. Intestinal polyps C. Diverticulitis D. Colon cancer

A Rationale: The use of a lavage solution is contraindicated in clients with intestinal obstruction or inflammatory bowel disease. It can safely be used with clients who have polyps, colon cancer, or diverticulitis. PTS: 1 REF: p. 1219 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? A. Measure and record drainage. B. Monitor drainage for change in color. C. Titrate the suction every hour. D. Feed the client via the G tube as prescribed.

A Rationale: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage. PTS: 1 REF: p. 1251 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client's declining cardiac status has been attributed to decreased cardiac action potential. Interventions should be aimed at restoring what aspect of cardiac physiology? A. The cycle of depolarization and repolarization B. The time it takes from the firing of the SA node to the contraction of the ventricles C. The time between the contraction of the atria and the contraction of the ventricles D. The cycle of the firing of the AV node and the contraction of the myocardium

A Rationale: This exchange of ions creates a positively charged intracellular space and a negatively charged extracellular space that characterizes the period known as depolarization. Once depolarization is complete, the exchange of ions reverts to its resting state; this period is known as repolarization. The repeated cycle of depolarization and repolarization is called the cardiac action potential. PTS: 1 REF: p. 654 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

A Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use. PTS: 1 REF: p. 2037 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 30. A client with multiple food and environmental allergies expresses frustration and anger over having to be so watchful all the time and wonders if it is really worth it. Which response by the nurse would be best? A. "I can only imagine how you feel. Would you like to talk about it?" B. "Let's find a quiet spot, and I'll teach you a few coping strategies." C. "That's the same way that most clients who have a chronic illness feel." D. "Do you think that maybe you could be managing things more efficiently?"

A Rationale: To assist the client in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the client. The client is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the client has been mismanaging this health problem, and the nurse should not make comparisons with other clients. Further assessment should precede educational interventions. PTS: 1 REF: p. 1054 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client? A. "Push the knees into the mattress." B. "Lie prone in bed." C. "Contract the buttock muscles." D. "Bend the knees."

A Rationale: To perform quadriceps setting exercises, the client lies in the supine (face up) position with legs extended, and pushes the knees into the bed while contracting the anterior thigh muscles. The client does not lie prone (face down), contract the buttocks, or bend the knees. PTS: 1 REF: p. 1187 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer antianxiety medications as prescribed. D. Reassure the client and family members.

A Rationale: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period. PTS: 1 REF: p. 2020 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A nurse is caring for a client newly diagnosed with type 1 diabetes. The nurse is educating the client about self-administration of insulin in the home setting. The nurse should teach the client to do what action? A. Avoid using the same injection site more than once in 2 to 3 weeks. B. Avoid mixing more than one type of insulin in a syringe. C. Cleanse the injection site thoroughly with alcohol prior to injecting. D. Inject at a 45-degree angle.

A Rationale: To prevent lipodystrophy, the client should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable, within specific guidelines, and the needle is usually inserted at a 90-degree angle. Cleansing the injection site with alcohol is optional. PTS: 1 REF: p. 1509 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information? A. The possibility of surgery, chemotherapy and radiotherapy B. The possibility of needing a short-term or long-term colostomy C. The benefits of weight loss and exercise as tolerated during recovery D. The good prognosis for clients who are treated for gastric cancer

A Rationale: Treatment of gastric cancer is usually multimodal, but does not necessitate a colostomy. Weight loss is not a goal during recovery; exercise is not a high priority and may be unrealistic. The prognosis for clients with gastric cancer is generally poor. PTS: 1 REF: p. 1278 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 39. A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18, 18% Rationale: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9% and the forearm is 9%, for a total of 18% in this client. PTS: 1 REF: p. 1868 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? A. Plasma cells B. Neutrophils C. Red blood cells D. Platelets

A Rationale: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells. PTS: 1 REF: p. 885 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. Dipstick testing of an older adult client's urine indicates the presence of protein. Which statement is true of this assessment finding? A. This finding needs to be considered in light of other forms of testing. B. This finding is a risk factor for urinary incontinence. C. This finding is likely the result of an age-related physiologic change. D. This result confirms that the client has diabetes.

A Rationale: A dipstick examination should be used as a screening test only, because urine concentration, pH, hematuria, and radiocontrast materials all affect the results. Proteinuria is not diagnostic of diabetes, and it is neither an age-related change nor a risk factor for incontinence. PTS: 1 REF: p. 1548 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate? A. Help the client to sit, with head lowered below knees. B. Administer supplementary oxygen by nasal prongs. C. Obtain a full set of vital signs. D. Inform a health care provider or other primary care provider.

A Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. There is no immediate need for a health care provider's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A. Glucose tolerance test B. ERCP C. Pancreatic biopsy D. Abdominal ultrasonography

A Rationale: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound. PTS: 1 REF: p. 1437 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed? A. Iron deficiency anemia B. Pernicious anemia C. Sickle cell disease D. Hemolytic anemia

A Rationale: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica. PTS: 1 REF: p. 914 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 14. A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

A Rationale: A major focus of nursing care for the client with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the client than managing physical activity. PTS: 1 REF: p. 1293 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A. Lumbar puncture B. MRI C. Cerebral angiography D. EEG

A Rationale: A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Client preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture. PTS: 1 REF: p. 1988 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

A Rationale: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a client who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur. PTS: 1 REF: p. 1272 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what amount? A. 30 mL B. 50 mL C. 100 mL D. 125 mL

A Rationale: A urine output below 0.5 mL/kg/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis. PTS: 1 REF: p. 1628 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is caring for a client whose acute kidney injury (AKI) resulted from a prerenal cause. Which condition most likely caused this client's health problem? A. Burns B. Glomerulonephritis C. Ureterolithiasis D. Pregnancy

A Rationale: AKI has categories that identify causation. These are prerenal, intrarenal, and postrenal. Prerenal AKI results from hypoperfusion of the kidney caused by volume depletion. Common causes are burns, hemorrhage, gastrointestinal losses, sepsis, and shock. Glomerulonephritis and ureterolithiasis (kidney stones) are associated with intrarenal causes. Pregnancy is linked to postrenal AKI (obstructions distal to the kidney). PTS: 1 REF: p. 1566 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 40. A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Obtain a prescription for a different analgesic. C. Encourage the client to wiggle and move the fingers. D. Petal the edges of the client's cast.

A Rationale: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Prescribing different analgesics does not address the underlying problem. Encouraging the client to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome. PTS: 1 REF: p. 1164 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A. Administer antidiarrheal medications on a scheduled basis, as prescribed. B. Encourage the client to eat three balanced meals and a snack at bedtime. C. Increase the client's oral fluid intake. D. Encourage the client to increase his or her activity level.

A Rationale: Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the client's diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the client has frequent diarrhea. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

A Rationale: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is given for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia. PTS: 1 REF: p. 1316 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is caring for a client postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A. Assessment of the quantity of the client's urine output B. Assessment of the client's incision C. Assessment of the client's abdominal girth D. Assessment for flank or abdominal pain

A Rationale: After kidney transplantation, the nurse should perform all of the listed assessments. However, oliguria is considered to be more suggestive of rejection than changes to the client's abdomen or incision. PTS: 1 REF: p. 1599 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A. "Make sure you don't bring your knees close together." B. "Try to lie as still as possible for the first few days." C. "Try to avoid bending your knees until next week." D. "Keep your legs higher than your chest whenever you can."

A Rationale: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the client's legs do not need to be higher than the level of the chest. PTS: 1 REF: p. 1185 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? A. Presence of a cough and gag reflex B. Absence of nausea C. Ability to demonstrate deep inspiration D. Oxygen saturation of greater than or equal to92%

A Rationale: After the procedure, it is important that the client takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration. PTS: 1 REF: p. 491 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse is giving discharge instructions to a client following urodynamic testing. What are the priority topics to be addressed by the nurse? A. Beverage limitations, pain control, and urinary expectations B. Antibiotic adherence, carbohydrate restrictions, and urinary expectations C. Protein intake, mobility limitations, and urinary expectations D. Opioid usage, urinary expectations, fat and protein limitations

A Rationale: After the procedure, the client should avoid caffeinated, carbonated, and alcoholic beverages because they can further irritate the bowel and cause pain. The client is encouraged to drink fluids that are not restricted to help clear any hematuria. No other dietary restrictions or limitations are needed. Symptoms of urinary pain and frequency should decrease or subside within a day after the procedure. A further recommendation for pain control is a sitz bath, not opioid use. Clients after this procedure should have instruction about urinary frequency, urgency, dysuria, hematuria, and signs of a urinary tract infection. If an antibiotic was given to the client before the procedure, then the client is encouraged to continue taking the medication. PTS: 1 REF: p. 1546 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. The nurse is aware that afterload influences a client's stroke volume. The nurse recognizes that which factor increases afterload? A. Arterial vasoconstriction B. Venous vasoconstriction C. Arterial vasodilation D. Venous vasodilation

A Rationale: Afterload, or resistance to ejection of blood from the ventricle, is one determinant of stroke volume. There is an inverse relationship between afterload and stroke volume. Arterial vasoconstriction increases afterload, which leads to decreased stroke volume. Conversely, arterial vasodilation decreases afterload because there is less resistance to ejection, and stroke volume increases. Preload, or the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole, is another determinant of stroke volume. There is a direct relationship between preload and stroke volume. Venous vasoconstriction increases preload, which leads to increased stroke volume. Conversely, venous vasodilation decreases preload, which leads to decreased stroke volume. Because the ventricles only eject blood into arteries, not veins, afterload is only affected by arterial, not venous, vasoconstriction and vasodilation. Because the ventricles only receive blood from veins, not arteries, preload is only affected by venous, not arterial, vasoconstriction and vasodilation. PTS: 1 REF: p. 656 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

A Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury. PTS: 1 REF: p. 1876 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 19. A client's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A. Risk for imbalanced fluid volume related to low albumin B. Risk for infection related to low albumin C. Ineffective tissue perfusion related to low albumin D. Impaired skin integrity related to low albumin

A Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection. PTS: 1 REF: p. 890 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A nurse is planning the care of a client with acquired immunodeficiency syndrome (AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? A. Ineffective airway clearance B. Impaired oral mucous membranes C. Imbalanced nutrition: Less than body requirements D. Activity intolerance

A Rationale: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with PCP. Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences. PTS: 1 REF: p. 1028 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable vital signs and arterial blood gases (ABGs) B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGs D. Normal level of consciousness

A Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have a normal level of consciousness. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure? A. An S3 heart sound B. Pleural friction rub C. Faint breath sounds D. A heart murmur

A Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Heart failure does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of heart failure. PTS: 1 REF: p. 805 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A client with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in the client's cortisol levels. How should the nurse interpret this finding? A. The client's pituitary function is compromised. B. The client's adrenal insufficiency is not treatable. C. The client has insufficient hypothalamic function. D. The client would benefit from surgery.

A Rationale: An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested. Hypothalamic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated. PTS: 1 REF: p. 1449 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response? A. Explore the factors underlying the client's anxiety. B. Teach the client guided imagery techniques. C. Obtain an order for a PRN benzodiazepine. D. Describe the procedure in greater detail.

A Rationale: An assessment of anxiety levels is required in the client to assist the client in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client's anxiety before providing interventions such as education or medications. PTS: 1 REF: p. 752 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 24. A client with a diagnosis of heart failure is started on a beta-blocker. What is the nurse's priority role during gradual increases in the client's dose? A. Educating the client that symptom relief may not occur for several weeks B. Stressing that symptom relief may take up to 4 months to occur C. Making adjustments to each day's dose based on the blood pressure trends D. Educating the client about the potential changes in LOC that may result from the drug

A Rationale: An important nursing role during titration is educating the client about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC. PTS: 1 REF: p. 802 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is caring for a 73-year-old client with a urethral obstruction related to prostatic enlargement. When planning this client's care, the nurse should be aware of the risk of what complication? A. Urinary tract infection B. Enuresis C. Polyuria D. Proteinuria

A Rationale: An obstruction of the bladder outlet, such as in advanced benign prostatic hyperplasia, results in abnormally high voiding pressure with a slow, prolonged flow of urine. The urine may remain in the bladder, which increases the potential of a urinary tract infection. Older male clients are at risk for prostatic enlargement, which causes urethral obstruction and can result in hydronephrosis, kidney injury, and urinary tract infections. PTS: 1 REF: p. 1541 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the client refrain from food and fluids after midnight. B. Administer the contrast agent orally 10 to 12 hours before the study. C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A Rationale: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves. PTS: 1 REF: p. 1421 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. Which client would have this type of reaction? A. A client with an anaphylactic reaction after a bee sting B. A client with a skin reaction resulting from adhesive tape C. A client with a diagnosis of myasthenia gravis D. A client with rheumatoid arthritis

A Rationale: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by immunoglobulin E antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV, and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 15. The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? A. The client experiences chest pain, palpitations, or dyspnea. B. The client experiences a noticeable increase in heart rate during activity. C. The client's oxygen saturation level drops below 96%. D. The client's respiratory rate exceeds 30 breaths/min.

A Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the client with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most clients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity. PTS: 1 REF: p. 741 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? A. Defibrillation B. ECG monitoring C. Implantation of a cardioverter defibrillator D. Angioplasty

A Rationale: Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia. PTS: 1 REF: p. 707 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. An older adult client has been diagnosed with aortic regurgitation. Which change in blood flow should the nurse expect to see on this client's echocardiogram? A. Blood to flow back from the aorta to the left ventricle B. Obstruction of blood flow from the left ventricle C. Blood to flow back from the left atrium to the left ventricle D. Obstruction of blood from the left atrium to left ventricle

A Rationale: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle. PTS: 1 REF: p. 767 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice Chapter 23: Management of Patients with Coronary Vascular Disorders 1. The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? A. Lipids and fibrous tissue B. White blood cells C. Lipoproteins D. High-density cholesterol

A Rationale: As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol. PTS: 1 REF: p. 726 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? A. Communicate clearly and frequently with the client's family. B. Taper down interventions slowly when the prognosis worsens. C. Transfer the client to a subacute unit when recovery appears unlikely. D. Ask the client's family how they would prefer treatment to proceed.

A Rationale: As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided throughout the client's care for the family to see, touch, and talk to the client. However, the onus should not be placed on the family to guide care. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client would not be transferred to a subacute unit. PTS: 1 REF: p. 281 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 24. A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

A Rationale: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates. PTS: 1 REF: p. 2042 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? A. "Do you feel any muscle twitches or spasms?" B. "Do you feel flushed or sweaty?" C. "Are you experiencing any dizziness or lightheadedness?" D. "Are you having any pain that seems to be radiating from your bones?"

A Rationale: As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia. PTS: 1 REF: p. 1470 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? A. Initiate chest physiotherapy. B. Immobilize the ribs with an abdominal binder. C. Prepare the client for surgery. D. Immediately sedate and intubate the client.

A Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury. PTS: 1 REF: p. 591 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. The nurse has identified the nursing diagnosis of "Risk for Infection" in a client who undergoes peritoneal dialysis. What nursing action best addresses this risk? A. Maintain aseptic technique when administering dialysate. B. Wash the skin surrounding the catheter site with soap and water prior to each exchange. C. Add antibiotics to the dialysate as prescribed. D. Administer prophylactic antibiotics by mouth or IV as prescribed.

A Rationale: Aseptic technique is used to prevent peritonitis and other infectious complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection. PTS: 1 REF: p. 1585 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

A Rationale: Assessment of the client with an altered LOC often starts with assessing the verbal response through determining the client's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated. PTS: 1 REF: p. 1994 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this client is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B. Administer atropine as a continuous infusion until symptoms resolve. C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D. Administer atropine 1.0 mg sublingually.

A Rationale: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake

A Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated. PTS: 1 REF: p. 1391 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 28. A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure? A. The test is noninvasive, and nothing will be inserted into the client's body. B. The client's pain will be managed aggressively during the procedure. C. The test will provide a detailed profile of the heart's electrical activity. D. The client will remain on bed rest for 1 to 2 hours after the test.

A Rationale: Before transthoracic echocardiography, the nurse informs the client about the test, explaining that it is painless. The test does not evaluate electrophysiology, and bed rest is unnecessary after the procedure. PTS: 1 REF: p. 680 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 27. A client with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A. Blood glucose B. Assessment of urine for blood C. Weight D. Oral temperature

A Rationale: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The client's blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication. PTS: 1 REF: p. 1480 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A teenage client is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? A. Type 1 diabetes B. Type 2 diabetes C. Non-insulin-dependent diabetes D. Prediabetes

A Rationale: Beta cell destruction is the hallmark of type 1 diabetes. Non-insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy. PTS: 1 REF: p. 1490 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. The nurse is caring for a client who has had a biventricular pacemaker implanted. When planning the client's care, the nurse should recognize what goal of this intervention? A. Resynchronization B. Defibrillation C. Angioplasty D. Ablation

A Rationale: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy. PTS: 1 REF: p. 715 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. The nurse is caring for a client who has returned to the postsurgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response? A. Assess the client for signs of bleeding and inform the primary provider. B. Perform a full neurological assessment and notify the primary care provider. C. Increase the frequency of taking vital signs, monitor urine output, and notify the provider. D. Palpate the client's torso bilaterally for flank pain and notify the primary care provider.

A Rationale: Bleeding is a major complication of kidney surgery, and if missed can lead to hypovolemic (decreased volume of circulating blood) and hemorrhagic shock. Bleeding can be suspected when the client experiences fatigue, shortness of breath, and urine output of less than 400 mL within 24 hours. The postoperative client is monitored closely and these findings should be reported to the primary care provider. Ruling out the complication of the life-threatening condition of bleeding is the priority decision for this client. Performing a full neurological assessment will be warranted after the priority complications of surgery are ruled out. Increasing the monitoring of vital signs and urine output are just small parts of assessing the client for bleeding. Palpating the client's torso for flank pain may increase the client's pain and does not (in itself) address the most common cause of the client's signs and symptoms. PTS: 1 REF: p. 1595 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

A Rationale: Blood clotting abnormalities have been found to occur in COVID-19 afflicted clients. With the clotting abnormalities, there is an increased risk for ischemic stroke. There is no evidence that COVID-19 causes any of the other conditions. PTS: 1 REF: p. 2032 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of which condition? A. Retinal blood vessel damage B. Glaucoma C. Cranial nerve damage D. Hypertensive emergency

A Rationale: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset. PTS: 1 REF: p. 879 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. "That's something that you and your doctor will likely talk about after your scars mature." B. "That is something for you to talk to your doctor about because it's not a nursing responsibility." C. "I know this is really important to you, but you have to realize that no one can make you look like you used to." D. "Unfortunately, it's likely that these scars will look like this for the rest of your life."

A Rationale: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the client's query. It is true that the client will not realistically look like he or she used to, but this does not instill hope. PTS: 1 REF: p. 1889 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 34. A medical client's CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding? A. The client may have cancer, but other GI disease must be ruled out. B. The client most likely has early-stage colorectal cancer. C. The client has a genetic predisposition to gastric cancer. D. The client has cancer, but the site is unknown.

A Rationale: CA 19-9 levels are elevated in most clients with advanced pancreatic cancer, but they may also be elevated in other conditions such as colorectal, lung, and gallbladder cancers; gallstones; pancreatitis; cystic fibrosis; and liver disease. A cancer diagnosis cannot be made solely on CA 19-9 results. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect? A. Reducing the heart's workload by decreasing heart rate and myocardial contraction B. Preventing platelet aggregation and subsequent thrombosis C. Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D. Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain

A Rationale: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are given to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries. PTS: 1 REF: p. 734 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 15. The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. The nurse should explain that cardiac catheterization is most commonly done for which purpose? A. To assess how blocked or open a client's coronary arteries are B. To detect how efficiently a client's heart muscle contracts C. To evaluate cardiovascular response to stress D. To evaluate cardiac electrical activity

A Rationale: Cardiac catheterization is usually used to assess coronary artery patency to determine whether revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart. PTS: 1 REF: p. 681 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 36. A postoperative cardiac client experiences signs and symptoms of cardiac tamponade. Which action by the nurse would be most appropriate? A. Prepare to assist with pericardiocentesis. B. Reposition the client into a prone position. C. Administer a dose of metoprolol as prescribed. D. Administer a bolus of normal saline as prescribed.

A Rationale: Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not relieve the pressure on the heart and prone positioning would likely exacerbate symptoms. PTS: 1 REF: p. 788 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor? A. Arrhythmias B. Elevated B-natriuretic peptide (BNP) C. Use of thrombolytics D. Dehydration

A Rationale: Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. An elevated BNP is noted after an MI has occurred and does not increase risk. Use of thrombolytics decreases risk of developing blood clots. Dehydration does not lead to MI. PTS: 1 REF: p. 279 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which client is at greatest risk for developing chronic pharyngitis? A. A client who is a habitual user of alcohol and tobacco B. A client who is a habitual user of caffeine and other stimulants C. A client who eats a diet high in spicy foods D. A client who has gastrointestinal reflux disease (GERD)

A Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, experience chronic cough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The emergency department (ED) nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. Which condition should the ED nurse suspect? A. Fracture of the cribriform plate B. Rupture of an ethmoid sinus C. Abrasion of the soft tissue D. Fracture of the nasal septum

A Rationale: Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 31. A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. Which action is the nurse's best action? A. Rapidly assess the client's cardiopulmonary status. B. Arrange for an electrocardiogram (ECG). C. Increase the height of the client's bed. D. Manage the client's anxiety.

A Rationale: Client management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the client, even though each of these actions may be appropriate and necessary. PTS: 1 REF: p. 811 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is providing education to a client diagnosed with acute rhinosinusitis. For which possible complication should the nurse teach the client to seek follow-up care? A. Periorbital edema B. Headache unrelieved by over-the-counter medications C. Clear drainage from nose D. Blood-tinged mucus when blowing the nose

A Rationale: Client teaching is an important aspect of nursing care for the client with acute rhinosinusitis. The nurse instructs the client about symptoms of complications that require follow-up. Referral to a health care provider is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the client has acute rhinosinusitis. A persistent headache does not necessarily warrant follow-up. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 21. A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment? A. Blood pressure B. Level of consciousness (LOC) C. Nausea D. Oxygen saturation

A Rationale: Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea. PTS: 1 REF: p. 801 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize? A. Rising slowly from a lying or sitting position B. Increasing fluids to maintain BP C. Stopping medication if dizziness persists D. Taking medication first thing in the morning

A Rationale: Clients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these clients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Clients should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice. PTS: 1 REF: p. 879 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. A client who has undergone valve replacement surgery is being prepared for discharge home. Because the client will be discharged with a prescription for warfarin, the nurse would educate the client about the need to take which action? A. Undergo regular testing of the International Normalized Ratio (INR). B. Sleep in a semi-Fowler position for the first 6 to 8 weeks to prevent emboli. C. Avoid foods that contain vitamin K. D. Take enteric-coated acetylsalicylic acid (ASA) on a daily basis.

A Rationale: Clients who take warfarin after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary. PTS: 1 REF: p. 775 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

A Rationale: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room. PTS: 1 REF: p. 2043 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. The nurse is providing client education prior to a client's discharge home after treatment for heart failure. The nurse gives the client a home care checklist as part of the discharge teaching. What should be included on this checklist? A. Know how to recognize and prevent orthostatic hypotension. B. Weigh yourself weekly at a consistent time of day. C. Measure everything you eat and drink until otherwise instructed. D. Limit physical activity to only those tasks that are absolutely necessary.

A Rationale: Clients with heart failure should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort. PTS: 1 REF: p. 810 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? A. Packed red blood cells (PRBCs) B. Vitamin K C. Oral anticoagulants D. Heparin infusion

A Rationale: Clients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh-frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be prescribed once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the client's bleeding. PTS: 1 REF: p. 939 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the client's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?" B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?" D. "Do any of your family members have training in first aid?"

A Rationale: Clients with malabsorption of vitamin B12 need information about lifelong vitamin B12 injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the client to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant. PTS: 1 REF: p. 1270 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is caring for a client who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the client for which clinical manifestation? A. Hemoptysis B. Pain on inspiration C. Pigeon chest D. Dry cough

A Rationale: Clinical manifestations of bronchiectasis include hemoptysis, chronic cough, copious purulent sputum, and clubbing of the fingers. Because of the copious production of sputum, the cough is rarely dry. A pigeon chest or pectus carinatum is a deformity of the chest wall, with children and adolescents being typically affected. Pigeon chest is not associated with this disease. Pain on inspiration is usually associated with respiratory conditions such as pleurisy, pneumonia, or pneumothorax. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. The most recent blood work of a client with a long-standing diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse's most appropriate action? A. Teach the client about actions to slow the progression of nephropathy. B. Ensure that the client receives a comprehensive assessment of liver function. C. Determine whether the client has been using expired insulin. D. Administer a fluid challenge and have the test repeated.

A Rationale: Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the client's liver function is not likely affected. There is no indication for the use of a fluid challenge. PTS: 1 REF: p. 1522 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A pediatric nurse practitioner is caring for a 2-year-old client who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. Which potential causative agent that may trigger an attack should the nurse describe? A. Household pets B. Inadequate sleep C. Psychosocial stress D. Bacteria

A Rationale: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Although some research links inadequate sleep to making asthma worse, it is not a common trigger for attacks. Psychosocial stress is anything that translates to a perceived threat to social status. Stress is listed as a trigger for asthma, but this type of stress is unlikely in a 2-year-old client. A viral, not bacterial, component is linked to asthma triggers. PTS: 1 REF: p. 634 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? A. Have the client identify familiar odors with the eyes closed. B. Assess papillary reflex. C. Utilize the Snellen chart. D. Test for air and bone conduction (Rinne test).

A Rationale: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic). PTS: 1 REF: p. 1969 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) B. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) C. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions D. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)

A Rationale: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L). PTS: 1 REF: p. 1492 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. The nurse is caring for a client who needs education on medication therapy for allergic rhinitis. The client is to take cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication? A. It inhibits the release of histamine and other chemicals. B. It inhibits the action of proton pumps. C. It inhibits the action of the sodium-potassium pump in the nasal epithelium. D. It causes bronchodilation and relaxes smooth muscle in the bronchi.

A Rationale: Cromolyn inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? A. Lactated Ringer B. Albumin C. Dextran D. 3% NaCl

A Rationale: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. The 3% NaCl is a hypertonic solution and is not isotonic. PTS: 1 REF: p. 282 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

A Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present. PTS: 1 REF: p. 1304 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client with a long-standing diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the client for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A. Infection B. Acute pain C. Acute confusion D. Impaired urinary elimination

A Rationale: Decreased sensations of pain and temperature place clients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function. PTS: 1 REF: p. 1523 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client's health issues? A. Stomach emptying takes place more slowly. B. The villi and epithelium of the small intestine become thinner. C. The esophageal sphincter becomes incompetent. D. Saliva production decreases.

A Rationale: Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change. PTS: 1 REF: p. 1212 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 28. A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." B. "A platelet transfusion often further blunts your body's own production of platelets." C. "Finding a matching donor for a platelet transfusion is exceedingly difficult." D. "A very small percentage of the platelets in a transfusion are actually functional."

A Rationale: Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional but because the client's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed. Matching the client's blood type is not usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet production. PTS: 1 REF: p. 933 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is developing a nursing care plan for a client who is being treated for hypertension. Which outcome is most appropriate for the nurse to include? A. Client will reduce Na+ intake to less than 2 g daily. B. Client will have a stable BUN and serum creatinine levels. C. Client will abstain from fat intake and reduce calorie intake. D. Client will maintain a normal body weight.

A Rationale: Dietary sodium intake of less than 2 g daily is recommended as a dietary lifestyle modification to prevent and manage hypertension. Also, giving a specific amount of allowable sodium intake makes this a measurable goal and therefore more appropriate than the other goals, which are not quantifiable or measurable. PTS: 1 REF: p. 870 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize? A. Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B. Reviewing medications, performing a focused cardiovascular assessment, and providing client education C. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D. Routine monitoring of vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions

A Rationale: Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. When vasoactive medications are given, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated), not "routinely." Vasoactive medications should be given through a central, not peripheral, venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. High doses can cause vasoconstriction, which increases afterload and thus increases cardiac workload. Because this effect is undesirable in clients with cardiogenic shock, dopamine doses must be carefully titrated. Reviewing medications and laboratory findings, monitoring urine output, assessing for peripheral edema, performing a focused cardiovascular assessment, and providing client education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. PTS: 1 REF: p. 289 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 23. An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? A. Measure the client's abdominal girth daily. B. Limit the use of opioid analgesics. C. Monitor the client for signs of dysphagia. D. Encourage activity as tolerated.

A Rationale: Due to the risk of ascites, the nurse should monitor the client's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited. PTS: 1 REF: p. 1433 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. The nurse is working with a client whose health history includes occasional episodes of urinary retention. What assessment finding would suggest that the client is currently retaining urine? A. The client's suprapubic region is dull on percussion. B. The client is uncharacteristically drowsy. C. The client claims to void large amounts of urine two to three times daily. D. The client takes a beta adrenergic blocker for the treatment of hypertension.

A Rationale: Dullness on percussion of the suprapubic region is suggestive of urinary retention. Clients retaining urine are typically restless, not drowsy. A client experiencing retention usually voids frequent, small amounts of urine and the use of beta-blockers is unrelated to urinary retention. PTS: 1 REF: p. 1627 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? A. The client's bladder is not completely empty. B. The client has kidney enlargement. C. The client has a ureteral obstruction. D. The client has a fluid volume deficit.

A Rationale: Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying. Enlargement of the kidneys can be attributed to numerous conditions such as polycystic kidney disease or hydronephrosis and is not related to bladder fullness. Dehydration and ureteral obstruction are not related to bladder fullness; in fact, these conditions result in decreased flow of urine to the bladder. PTS: 1 REF: p. 1545 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 36. When assessing venous disease in a client's lower extremities, the nurse knows that what test will most likely be prescribed? A. Duplex ultrasonography B. Echocardiography C. Positron emission tomography (PET) D. Radiography

A Rationale: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow. PTS: 1 REF: p. 825 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 27. Cardiopulmonary resuscitation has been initiated on a client who was found unresponsive. When performing chest compressions, the nurse should do which of the following actions? A. Perform at least 100 chest compressions per minute. B. Pause to allow a colleague to provide a breath every 10 compressions. C. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D. Perform high-quality chest compressions as rapidly as possible.

A Rationale: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitator's goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring. PTS: 1 REF: p. 813 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. Following an addisonian crisis, a client's adrenal function has been gradually regained. The nurse should ensure that the client knows about the need for supplementary corticosteroid therapy in which circumstance? A. A significant illness B. Periods of dehydration C. Episodes of physical exertion D. Administration of a vaccine

A Rationale: During stressful procedures, significant illnesses, or for clients in the third trimester of pregnancy, additional supplementary therapy with corticosteroids is required to prevent addisonian crisis. Physical activity, dehydration, and vaccine administration would not normally add significant stress and would not require supplemental therapy. PTS: 1 REF: p. 1477 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 8. A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period. PTS: 1 REF: p. 1873 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 22: Management of Patients with Arrhythmias and Conduction Problems 1. The nurse is caring for a client who has had an ECG. The nurse notices that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A. Recognize that the view of the electrical current changes in relation to the lead placement. B. Recognize that the electrophysiological conduction of the heart differs with lead placement. C. Inform the technician that the ECG equipment has malfunctioned. D. Inform the health care provider that the client is experiencing a new onset of dysrhythmia.

A Rationale: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias. PTS: 1 REF: p. 692 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

A Rationale: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex. PTS: 1 REF: p. 2009 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement? A. "Increased LDL and decreased HDL increase my risk of coronary artery disease." B. "Increased LDL has the potential to decrease my risk of heart disease." C. "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." D. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

A Rationale: Elevated LDL levels and decreased HDL levels are associated with a greater incidence of coronary artery disease. PTS: 1 REF: p. 695 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 37. When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism

A Rationale: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out. PTS: 1 REF: p. 2044 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 9. A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? A. Encourage the client and family to be active partners in the management of the immunodeficiency. B. Encourage the client and family to manage the client's activity level and activities of daily living effectively. C. Make sure that the client and family understand the importance of monitoring fluid balance. D. Make sure that the client and family know how to adjust dosages of the medications used in treatment.

A Rationale: Encouraging the client and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the client's activity and functional status. Medications should not be adjusted without consultation from the primary provider. Fluid balance is not normally a central concern. PTS: 1 REF: p. 1007 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication? A. Epinephrine 1 mg IV push B. Lidocaine 100 mg IV push C. Amiodarone 300 mg IV push D. Sodium bicarbonate 1 amp IV push

A Rationale: Epinephrine should be given as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists. PTS: 1 REF: p. 714 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. The nurse is assessing a diverse group of clients. What client is at a greater risk for the development of hypothyroidism? A. A 75-year-old female client with osteoporosis B. A 50-year-old male client who is obese C. A 45-year-old female client who uses oral contraceptives D. A 25-year-old male client who uses recreational drugs

A Rationale: Even though osteoporosis is not a risk factor for hypothyroidism, the condition occurs most frequently in older women. Younger men and women generally face a lower risk. PTS: 1 REF: p. 1456 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

A Rationale: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Periorbital edema (swelling around the eyes) is not suggestive of a stroke, and clients less commonly experience dysrhythmias or vomiting. PTS: 1 REF: p. 2051 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 13. A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the health care provider. C. Encourage the client to mobilize in order to enhance motility. D. Contact the health care provider and obtain a swab of the stoma for culture.

B Rationale: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma because infection is unrelated to this problem. PTS: 1 REF: p. 1322 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex

B Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa. PTS: 1 REF: p. 559 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS? A. Risk for disuse syndrome related to Kaposi sarcoma B. Impaired skin integrity related to Kaposi sarcoma C. Diarrhea related to Kaposi sarcoma D. Impaired swallowing related to Kaposi sarcoma

B Rationale: Kaposi sarcoma is a type of cancer caused by human herpesvirus-8 that involves the epithelial layer of blood and lymphatic vessels. It exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs, which may be the first manifestation of HIV, can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome. PTS: 1 REF: p. 1022 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

B Rationale: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function. PTS: 1 REF: p. 1994 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? A. Silver sulfadiazine 1% (Silvadene) water-soluble cream B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C. Silver nitrate 0.5% aqueous solution D. Acticoat

B Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing. PTS: 1 REF: p. 1881 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

B Rationale: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate. PTS: 1 REF: p. 1994 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client is learning about a new diagnosis of asthma with the asthma nurse. What medication will best prevent the onset of acute asthma exacerbations? A. Diphenhydramine B. Montelukast C. Albuterol sulfate D. Epinephrine

B Rationale: Many manifestations of inflammation can be attributed in part to leukotrienes. Medications categorized as leukotriene antagonists or modifiers such as montelukast block the synthesis or action of leukotrienes and prevent signs and symptoms associated with asthma. Diphenhydramine prevents histamine's effect on smooth muscle. Albuterol sulfate relaxes smooth muscle during an asthma attack. Epinephrine relaxes bronchial smooth muscle but is not used on a preventative basis. PTS: 1 REF: p. 1052 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance? A. Plasminogen B. Hemoglobin C. Hematocrit D. Fibrin

B Rationale: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. Erythrocytes are not made of fibrin or plasminogen. Hematocrit is a measure of erythrocyte volume in whole blood. PTS: 1 REF: p. 887 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 9. The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

B Rationale: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement. PTS: 1 REF: p. 1881 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse is caring for a client who is scheduled to undergo mechanical valve replacement. Client education would include coverage of which intervention? A. Use of client-controlled analgesia B. Long-term anticoagulant therapy C. Steroid therapy D. Use of IV diuretics

B Rationale: Mechanical valves necessitate long-term use of required anticoagulants. Diuretics and steroids are not indicated and client-controlled analgesia may or may be not be used in the immediate postoperative period. PTS: 1 REF: p. 775 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous diazepam C. Oral lorazepam D. Oral phenytoin

B Rationale: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus. PTS: 1 REF: p. 2026 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? A. Negative Brudzinski sign B. Positive Kernig sign C. Hyperpatellar reflex D. Sluggish pupil reaction

B Rationale: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis. PTS: 1 REF: p. 2089 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure? A. The need to protect the incision postprocedure B. The use of moderate sedation C. The need to infuse 50% dextrose during the procedure D. The use of general anesthesia

B Rationale: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not given and the procedure does not involve the creation of an incision. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

B Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the client's physiologic deterioration. PTS: 1 REF: p. 1404 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 11. A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A. Taking an opioid analgesic as prescribed B. Applying a cold pack to the injured site C. Performing passive ROM exercises D. Applying a heating pad to the affected muscle

B Rationale: Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids. PTS: 1 REF: p. 1153 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel. B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection. D. The H. pylori microorganism is endemic in warm, moist climates.

B Rationale: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to many areas, not only warm, moist climates. Genetic factors have not been identified. PTS: 1 REF: p. 1271 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 37. In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A. Muscle dexterity B. Muscle tone C. Motor symmetry D. Deep tendon reflexes

B Rationale: Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the client's dexterity, reflexes, or motor symmetry. PTS: 1 REF: p. 1980 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 31. A client who has been taking corticosteroids for several months is experiencing muscle wasting. The client has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? A. Activity limitation to conserve energy B. Consumption of a high-protein diet C. Use of over-the-counter (OTC) vitamin D and calcium supplements D. Passive range-of-motion exercises

B Rationale: Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem. PTS: 1 REF: p. 1485 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? A. The need for frequent eye examinations for clients with diabetes B. The fact that clients with diabetes have an elevated risk of myocardial infarction C. The relationship between kidney function and blood glucose levels D. The need to monitor urine for the presence of albumin

B Rationale: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular. PTS: 1 REF: p. 1519 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

B Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss. PTS: 1 REF: p. 296 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? A. Ask the client to describe the process in detail. B. Observe the client drawing up and administering the insulin. C. Provide a health education session reviewing the main points of insulin delivery. D. Review the client's first hemoglobin A1C result after discharge.

B Rationale: Nurses should assess the client's ability to perform diabetes-related self-care as soon as possible during the hospitalization or office visit to determine whether the client requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the client performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the client about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning. PTS: 1 REF: p. 1509 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? A. Reviewing the cause of shock and prioritizing the client's psychosocial needs B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C. Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive D. Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock

B Rationale: Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of clients in shock; thus, suspecting that a client may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health. PTS: 1 REF: p. 279 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation? A. Loss of adipose tissue B. Loss of skeletal muscle C. Inability to convert adipose tissue to energy D. Inability to maintain normal body mass

B Rationale: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the client has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the client's recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this client. PTS: 1 REF: p. 298 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which item should the nurse integrate into the management of this client's hypertension? A. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption. B. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C. Recognize that an older adult is less likely to adhere to the medication regimen than a younger client. D. Carefully assess for weight loss because of impaired kidney function resulting from normal aging.

B Rationale: Older adults have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more, antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline. PTS: 1 REF: p. 879 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A client was prescribed an oral antibiotic for the treatment of sinusitis. The client has now stopped, reporting the development of a rash shortly after taking the first dose of the drug. Which response by the nurse would be most appropriate? A. Encourage the client to continue with the medication while monitoring the skin condition closely. B. Refer the client to a primary care provider to have the medication changed. C. Arrange for the client to go to the nearest emergency department. D. Encourage the client to take an over-the-counter antihistamine with each dose of the antibiotic.

B Rationale: On discovery of a medication allergy, clients are warned that they have a hypersensitivity to a particular medication and are advised not to take it again. As a result, the client would need to liaise with the primary provider. There is no need for emergency care unless symptoms worsen to involve respiratory function. An antihistamine would not be an adequate or appropriate recommendation from the nurse. PTS: 1 REF: p. 1058 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A. "Cardioversion is done on a beating heart; defibrillation is not." B. "The difference is the timing of the delivery of the electric current." C. "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D. "Cardioversion is always attempted before defibrillation because it has fewer risks."

B Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 20. The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should identify the priority nursing diagnosis of a risk for which outcome in the client's plan of care? A. Ineffective breathing pattern related to hypotension B. Falls related to orthostatic hypotension C. Ineffective role performance related to hypotension D. Imbalanced fluid balance related to hemodynamic variability

B Rationale: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompany it. It does not normally affect breathing or fluid balance. The client's ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety. PTS: 1 REF: p. 666 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 29. The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan? A. Facilitate daily arterial blood gas (ABG) sampling. B. Administer supplementary oxygen, as needed. C. Have client maintain supine positioning when in bed. D. Perform chest physiotherapy, as indicated.

B Rationale: Oxygen should be given along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS. PTS: 1 REF: p. 740 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A. Numbness and tingling in the distal extremities B. Unequal peripheral pulses between extremities C. Visible clubbing of the fingers and toes D. Reddened extremities with muscle atrophy

B Rationale: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD. PTS: 1 REF: p. 835 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 35. A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte values D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B Rationale: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the client's fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual client based on clinical findings and laboratory data. It is not infused more quickly at mealtimes. PTS: 1 REF: p. 1314 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. A client is receiving pharmacologic therapy for treatment of hyperthyroidism and is prescribed propylthiouracil (PTU). When developing this client's plan of care, the nurse integrates understanding that this drug: A. suppresses release of thyroid hormone. B. blocks synthesis of T3 to T4. C. reduces the amount of thyroid tissue. D. destroys overactive thyroid cells.

B Rationale: PTU blocks the synthesis of hormones, the conversion of T3 to T4. Sodium or potassium iodide (SSKI) and dexamethasone suppress the release of thyroid hormones. Thyroid hormones aid in reducing the amount of thyroid tissue and may be given with antithyroid medications to put the thyroid gland at rest. Radioactive iodine is used to destroy overactive thyroid cells. PTS: 1 REF: p. 1453 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? A. Premature degradation of acetylcholine B. Decreased availability of dopamine C. Insufficient synthesis of epinephrine D. Delayed reuptake of serotonin

B Rationale: Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin. PTS: 1 REF: p. 1968 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. An asthma educator is teaching a client newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures highest airflow during which type of breath? A. Forced inspiration B. Forced expiration C. Normal inspiration D. Normal expiration

B Rationale: Peak flow meters measure the highest airflow during a forced expiration. PTS: 1 REF: p. 639 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 8. The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? A. Provide medication teaching related to pseudoephedrine sulfate. B. Teach the client to perform pelvic floor muscle exercises. C. Prepare the client for an anterior vaginal repair procedure. D. Provide information on periurethral bulking.

B Rationale: Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions have a behavioral approach. PTS: 1 REF: p. 1613 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. A client has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? A. Acid-base balance B. Perfusion C. Diffusion D. Ventilation

B Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid-base balance. PTS: 1 REF: p. 467 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A. Folic acid B. Vitamin B12 C. Lactulose D. Magnesium sulfate

B Rationale: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia. PTS: 1 REF: p. 918 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A. Administer analgesics as required. B. Place a pillow between the client's legs when turning. C. Maintain prone positioning at all times. D. Encourage internal and external rotation of the affected leg.

B Rationale: Placing a pillow between the client's legs when turning prevents adduction and supports the client's legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times. PTS: 1 REF: p. 1185 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse is assessing a client who is receiving traction. The nurse's assessment confirms that the client is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A. The leg that was assessed is free from DVT. B. The client's tibial nerve is functional. C. Circulation to the distal extremity is adequate. D. The client does not have peripheral neurovascular dysfunction.

B Rationale: Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction. PTS: 1 REF: p. 1175 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A. Myocardial muscle tissue B. All body fluids C. Cerebral tissue D. Venous and arterial vessel walls

B Rationale: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue. PTS: 1 REF: p. 891 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Response 39. An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock? A. Apply an antibiotic ointment to the client's mucous membranes, as prescribed. B. Perform passive range-of-motion exercises unless contraindicated. C. Initiate total parenteral nutrition (TPN). D. Remove invasive devices as soon as they are no longer needed.

D Rationale: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention. PTS: 1 REF: p. 292 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A. Administration of prophylactic antibiotics B. Administration of pneumococcal vaccine to vulnerable individuals C. Obtaining culture and sensitivity swabs from all newly admitted clients D. Administration of antiretroviral medications to clients over age 65

B Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A one-time vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum. PTS: 1 REF: p. 532 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia

B Rationale: Posttraumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns. PTS: 1 REF: p. 1868 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 28. The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea

B Rationale: Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but prevention of these problems is not the primary rationale for confirming placement. PTS: 1 REF: p. 1240 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. The critical care nurse is caring for a client who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the client's left ventricular function? A. Central venous pressure (CVP) monitoring B. Pulmonary artery pressure monitoring (PAPM) C. Systemic arterial pressure monitoring (SAPM) D. Arterial blood gases (ABGs)

B Rationale: Pulmonary artery pressure monitoring is used to assess left ventricular function. CVP is used to assess right ventricular function; systemic arterial pressure monitoring is used for continual assessment of BP. ABGs are used to assess for acidic and alkalotic levels in the blood. PTS: 1 REF: p. 685 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 38. A client with hyperthyroidism is being treated with radioactive iodine therapy. After receiving the dose of radioiodine, the nurse would assess the client for: A. hypothyroidism. B. thyroid storm. C. hypothermia. D. agranulocytosis.

B Rationale: Radioactive iodine ablation initially causes an acute release of thyroid hormone from the thyroid gland and may cause an increase of symptoms. The client is observed for signs of thyroid storm, not hypothyroidism. Hyperpyrexia, not hypothermia, is associated with thyroid storm. Agranulocytosis is a complication associated with antithyroid drug therapy. PTS: 1 REF: p. 1462 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 17. A client is scheduled for a CT scan of the abdomen with contrast. The client has a baseline creatinine level of 2.3 mg/dL (203 mol/L). In preparing this client for the procedure, the nurse anticipates what orders? A. Monitor the client's electrolyte values every hour before the procedure. B. Provide adequate hydration before the procedure C. Start hemodialysis immediately prior to the CT scan D. Obtain a creatinine clearance by collecting a 24-hour urine specimen.

B Rationale: Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL (177 mol/L) identify the client as being at high risk. Preprocedure hydration the day prior to the test is effective in prevention. The nurse would not monitor the client's electrolytes every hour pre-procedure because this would not change the client's risk factors. To decrease this risk factor, an intervention is needed. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast. PTS: 1 REF: p. 1567 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address which nursing diagnosis? A. Chronic pain B. Ineffective tissue perfusion C. Impaired skin integrity D. Risk for injury

B Rationale: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the client is not at a high risk for injury. PTS: 1 REF: p. 844 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A client has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the client's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A. 1, 2, 5, 4, 3 B. 1, 2, 3, 4, 5 C. 2, 3, 1, 4, 5 D. 3, 1, 2, 5, 4

B Rationale: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the client becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the client may die of fulminant hepatic failure unless he or she receives a liver transplant. PTS: 1 REF: p. 1392 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.

B Rationale: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary. PTS: 1 REF: p. 1321 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? A. Hyperactive deep tendon reflexes B. Reduction in cerebral blood flow C. Increased cerebral metabolism D. Hypersensitivity to painful stimuli

B Rationale: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. PTS: 1 REF: p. 1984 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry cough D. Orthopnea

B Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure. PTS: 1 REF: p. 805 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 33. The health care provider has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder? A. Hypothalamic disorder B. Demyelinating disease C. Brainstem deficit D. Diabetic neuropathy

B Rationale: SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies. PTS: 1 REF: p. 1990 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. The nurse is providing care for a client who has a diagnosis of hereditary angioedema. When planning this client's care, what nursing diagnosis should be prioritized? A. Risk for infection related to skin sloughing B. Risk for acute pain related to loss of skin integrity C. Risk for impaired skin integrity related to cutaneous lesions D. Risk for impaired gas exchange related to airway obstruction

D Rationale: Edema of the respiratory tract can compromise the airway in clients with hereditary angioedema. As such, this is a priority nursing diagnosis over pain and possible infection. Skin integrity is not threatened by angioedema. PTS: 1 REF: p. 1060 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome 1. A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem? A. Blood is shunted from vital organs to peripheral areas of the body. B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

B Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells do not have an adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock. PTS: 1 REF: p. 274 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 5. A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? A. 10:45 AM B. 11:30 AM C. 11:45 AM D. 11:50 AM

B Rationale: Short-acting insulin is called regular insulin. It is in a clear solution and is usually given 15 minutes before a meal or in combination with a longer-acting insulin. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia. PTS: 1 REF: p. 1500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? A. Concurrent use of calcium supplements is contraindicated. B. Blood levels of the drug must be monitored. C. The drug is likely to cause hyperactivity and agitation. D. Carbamazepine can cause tinnitus during the first few days of treatment.

B Rationale: Side effects of carbamazepine include nausea, dizziness, drowsiness, and aplastic anemia. The client must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of the drug. PTS: 1 REF: p. 2108 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 18. A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The nurse assesses that the indwelling urinary catheter was removed one hour ago in the post-anesthesia care unit and that the client has not yet voided. Which action should the nurse take? A. Inform the primary provider promptly. B. Ask if the client needs to void. C. Perform intermittent catheterization. D. Obtain an order to reinsert the indwelling urinary catheter.

B Rationale: Since the indwelling urinary catheter was removed one hour earlier, the client would be expected to void within the next five hours (six hours after removal of the catheter). The nurse should ask the client if there is an urge to void. If the client does not feel the urge to void, the nurse should check periodically over the next 5 hours. Since not voiding within one hour of catheter removal is within normal, the nurse does not need to inform the health care provider, perform intermittent catheterization, or obtain an order to insert an indwelling catheter. PTS: 1 REF: p. 1186 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infection B. The correct procedure for taking a sitz bath C. The need to eat a low-residue, low-fat diet for the next 2 weeks D. The correct technique for keeping the perianal region clean without the use of water

B Rationale: Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat diet is not necessary and water is used to keep the region clean. Postoperative antibiotics are not routinely prescribed. PTS: 1 REF: p. 1336 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. A client with recurrent urinary tract infections has just undergone a cystoscopy and reports slight hematuria during the first void after the procedure. What is the nurse's most appropriate action? A. Administer a STAT dose of vitamin K, as prescribed. B. Reassure the client that this is not unexpected and then monitor the client for further bleeding. C. Promptly inform the health care provider of this assessment finding. D. Position the client supine and insert a Foley catheter, as prescribed.

B Rationale: Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected after cystoscopy. The nurse should explain this to the client and ensure that the bleeding resolves. No clear need exists to report this finding and it does not warrant insertion of a Foley catheter or vitamin K administration. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time would it be best for the nurse to collect the sample? A. Immediately after a meal B. First thing in the morning C. At bedtime D. After a period of exercise

B Rationale: Sputum samples ideally are obtained early in the morning before the client has had anything to eat or drink. PTS: 1 REF: p. 488 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client's room. The nurse asks when the client produced the sputum specimen, and the client states that the specimen is about 4 hours old. What action should the nurse take? A. Immediately take the sputum specimen to the laboratory. B. Discard the specimen and assist the client in obtaining another specimen. C. Refrigerate the sputum specimen and submit it once it is chilled. D. Add a small amount of normal saline to moisten the specimen.

B Rationale: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions. PTS: 1 REF: p. 488 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

B Rationale: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity. PTS: 1 REF: p. 2019 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze

Multiple Choice 36. A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Position the client in high Fowler position B. Discontinue the transfusion. C. Auscultate the client's lungs. D. Obtain a blood specimen from the client.

B Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens. PTS: 1 REF: p. 903 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is caring for a client with gastrointestinal symptoms who reports being under a significant amount of stress at home and at work. Which gastrointestinal effect of stress should the nurse anticipate is affecting this client? A. Increased gastric acid secretion B. Slowed peristalsis C. Increased enteric blood flow D. Relaxed sphincter muscles

B Rationale: Stress stimulates the sympathetic nervous system which slows motility in the gastrointestinal tract, reduces gastric secretions, and causes vasoconstriction. Stimulation of the parasympathetic nervous system causes the non-voluntary sphincters to relax. PTS: 1 REF: p. 1209 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 5. A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? A. The client must not have received an immunization within 7 days. B. The nurse should administer albuterol 30 to 45 minutes prior to the test. C. Prophylactic epinephrine should be given before the test. D. Emergency equipment should be readily available.

D Rationale: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing. PTS: 1 REF: p. 1044 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the health care provider prescribe for this client? A. A sulfonylurea B. A biguanide C. A thiazolidinedione D. An alpha-glucosidase inhibitor

B Rationale: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin, and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha-glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level. PTS: 1 REF: p. 1505 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow? A. Temporal lobe B. Medulla oblongata C. Cerebellum D. Pons

B Rationale: Swallowing is a voluntary act that is regulated by a swallowing center in the medulla oblongata of the central nervous system. Swallowing is not regulated by the temporal lobe, cerebellum, or pons. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD? A. A client with a history of polycystic kidney disease B. A client with diabetes mellitus and poorly controlled hypertension C. A client who is morbidly obese with a history of vascular disorders D. A client with severe chronic obstructive pulmonary disease

B Rationale: Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents may cause ESKD. A client with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the client with diabetes and hypertension is likely at highest risk for ESKD. PTS: 1 REF: p. 1570 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Response 19. The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the client. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A. P-wave inversion B. T-wave inversion C. Qwave changes with no change in ST or T wave D. P-wave enlargement

B Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI. PTS: 1 REF: p. 738 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina (USA)? A. A 63-year-old client with elevated troponins and no elevation in the ST segment. B. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. C. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and ST segment elevations in two contiguous leads on the electrocardiogram (ECG). D. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves.

B Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI. The 48- and 54-year-old clients had test results consistent with an ST-elevated myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous leads, ST elevation, and Q wave abnormalities. PTS: 1 REF: p. 739 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased? A. Magnetic resonance imaging (MRI) B. Electroencephalography (EEG) C. Electromyography (EMG) D. Computed tomography (CT)

B Rationale: The EEG can be used to determine that brain activity has ceased.. MRI and CT scans have been used to declare brain death by showing an absence of blood flow, but this is not the best way to determine that brain activity has ceased. EMG is not normally used to determine brain death. PTS: 1 REF: p. 1988 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart? A. P wave B. T wave C. U wave D. QRS complex

B Rationale: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 30. A gerontologic nurse is analyzing the data from a client's focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiologic change? A. Increased diffusion of gases B. Decreased diffusion capacity for oxygen C. Decreased shunting of blood D. Increased ventilation

B Rationale: The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age. PTS: 1 REF: p. 470 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse is teaching a health class of older adults about urinary tract infections (UTI)s. What characteristic of UTIs should the nurse cite? A. Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. B. The prevalence of UTIs in older men approaches that of women in the same age group. C. Men of all ages are less prone to UTIs, but typically experience more severe symptoms. D. The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.

B Rationale: The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging, resulting in increased incidence. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs. PTS: 1 REF: p. 1605 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 8. A client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this medication? A. Carbamazepine is not known to have serious adverse effects. B. The client should be monitored for bone marrow depression. C. Side effects of the medication include renal dysfunction. D. The medication should be first taken in the maximum dosage form to be effective.

B Rationale: The anticonvulsant agents carbamazepine and phenytoin relieve pain in most clients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased until pain relief is obtained. PTS: 1 REF: p. 2108 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. What should the nurse teach a client on corticosteroid therapy in order to reduce the client's risk of adrenal insufficiency? A. Take the medication late in the day to mimic the body's natural rhythms. B. Always have enough medication on hand to avoid running out. C. Skip up to 2 doses in cases of illness involving nausea. D. Take up to 1 extra dose per day during times of stress.

B Rationale: The client and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The client should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms. PTS: 1 REF: p. 1484 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 36. Resection of a client's bladder tumor has been incomplete and the client is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the client, the nurse should emphasize the need to do which of the following? A. Remain NPO for 12 hours prior to the treatment. B. Hold the solution in the bladder for 2 hours before voiding. C. Drink the intravesical solution quickly and on an empty stomach. D. Avoid acidic foods and beverages until the full cycle of treatment is complete.

B Rationale: The client is allowed to eat and drink before the instillation procedure. Once the bladder is full, the client must retain the intravesical solution for 2 hours before voiding. The solution is instilled through the meatus; it is not consumed orally. There is no need to avoid acidic foods and beverages during treatment. PTS: 1 REF: p. 1627 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is caring for a client who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse explains that the client should self-administer epinephrine at which site? A. Forearm B. Thigh C. Deltoid muscle D. Abdomen

B Rationale: The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue. The muscle of the lateral thigh is the best site to administer epinephrine because it is one of the largest muscles in the body and has significant blood flow, which allows more rapid absorption of the medication than in the smaller muscles in the forearm or shoulder (deltoid) or subcutaneously in the abdomen. PTS: 1 REF: p. 1048 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A nurse is caring for a female client whose urinary retention has not responded to conservative treatment. When educating this client about self-catheterization, the nurse should encourage what practice? A. Assuming a supine position for self-catheterization B. Using clean technique at home to catheterize C. Inserting the catheter 1 to 2 inches (2.5 to 5 cm) into the urethra D. Self-catheterizing every 2 hours at home

B Rationale: The client may use a "clean" (nonsterile) technique at home, where the risk of cross-contamination is reduced. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The female client assumes a Fowler position and uses a mirror to help locate the urinary meatus. The nurse teaches her to catheterize herself by inserting a catheter 7.5 cm (3 inches) into the urethra, in a downward and backward direction. PTS: 1 REF: p. 1620 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to perform ADLs independently. B. Client is able to perform transfers safely. C. Client is able to weight-bear equally on both legs. D. Client is able to demonstrate full ROM of the affected hip.

B Rationale: The client must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the client who has undergone recent hip replacement. PTS: 1 REF: p. 1185 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A client is brought to the renal unit from the PACU status postresection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this client? A. Increasing oral intake B. Managing postoperative pain C. Managing dialysis D. Increasing mobility

B Rationale: The client requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. Increasing oral intake and mobility are not priority nursing actions in the immediate postoperative care of this client. Dialysis is not necessary following kidney surgery. PTS: 1 REF: p. 1564 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend what action? A. Rinse the mouth with alcohol before bedtime for the next 7 days. B. Use warm saline to rinse the mouth as needed. C. Brush around the area with a firm toothbrush to prevent infection. D. Use a toothpick to dislodge any debris that gets lodged in the socket.

B Rationale: The client should be assessed for bleeding after the tooth is extracted. The mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or toothpick could injure the tissues around the extracted area. Alcohol would injure tissues that are healing. PTS: 1 REF: p. 1233 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders 1. A client with sickle cell disease is taking narcotic analgesics for pain control. Which intervention by the nurse would decrease the risk for narcotic substance abuse? A. Encourage the client to rely on complementary and alternative therapies. B. Encourage the client to seek care from a single provider for pain relief. C. Teach the client to accept chronic pain as an inevitable aspect of the disease. D. Limit the reporting of emergency department visits to the primary health care provider.

B Rationale: The client should be encouraged to use a single primary provider to address health care concerns. Emergency department visits should be reported to the primary provider to achieve optimal management of the disease. It would be inappropriate to teach the client to simply accept the pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease. PTS: 1 REF: p. 925 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this client, what would the nurse be sure to include? A. Increasing calcium intake to promote bone healing B. Avoiding chewing food for the specified number of weeks after surgery C. Techniques for managing parenteral nutrition in the home setting D. Techniques for managing a gastrostomy

B Rationale: The client who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary. PTS: 1 REF: p. 1234 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. A 52-year-old client is scheduled to undergo ileal conduit surgery. When planning this client's discharge education, what is the most plausible nursing diagnosis that the nurse should address? A. Impaired mobility related to limitations posed by the ileal conduit B. Deficient knowledge related to care of the ileal conduit C. Risk for deficient fluid volume related to urinary diversion D. Risk for autonomic dysreflexia related to disruption of the sacral plexus

B Rationale: The client will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion. PTS: 1 REF: p. 1629 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client's current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client's medication regimen? A. Avoid high-fat meals while taking this medication. B. Limit fluid intake to 2 L/day. C. Limit sodium intake to 2 g/day. D. Take this medication without regard to meals.

D Rationale: Enfuvirtide (T-20) is injected subcutaneously, so meals are not an important variable. Protein, sodium, and fluid levels are not significant. PTS: 1 REF: p. 1020 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 10. A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

B Rationale: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic. PTS: 1 REF: p. 1299 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. Which assessment should the nurse prioritize? A. The client's swallowing ability B. The client's airway patency C. The client's pain level D. Signs and symptoms of infection

B Rationale: The client with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters, including swallowing ability, pain level, and signs and symptoms of infection, all of which can be assessed after assessing the client's airway patency. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.

B Rationale: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP. PTS: 1 REF: p. 2005 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories B. Morphine sulphate, oxygen, and bed rest C. Oxygen and beta-adrenergic blockers D. Bed rest, albuterol nebulizer treatments, and oxygen

B Rationale: The client with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate. PTS: 1 REF: p. 740 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined? A. By considering the client's age and prognosis B. By objectively determining the client's medical need C. By objectively assessing the client's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options

B Rationale: The client would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options. PTS: 1 REF: p. 1408 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 3. A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.

B Rationale: The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority. PTS: 1 REF: p. 1302 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective? A. "I will have a ham and cheese sandwich for lunch." B. "I will have a baked potato with broiled chicken for dinner." C. "I will have a tossed salad with cheese and croutons for lunch." D. "I will have chicken noodle soup with crackers and an apple for lunch."

B Rationale: The client's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium. PTS: 1 REF: p. 799 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 6. A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? A. An increased hemoglobin and decreased hematocrit B. A decreased hemoglobin and hematocrit C. A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) D. An increased mean corpuscular volume (MCV) and red cell distribution width (RDW)

B Rationale: The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The client will have normal MCV and RDW because the erythrocytes are normal in appearance. PTS: 1 REF: p. 915 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 34. The nurse is reviewing the electronic health record of a client with a history of incontinence. The nurse reads that the health care provider assessed the client's deep tendon reflexes. What condition of the urinary/renal system does this assessment address? A. Renal calculi B. Bladder dysfunction C. Benign prostatic hyperplasia (BPH) D. Recurrent urinary tract infections (UTIs)

B Rationale: The deep tendon reflexes of the knee are examined for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction because the sacral area, which innervates the lower extremities, is in the same peripheral nerve area responsible for urinary continence. Neurologic function does not directly influence the course of renal calculi, BPH or UTIs. PTS: 1 REF: p. 1546 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A client has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the client may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D. Spontaneous bleeding and jaundice

B Rationale: The early manifestations of malignancy of the liver include pain—a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs. PTS: 1 REF: p. 1413 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 21. The nurse is caring for a client with complex cardiac history. How should the nurse best explain the process of depolarization to a colleague? A. Mechanical contraction of the heart muscles B. Electrical stimulation of the heart muscles C. Electrical relaxation of the heart muscles. D. Mechanical relaxation of the heart muscles

B Rationale: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole. PTS: 1 REF: p. 691 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Choice 6. A client newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. Which valvular disorder would the nurse anticipate being diagnosed in this client? A. Aortic regurgitation B. Mitral stenosis C. Mitral valve prolapse D. Aortic stenosis

B Rationale: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Clients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Clients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea, and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis. PTS: 1 REF: p. 768 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range-of-motion exercises.

D Rationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process. PTS: 1 REF: p. 1888 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A. Temperature and oxygen saturation B. Heart rate and blood pressure C. Breath sounds and bowel sounds D. Color, warmth, movement, and sensation of extremities

B Rationale: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The client's condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, blood pressure and heart rate monitoring are priorities over the other listed assessments. PTS: 1 REF: p. 1451 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF? A. Alveolar mucus plugging, infection, and eventual bronchiectasis B. Bronchial mucus plugging, inflammation, and eventual bronchiectasis C. Atelectasis, infection, and eventual COPD D. Bronchial mucus plugging, infection, and eventual COPD

B Rationale: The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes. Infection, atelectasis, and COPD are not hallmark pathologies of CF. PTS: 1 REF: p. 643 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 12. The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

B Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis. PTS: 1 REF: p. 1291 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? A. Risk for activity intolerance related to the presence of a subclavian catheter B. Risk for infection related to the presence of a subclavian catheter C. Risk for functional urinary incontinence related to the presence of a subclavian catheter D. Risk for sleep deprivation related to the presence of a subclavian catheter

B Rationale: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The client will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these. PTS: 1 REF: p. 1315 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia? A. A 50-year-old black woman who is going through menopause B. An 81-year-old woman who has chronic heart failure C. A 48-year-old man who travels extensively and has a high-stress job D. A 13-year-old girl who has just experienced menarche

B Rationale: The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia. PTS: 1 REF: p. 911 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response? A. "In many cases, this type of cancer spreads to other parts of the body." B. "This cancer usually does not spread to distant sites in the body." C. "You will have to speak to your oncologist about that." D. "When it spreads to other parts of the body, the care team will treat it aggressively."

B Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The client's prognosis is determined by the oncologist, but the client has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the client's concerns. PTS: 1 REF: p. 515 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A. Blowing up balloons B. Deliberately frowning C. Smiling repeatedly D. Whistling

D Rationale: Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Blowing up balloons, frowning, and smiling are not considered facial exercises. PTS: 1 REF: p. 2110 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? A. Sequestering free hydrogen ions in the nephrons B. Returning bicarbonate to the body's circulation C. Retaining ammonium chloride D. Excreting bicarbonate in the urine

B Rationale: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions. Other functions include synthesizing ammonia and excreting ammonium chloride PTS: 1 REF: p. 1539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 39. During an adult client's last two office visits, the nurse obtained BP readings of 122/76 mm Hg and 128/78 mm Hg, respectively. How would this client's BP be categorized? A. Normal B. Elevated C. Stage 1 hypertension D. Stage 2 hypertension

B Rationale: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg. PTS: 1 REF: p. 866 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 9. A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A. "Cover the cast with a blanket until the cast dries." B. "Keep your right leg elevated above heart level." C. "Use a clean object to scratch itches inside the cast." D. "A foul smell from the cast is normal after the first few days."

B Rationale: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection. PTS: 1 REF: p. 1168 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? A. Pleurisy B. Heart failure C. Valve dysfunction D. Cardiomyopathy

B Rationale: The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF. It is not specific to cardiomyopathy, pleurisy, or valve dysfunction. PTS: 1 REF: p. 674 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 39. A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutrition C. Bowel incontinence related to parenteral nutrition D. Chronic pain related to catheter placement

B Rationale: The limitations associated with PN can make it difficult for clients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction. PTS: 1 REF: p. 1318 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 32: Management of Patients with Immune Deficiency Disorders 1. A client has just been diagnosed with a primary immune deficiency disease (PIDD). The client has done some research online and believes this is an unlikely diagnosis due to the client's age. At which stage of life are people most commonly diagnosed with PIDD? A. Early childhood B. Infancy C. Adolescence D. Early adulthood

B Rationale: The majority of PIDDs, which are a grouping of rare genetic disorders that impair the immune system, are commonly diagnosed in infancy, with a male to female ratio of 5 to 1. However, some PIDDs are not diagnosed until adolescence or early adulthood. There are more than 200 forms of PIDDs with 270 different genes associated with this condition. PTS: 1 REF: p. 1005 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 23. The nurse is caring for a client with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the client's most recent cardiac imaging, which notes the presence of scarring on the atria. How should the nurse best interpret this finding? A. Recognize that the procedure was unsuccessful. B. Recognize this as a therapeutic goal of the procedure. C. Liaise with the care team in preparation for repeating the maze procedure. D. Prepare the client for pacemaker implantation.

B Rationale: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of the electrical impulse. Consequently, scar formation would constitute a successful procedure. There is no indication for repeating the procedure or implanting a pacemaker. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 5. A client with pericarditis has just been admitted to the critical care unit. The nurse planning the client's care should prioritize which nursing diagnosis? A. Anxiety related to pericarditis B. Acute pain related to pericarditis C. Ineffective tissue perfusion related to pericarditis D. Ineffective breathing pattern related to pericarditis

B Rationale: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment. PTS: 1 REF: p. 789 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones? A. Femur B. Humerus C. Radial head D. Clavicle

B Rationale: The most serious complication of a supracondylar fracture of the humerus is Volkmann ischemic contracture, which results from antecubital swelling or damage to the brachial artery. This complication is specific to humeral fractures. PTS: 1 REF: p. 1180 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Perform chest auscultation. D. Monitor incentive spirometry volumes.

B Rationale: The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status. PTS: 1 REF: p. 540 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. The nurse is doing discharge teaching in the ED with a client who had a nosebleed. What should the nurse include in the discharge teaching of this client? A. Avoid blowing the nose for the next 45 minutes. B. In case of recurrence, apply direct pressure for 15 minutes. C. Do not take aspirin for the next 2 weeks. D. Seek immediate medical attention if the nosebleed recurs.

B Rationale: The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the client is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the client should avoid blowing the nose for an extended period of time, not just 45 minutes. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 31. A client with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the client's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringe B. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheter D. Assessing the patency of the drainage catheter

D Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary. PTS: 1 REF: p. 1407 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A nurse at an allergy clinic is providing education for a client starting immunotherapy for the treatment of allergies. Which education should the nurse prioritize? A. Scheduling appointments for the same time each month B. Keeping appointments for desensitization procedures C. Avoiding antihistamines for the duration of treatment D. Keeping a diary of reactions to the immunotherapy

B Rationale: The nurse informs and reminds the client of the importance of keeping appointments for desensitization procedures, because dosages are usually adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment. Appointments are more frequent than monthly, and antihistamines are not contraindicated. There is no need to keep a diary of reactions. PTS: 1 REF: p. 1054 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 23. When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? A. The client's activities, limitations, and level of consciousness after the attacks B. The client's symptoms and the activities that precipitate attacks C. The client's understanding of the pathology of angina D. The client's coping strategies surrounding the attacks

B Rationale: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview. PTS: 1 REF: p. 735 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse reviews foot care with an older adult client. Why would the nurse feel that foot care is so important to this client? A. An older adult client with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy. B. Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. C. Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. D. Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities.

B Rationale: The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the older adult with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs given for diabetes. PTS: 1 REF: p. 1525 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements.

B Rationale: The nurse should follow the nursing process and perform an assessment prior to interventions. The client's food and fluid intake is more likely to affect bowel function than surgery. PTS: 1 REF: p. 1287 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Elevate the affected extremity to shoulder level when at rest. B. Engage in exercises that strengthen the unaffected muscles. C. Apply topical anesthetics to accessible skin surfaces as needed. D. Avoid using analgesics so that further damage is not masked.

B Rationale: The nurse will encourage the client to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used. PTS: 1 REF: p. 1160 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis? A. Elevate the legs and arms above the heart when resting. B. Encourage the client to engage in a moderate amount of exercise. C. Encourage extended periods of sitting or standing. D. Discourage walking in order to limit pain.

B Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the client to engage in a moderate amount of exercise serves to improve circulation. Elevating the client's legs and arms above the heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain. PTS: 1 REF: p. 830 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? A. Facilitation of long-term intubation B. Restoration of adequate gas exchange C. Attainment of effective coping D. Self-management of oxygen therapy

B Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated. PTS: 1 REF: p. 556 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this client? A. Oral oxycodone B. IV hydromorphone C. IM meperidine D. Oral naproxen

B Rationale: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl, or hydromorphone. There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs. PTS: 1 REF: p. 1431 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client's current health status is most accurate? A. The client's HIV antibodies are successfully, but temporarily, killing the virus. B. The client is infected with HIV but lacks HIV-specific antibodies. C. The client's risk for opportunistic infections is at its peak. D. The client may or may not develop long-standing HIV infection.

B Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. A nurse is providing care to a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse understands that the primary problem involves the: A. anterior pituitary gland. B. posterior pituitary gland. C. thyroid gland. D. adrenal gland.

B Rationale: The posterior lobe of the pituitary gland secretes antidiuretic hormone (ADH), also known as vasopressin; too little ADH results in diabetes insipidus (DI), while too much ADH leads to syndrome of inappropriate antidiuretic hormone (SIADH). SIADH is not associated with a problem involving the anterior pituitary, thyroid, or adrenal glands. PTS: 1 REF: p. 1450 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? A. Change the client's position as indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D. Monitor arterial blood gas (ABG) values.

B Rationale: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in clients with cerebral edema. Changing the client's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume. PTS: 1 REF: p. 2014 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? A. Risk for deficient fluid volume related to impaired erythropoiesis B. Risk for infection related to tissue hypoxia C. Acute pain related to uncontrolled hemolysis D. Fatigue related to decreased oxygen-carrying capacity

D Rationale: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely. PTS: 1 REF: p. 912 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A. Pacific Islanders B. African-Americans C. Asians D. Hispanics

B Rationale: The prevalence of hypertension varies by ethnicity and gender, and is estimated at approximately 32.9% among Caucasian men, 30.1% among Caucasian women, 44.9% among black men, 46.1% among black women, 29.6% among Hispanic men, and 29.9% among Hispanic women. The prevalence of hypertension among blacks is among the highest in the world. PTS: 1 REF: p. 866 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning | Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for clients with a history of transfusion reactions B. Prevention of viral infections from another person's blood C. Avoidance of complications in clients with alloantibodies D. Prevention of alloimmunization

B Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for clients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in clients with alloantibodies. PTS: 1 REF: p. 898 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 8. The nurse is providing education to a client newly diagnosed with hypertension. Which outcome would be most appropriate for this client? A. Client will have no visual disturbances. B. Client will return demonstrate measuring a blood pressure. C. Client will state two side effects of not taking antihypertensives. D. Client will lose two pounds within two weeks.

B Rationale: The primary outcome for this client is making sure that blood pressure remains under control. This is best done by measurement of blood pressure (BP) reading. Visual disturbances can happen with uncontrolled hypertension, but it is not the primary client outcome. Stating two detrimental effects of hypertension is important but not as important as measurement of BP. Losing weight is also important in controlling BP, but the question is not addressing obesity. PTS: 1 REF: p. 877 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a client with this condition? A. Risk for peripheral neurovascular dysfunction B. Excess fluid volume C. Hypothermia D. Ineffective airway clearance

B Rationale: The priority nursing diagnosis for a client with SIADH is excess fluid volume, as the client retains fluids and develops a sodium deficiency. Restricting fluid intake is a typical intervention for managing this syndrome. Temperature imbalances are not associated with SIADH. The client is not at risk for neurovascular dysfunction or a compromised airway. PTS: 1 REF: p. 1452 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action? A. Inform the surgeon of this finding. B. Explain the risks of flexion contracture to the client. C. Transfer the client to a sitting position. D. Encourage the client to perform active ROM exercises with the residual limb.

B Rationale: The residual limb should not be placed on a pillow because a flexion contracture of the hip may result. There is no acute need to contact the client's surgeon. Encouraging exercise or transferring the client does not address the risk of flexion contracture. PTS: 1 REF: p. 1199 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information? A. Skin turgor B. Potassium level C. White blood cell count D. Peripheral pulses

B Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity. PTS: 1 REF: p. 802 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 17: Assessment of Respiratory Function 1. A client is having the tonsils removed. The client asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response? A. "The tonsils separate your windpipe from your throat when you swallow." B. "The tonsils help to guard the body from invasion of organisms." C. "The tonsils make enzymes that you swallow and which aid with digestion." D. "The tonsils help with regulating the airflow down into your lungs."

B Rationale: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, separate the trachea from the esophagus, or regulate airflow to the bronchi. PTS: 1 REF: p. 464 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 13. A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription? A. Traction must temporarily be aligned in a slightly different direction. B. Extra weight is needed initially to keep the limb in proper alignment. C. A lighter weight should be initially used. D. Weight will temporarily alternate between heavier and lighter weights.

B Rationale: The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light. PTS: 1 REF: p. 1176 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. A client with human immunodeficiency virus (HIV) is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe which medication for the management of the client's diarrhea? A. Fluoxetine B. Octreotide acetate C. Levofloxacin D. Valganciclovir

B Rationale: Therapy with octreotide acetate, a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Fluoxetine is an antidepressant and would not be prescribed for the treatment of chronic diarrhea. Levofloxacin is an antibiotic and would not likely be prescribed for chronic severe diarrhea. Valganciclovir is an antiviral medication that is used to treat cytomegalovirus infection and would not be prescribed to treat chronic diarrhea. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)

B Rationale: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that antiviral agents are most effective. Immune globulins and FFP are not indicated. PTS: 1 REF: p. 1390 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A. Drowsiness or lethargy B. Increased urine output C. Decreased heart rate D. Mild agitation

B Rationale: Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output. These drugs do not cause bradycardia, agitation, or drowsiness. PTS: 1 REF: p. 870 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 20: Management of Patients with Chronic Pulmonary Disease 1. A nurse is caring for a 21-year-old client whose medical history includes an alpha1-antitrypsin deficiency. This client has an increased risk of which health problem? A. Pulmonary edema B. Panacinar emphysema C. Cystic fibrosis (CF) D. Empyema

B Rationale: This deficiency predisposes young adult clients to rapid development of panacinar lobular emphysema, even in the absence of smoking. Alpha-antitrypsin deficiency is a genetic disorder that may affect the lungs or liver. It is a risk factor for chronic obstructive pulmonary disease. Alpha1-antitrypsin is an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency does not influence the client's risk of pulmonary edema, CF, or empyema. PTS: 1 REF: p. 607 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. While assessing a client who has pneumonia, the nurse has the client repeat the letter E while the nurse auscultates. The nurse notes that the client's voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented? A. Bronchophony B. Egophony C. Whispered pectoriloquy D. Sonorous wheezes

B Rationale: This finding would be documented as egophony, which can be best assessed by instructing the client to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A. Sputum production B. Shortness of breath C. Throat discomfort D. Epistaxis

B Rationale: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in the health care facility and at home involves monitoring the client for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication. PTS: 1 REF: p. 492 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A medical client rings the call bell and expresses alarm to the nurse, stating, "I've just coughed up this blood. That can't be good, can it?" How can the nurse best determine whether the source of the blood was the client's lungs? A. Obtain a sample and test the pH of the blood, if possible. B. Try to see if the blood is frothy or mixed with mucus. C. Perform oral suctioning to see if blood is obtained. D. Swab the back of the client's throat to see if blood is present.

B Rationale: Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the client's mouth would not reveal the source. PTS: 1 REF: p. 474 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor? A. An attack on the platelets by antibodies B. Decreased production of platelets C. Impaired communication between platelets D. An autoimmune process causing platelet malfunction

B Rationale: Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Impaired platelet communication, antibodies, and autoimmune processes are not typical pathologies. PTS: 1 REF: p. 932 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A nurse is caring for a client with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples? A. A fasting serum potassium level and a random urine sample B. A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C. A BUN and serum creatinine level on three consecutive mornings D. A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values

B Rationale: To calculate creatinine clearance, a 24-hour urine specimen is collected. Midway through the collection, the serum creatinine level is measured. PTS: 1 REF: p. 1539 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test? A. Echocardiography B. Blood cultures C. Cardiac aspiration D. Full blood count

B Rationale: To help determine the causative organisms and the most effective antibiotic treatment for the client, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test. PTS: 1 REF: p. 786 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. A client has been diagnosed as being prehypertensive. What should the nurse encourage this client to do to aid in preventing a progression to a hypertensive state? A. Avoid excessive potassium intake. B. Exercise on a regular basis. C. Eat less protein and more vegetables. D. Limit morning activity.

B Rationale: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for clients to limit their activity in the morning or to avoid potassium and protein intake. PTS: 1 REF: p. 865 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A. Perform chest physiotherapy once per shift and as needed. B. Teach the client to perform deep breathing and coughing exercises. C. Administer prophylactic antibiotics as prescribed. D. Administer nebulized bronchodilators and corticosteroids as prescribed.

B Rationale: To prevent these complications, the nurse should educate the client about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis, and chest physiotherapy is unnecessary and implausible for a client in traction. PTS: 1 REF: p. 1178 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Drag and Drop 22. In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education? A. "I'll try to stay in bed for the first few days to allow myself to heal." B. "I'll make sure that I don't cross my legs when I'm resting in bed." C. "I'll keep pillows under my knees to help my blood circulate better." D. "I'll put on those compression stockings if I get pain in my calves."

B Rationale: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge. PTS: 1 REF: p. 762 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 12. A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the treatment has what main goal? A. Decrease SA node conduction. B. Control ventricular heart rate. C. Improve oxygenation. D. Maintain anticoagulation.

B Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin. PTS: 1 REF: p. 700 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture

B Rationale: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke. PTS: 1 REF: p. 2042 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A nurse is caring for a client with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The client asks how this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics? A. It inhibits the synthesis of bile. B. It inhibits the synthesis and secretion of cholesterol. C. It inhibits the secretion of bile. D. It inhibits the synthesis and secretion of amylase.

B Rationale: UDCA acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. UDCA does not directly inhibit either the synthesis or secretion of bile or amylase. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. The nurse is caring for a client recently diagnosed with renal calculi. The nurse should instruct the client to increase fluid intake to a level where the client produces at least how much urine each day? A. 1,250 mL B. 2,000 mL C. 2,750 mL D. 3,500 mL

B Rationale: Unless contraindicated by kidney injury or hydronephrosis, clients with renal stones should drink at least eight 8-oz (250 mL) glasses of water daily or have IV fluids prescribed to keep the urine dilute. Urine output exceeding 2 L a day is advisable. PTS: 1 REF: p. 1625 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A. Surgery is delayed until the client can eat a regular diet without vomiting. B. Surgery is delayed until the acute symptoms subside. C. The client requires aggressive nutritional support prior to surgery. D. Time is needed to determine whether a laparoscopic procedure can be used.

B Rationale: Unless the client's condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process. PTS: 1 REF: p. 1422 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 28. A client has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test? A. Impaired dentition related to gingivitis B. Risk for impaired skin integrity related to peptic ulcers C. Imbalanced nutrition: Less than body requirements related to enzyme deficiency D. Diarrhea related to Clostridium difficile infection

B Rationale: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 34. The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A. Apply the paddles directly to the client's skin. B. Use a conducting medium between the paddles and the skin. C. Always use a petroleum-based gel between the paddles and the skin. D. Any available liquid can be used between the paddles and the skin.

B Rationale: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 28. A postsurgical client has illuminated the call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the client's left leg is visibly swollen and reddened. Which action by the nurse would be most appropriate? A. Administer a PRN dose of subcutaneous heparin. B. Inform the health care provider that the client has signs and symptoms of venous thromboembolism (VTE). C. Mobilize the client promptly to dislodge any thrombi in the client's lower leg. D. Massage the client's lower leg to temporarily restore venous return.

B Rationale: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the client's leg and mobilizing the client would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism. PTS: 1 REF: p. 847 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the client's health care provider. B. Stop the transfusion immediately. C. Remove the client's IV access. D. Assess the client's chest sounds and vital signs.

B Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed. PTS: 1 REF: p. 906 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. The nurse is caring for a client who is admitted to the medical unit for the treatment of a venous ulcer in the area of the lateral malleolus that has been unresponsive to treatment. Which finding is the nurse most likely to identify during an assessment of this client's wound? A. Hemorrhage B. Heavy exudate C. Deep wound bed D. Pale-colored wound bed

B Rationale: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present. PTS: 1 REF: p. 856 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

B Rationale: Warm water irrigation is one of the methods that can be used to unclog a feeding tube. Removal is not warranted at this early stage and a flicking motion is unlikely to have an effect. The tube should not be withdrawn, even a few centimeters. PTS: 1 REF: p. 1251 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? A. 75 cells/mm3 of blood B. 200 cells/mm3 of blood C. 325 cells/mm3 of blood D. 450 cells/mm3 of blood

B Rationale: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. A nurse is performing a complex neurological assessment on a client recently diagnosed with Alzheimer disease. What question should the nurse anticipate to ask when assessing the client's language ability? A. "How are a pencil and pen alike?" B. "Can you write your name on this blank sheet of paper?" C. "Can you tell me what year it is?" D. "What is the name of the president of the United States?"

B Rationale: When assessing written and spoken language ability, clients are usually asked to read a newspaper article and explain the meaning. Clients are also asked to write their name or copy a simple figure drawn by the examiner. Comparison questions are associated with assessing a client's intellectual function. Asking about the year and current name of the president are associated with assessing a client's mental status. PTS: 1 REF: p. 1980 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. The nurse's assessment of a client with thyroidectomy suggests tetany, and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? A. Oral calcium chloride and vitamin D B. IV calcium gluconate C. STAT levothyroxine D. Administration of parathyroid hormone (PTH)

B Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication. PTS: 1 REF: p. 1473 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 23. A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population? A. Administer prophylactic antibiotics as prescribed. B. Limit the use of indwelling urinary catheters. C. Encourage frequent mobility and repositioning. D. Toilet residents who are immobile on a scheduled basis.

B Rationale: When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adult's risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally given. Mobility does not have a direct effect on UTI risk. PTS: 1 REF: p. 1607 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A. The drug should be discontinued immediately after blood pressure increases. B. The drug dose should be tapered down once vital signs improve. C. The client should have arterial blood gases drawn every 10 minutes during treatment. D. The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.

B Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but draws every 10 minutes are not the norm. PTS: 1 REF: p. 283 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend? A. "Position a fan blowing toxic substances away from you to prevent you from being exposed." B. "Wear protective attire and devices when working with a toxic substance." C. "Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins." D. "Always wear a disposable paper face mask when you are working with inhalable toxins."

B Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area. PTS: 1 REF: p. 577 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is preparing a plan of care for a client with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A. Disturbed body image B. Impaired skin integrity C. Nausea D. Risk for deficient fluid volume

B Rationale: While each of the diagnoses may be applicable to a client with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation. PTS: 1 REF: p. 1438 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A. "Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B. "Abdominal ultrasound poses no known safety risks of any kind." C. "Current guidelines state that a person can have up to 3 ultrasounds per year." D. "Current guidelines state that a person can have up to 6 ultrasounds per year."

B Rationale: An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy. PTS: 1 REF: p. 1217 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hours prior to exam B. Removing all metal-containing objects C. Instructing the client to void prior to the MRI D. Initiating an IV line for administration of contrast

B Rationale: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast. PTS: 1 REF: p. 1986 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 13. A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath after a prolonged episode of coughing. On assessment, the nurse notes an oxygen saturation of 84%, asymmetrical chest movement, and decreased breath sounds on the right side. Which condition should the nurse suspect and which interventions should the nurse implement based on these signs and symptoms? A. Expected response to coughing; give supplemental oxygen and encourage deep breathing exercises B. Pneumothorax; give supplemental oxygen and continue to monitor the client C. Oxygen toxicity; lower any supplemental oxygen and continue to monitor the client D. Chronic atelectasis; give supplemental oxygen and encourage deep breathing exercises

B Rationale: Development of a pneumothorax, a potentially life-threatening complication of COPD, may be spontaneous or related to severe coughing or large intrathoracic pressure changes. The combination of asymmetry of chest movement, differences in breath sounds, and a decreased pulse oximetry are indications of pneumothorax. In response, the nurse should administer supplemental oxygen and continue close bedside monitoring of this client. The signs and symptoms described are not normal findings after coughing or due to chronic atelectasis (alveolar collapse). While a decrease in saturation is expected after coughing, due to irritation of airways and decreased ability to fully oxygenate, the saturation was lower than expected. Oxygen toxicity occurs when too high of a concentration of oxygen is given over a period of time, which triggers a severe inflammatory response. Because no specific duration or amount of oxygen was listed and a hallmark of this condition is substernal discomfort and progressive respiratory difficulties, this was an unlikely choice. PTS: 1 REF: p. 623 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? A. Smoking up to three cigarettes weekly is generally allowable. B. Chronic inhalation of indoor toxins can cause lung damage. C. Minor respiratory infections are considered to be self-limited and are not treated with medication. D. Activities of daily living (ADLs) should be clustered in the early morning hours.

B Rationale: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress. PTS: 1 REF: p. 605 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education? A. The client should drink at least 2 liters of fluid in the next 12 hours. B. The client can resume a normal routine immediately. C. The client should expect fecal urgency for several hours. D. The client can expect some scant rectal bleeding.

B Rationale: Following sigmoidoscopy, clients can resume their regular activities and diet. There is no need to push fluids, and neither fecal urgency nor rectal bleeding is expected. PTS: 1 REF: p. 1224 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse's comprehensive assessment of a client who has heart failure includes evaluation of the client's hepatojugular reflux. What action should the nurse perform during this assessment? A. Elevate the client's head to 90 degrees. B. Press the right upper abdomen. C. Press above the client's symphysis pubis. D. Lay the client flat in bed.

B Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. PTS: 1 REF: p. 805 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 28. A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication? A. "This drug may make my heart beat slower." B. "This drug is particularly good at preventing asthma attacks during exercise." C. "I'll make sure to use this each time I feel an asthma attack coming on." D. "I understand that this drug is less effective at controlling night-time symptoms."

B Rationale: LABAs are effective in the prevention of exercise-induced asthma. They are also used with anti-inflammatory medications to control asthma symptoms, particularly those that occur during the night. LABAs are not indicated for immediate relief of symptoms. are not used for management of acute asthma symptoms. Tachycardia, not bradycardia, is a potential adverse effect of this medication. PTS: 1 REF: p. 639 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 23. A client on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurse's care of this client? A. The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life. B. The client's disease is incurable and the nurse's interventions will be supportive. C. The client will eventually require surgical removal of his or her renal cysts. D. The client is likely to respond favorably to lithotripsy treatment of the cysts.

B Rationale: Nursing actions focus on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy. PTS: 1 REF: p. 1562 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics? A. Avoid drinking fluids for 2 hours after taking the diuretic. B. Take the diuretic in the morning to avoid interfering with sleep. C. Avoid taking the medication within 2 hours consuming dairy products. D. Take the diuretic only on days when experiencing shortness of breath.

B Rationale: Oral diuretics should be given early in the morning so that diuresis does not interfere with the client's nighttime rest. Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated. PTS: 1 REF: p. 806 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. 0.45% NaCl with 40 mEq/L KCl C. Normal saline D. Lactated Ringer

D Rationale: Fluid resuscitation with lactated Ringer (LR) should be initiated using the American Burn Association's (ABA) fluid resuscitation formulas. LR is the crystalloid of choice because its composition and osmolality most closely resemble plasma and because use of normal saline is associated with hyperchloremic acidosis. Potassium chloride solutions would exacerbate the hyperkalemia that occurs following burn injuries. PTS: 1 REF: p. 1874 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A. "The majority of clients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B. "Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain." C. "Your health care provider will likely want to discuss the removal of your gallbladder to achieve pain relief." D. "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."

B Rationale: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the clients who undergo this procedure, but pain returns in a substantial number of clients as the disease progresses. This client had surgery 3 months ago; the client has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain. PTS: 1 REF: p. 1437 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. A client newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the client and advises that the client should avoid tobacco use. What is the primary rationale behind that advice to the client? A. Quitting smoking will cause the client's hypertension to resolve. B. Tobacco use increases the client's concurrent risk of heart disease. C. Tobacco use is associated with a sedentary lifestyle. D. Tobacco use causes ventricular hypertrophy.

B Rationale: Smoking increases the risk for heart disease, for which a client with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse's advice; the association with heart disease is more salient. PTS: 1 REF: p. 878 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 29. A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months

B Rationale: Symptoms improve in 75% of clients undergoing TPE; however, improvement lasts only a few weeks after treatment is completed. PTS: 1 REF: p. 2101 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 22. An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of this care should be prioritized by the home health nurse? A. Providing supervision to home health aides in providing necessary client care B. Assisting the client and family to identify and mobilize community resources C. Providing ongoing medical care during the family's rehabilitation phase D. Reinforcing the importance of continuous assessment with the family

B Rationale: The home care nurse reinforces the importance of continuing medical care and helps the client and family identify and mobilize community resources. The home health nurse is part of a team that provides client care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the client and family, not just the family. The nurse performs continuous and ongoing assessment of the client; he or she does not just reinforce the importance of that assessment. PTS: 1 REF: p. 298 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A client with diabetes is asking the nurse what causes diabetic ketoacidosis (DKA). Which of the following is a correct statement by the nurse? A. "DKA can be caused by taking too much insulin." B. "DKA can be caused by taking too little insulin." C. "DKA can happen without a cause." D. "DKA will not happen with type 1 diabetes."

B Rationale: Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and undiagnosed and untreated diabetes. DKA may be the initial manifestation of type 1 diabetes. For prevention of DKA related to illness, the client should attempt to consume frequent small portions of carbohydrates. Drinking fluid every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours, and the client should take the usual dose of insulin. PTS: 1 REF: p. 1514 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in this client? A. The client will have exaggerated symptoms of rhinosinusitis due to immunosuppression. B. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. C. Chronic rhinosinusitis can damage the transplanted organ. D. Immunosuppressive drugs can cause organ rejection.

B Rationale: URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection. PTS: 1 REF: p. 503 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. The critical care nurse is monitoring the client's urine output and drains following renal surgery. What should the nurse promptly report to the primary care provider? A. Increased pain on movement B. Absence of drain output C. Increased urine output D. Blood-tinged serosanguineous drain output

B Rationale: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage is promptly reported because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines. Reporting increased pain on movement has nothing to do with the scenario described. Increased urine output and serosanguineous drainage are expected. PTS: 1 REF: p. 1594 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the client states: A. "It is important that I see my health care provider for scheduled follow-up appointments while taking this medication." B. "I will take this medication for 2 weeks and then gradually stop taking it." C. "If I lose weight, the dose of the medication may need to be changed." D. "This medication will help dissolve small gallstones made of cholesterol."

B Rationale: Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. This drug can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many clients to dissolve stones, and monitoring of the client is required during this time. The effective dose of medication depends on body weight. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 5. While auscultating a client's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in which client? A. A 47-year-old client B. A 20-year-old client C. A client who has undergone valve replacement D. A client who takes a beta-adrenergic blocker

B A 20-year-old client Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is called a physiologic S3. It is an abnormal finding in a client with an artificial valve, an adult older than 40 years of age, or a client who takes a beta blocker. PTS: 1 REF: p. 669 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A. A change in position from standing to sitting B. A heart rate of 54 bpm C. A pulse oximetry reading of 94% D. An increase in preload related to ambulation

B A heart rate of 54 bpm Rationale: Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output. PTS: 1 REF: p. 655 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 32. A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B, C Rationale: If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool. PTS: 1 REF: p. 2044 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A. The ability to select basic medications for the neurologic dysfunction B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system E. The ability to interpret the results of diagnostic tests

B, C, D Rationale: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse. PTS: 1 REF: p. 1966 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. A nurse is assessing a client who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply. A. Pulmonary hypertension B. Airway obstruction C. Pulmonary infections D. Genetic disorders E. Atelectasis

B, C, D Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. A 69-year-old client is brought to the ED by ambulance because a family member found the client lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. A. Obtain a blood type and cross-match. B. Administer antipyretics as prescribed. C. Perform frequent neurologic assessments. D. Monitor pain levels and administer analgesics. E. Place the client in positive pressure isolation.

B, C, D Rationale: Clients with meningitis require antipyretics and analgesia to treat fever and pain. The client's neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised. PTS: 1 REF: p. 2089 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. A. When a neurogenic bladder develops B. When level of consciousness is decreased C. With brain stem pathology D. In the presence of peripheral nervous system disease E. When a spinal reflex is interrupted

B, C, D Rationale: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement. PTS: 1 REF: p. 1980 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A nurse is caring for a client admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. A. Pepsin B. Lipase C. Amylase D. Trypsin E. Ptyalin

B, C, D Rationale: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Pepsin is secreted by the stomach and ptyalin is secreted in the saliva. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. A. Petechiae B. Pain C. Gastrointestinal symptoms D. Changes in voiding E. Jaundice

B, C, D Rationale: Dysfunction of the kidney can produce a complex array of symptoms throughout the body. Pain, changes in voiding, and gastrointestinal symptoms are particularly suggestive of urinary tract disease. Petechiae is not associated with genitourinary health problems. Jaundice is not a sign of urinary tract infection in an adult; it is seen typically in newborns. PTS: 1 REF: p. 1542 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. A. Hypovolemia B. Difficulty breathing C. Cardiovascular overload D. Pulmonary edema E. Hypoglycemia

B, C, D Rationale: Fluid replacement complications can occur, often when large volumes are given rapidly. Therefore, the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement. PTS: 1 REF: p. 287 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A. Increased venous return B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions E. Decreased blood viscosity

B, C, D Rationale: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity. PTS: 1 REF: p. 870 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. The nurse is relating the deficits in a client's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply. A. Loop connectivity B. Excitability C. Automaticity D. Conductivity E. Independence

B, C, D Rationale: Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization: automaticity, or the ability to initiate an electrical impulse; excitability, or the ability to respond to an electrical impulse; and conductivity, the ability to transmit an electrical impulse from one cell to another. Loop connectivity is a distracter for this question. Independence of the cells has nothing to do with the synchronization described in the scenario. PTS: 1 REF: p. 653 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 38. A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. A. Dumping syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

B, C, D, E Rationale: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN. PTS: 1 REF: p. 1316 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client has been transported to the emergency department after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. A. Facilitate lung function testing. B. Assess breath sounds. C. Measure the client's oxygen saturation by oximeter. D. Monitor the client's respiratory pattern. E. Assess the client's respiratory rate.

B, C, D, E Rationale: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context. PTS: 1 REF: p. 1054 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. A. Massage B. Applying ice C. Compression dressings D. Resting the affected extremity E. Corticosteroids F. Elevating the injured limb

B, C, D, F Rationale: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries. PTS: 1 REF: p. 1153 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 39. A client is brought to the emergency department. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

B, C, E Rationale: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hyponatremia and increased osmolarity occur. Leukocytosis does not take place. PTS: 1 REF: p. 1516 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. The nurse is caring for a client at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply. A. Epistaxis B. Pallor C. Rapid respiratory rate D. Bounding pulse E. Hypotension

B, C, E Rationale: The client at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis. PTS: 1 REF: p. 1478 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply. A. White blood cell count B. Protein level C. Albumin level D. Platelet count E. Glucose level

B, C, E Rationale: The nurse assesses the client's general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the client's nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the client's nutritional status. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

B, D Rationale: Clients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged. PTS: 1 REF: p. 1291 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. An interdisciplinary team is planning the care of a client with bronchiectasis. What aspects of care should the nurse anticipate? Select all that apply. A. Occupational therapy B. Antimicrobial therapy C. Positive pressure isolation D. Chest physiotherapy E. Smoking cessation

B, D, E Rationale: Chest physiotherapy, antibiotics, and smoking cessation are cornerstones of the care of clients with bronchiectasis. Occupational therapy and isolation are not normally indicated. PTS: 1 REF: p. 631 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client with gross hematuria has been admitted to a surgical floor in preparation for an upper cystoscopy in the morning. What post-procedure interventions would the nurse anticipate for this client? Select all that apply. A. Nothing by mouth (NPO) B. Intermittent straight catheterization C. Sedative agent administration D. Moist heat to abdomen E. Monitor for urinary retention

B, D, E Rationale: Post-procedural management is directed at relieving any discomfort from the procedure. Moist heat to the lower abdomen and warm sitz baths are helpful in relieving pain and relaxing muscles. The client may experience urinary retention, so intermittent straight catheterization may be necessary for a few hours after the procedure. The nurse would also monitor the client for signs of urinary tract infection and obstruction. NPO and sedative agent administration is accomplished before the procedure. A cystoscope examination/procedure is used to directly visualize the urethra and bladder. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply. A. Coping B. Level of consciousness C. Oral intake D. Arterial blood gases E. Vital signs

B, D, E Rationale: Trauma clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment but would become more important later during recovery. PTS: 1 REF: p. 590 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. An inpatient client with acute kidney injury (AKI) has moderate edema to both legs. What resulting skin conditions would increase the client's likelihood of skin breakdown? Select all that apply. A. Atopic dermatitis B. Pruritus C. Psoriasis D. Urticaria E. Excoriation

B, E Rationale: The skin may be dry or susceptible to breakdown as a result of edema. Excoriation and itching (pruritus) may result from the deposits of irritating toxins in the client's tissue due to AKI. Prevention recommendations include bathing in cool water, assisting or encouraging frequent turning and repositioning as well as keeping the skin clean and moisturized. Clients should be instructed to keep nails trimmed to help prevent scratches. Atopic dermatitis or eczema has strong genetic links and is commonly associated with asthma and hay fever. Eczema results in red, dry, and itchy patches of skin. Urticaria or hives are raised, red welts that suddenly appear on the skin and are usually caused by an allergic reaction. Psoriasis is a chronic skin condition characterized by thick red patches or plaques of skin covered with white or silvery scales. Psoriasis is usually linked to an autoimmune response. PTS: 1 REF: p. 1567 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 22. A nurse's assessment reveals that a client with chronic obstructive pulmonary disease may be experiencing bronchospasm. Which assessment findings would suggest that the client is experiencing bronchospasm? Select all that apply. A. Fine or coarse crackles on auscultation B. Wheezes or diminished breath sounds on auscultation C. Reduced respiratory rate or lethargy D. Slow, deliberate respirations and diaphoresis E. Labored and rapid breathing

B, E Rationale: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, labored breathing and agitation, not slow, deliberate respirations, reduced respiratory rate, or lethargy. PTS: 1 REF: p. 642 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A client with type 2 diabetes and hypertension (HTN) has a routine follow-up appointment after a cardiac stent placement. On assessment the nurse notes the client weighs 250 lb/113.4 kg with a waist circumference of 40 inches/101.6 cm, blood pressure is 162/84 mm Hg, and fasting blood glucose is 220 mg/dl. Based on these findings, which syndrome should the nurse most suspect? A. Adams-Nance syndrome B. Postpericardiotomy syndrome C. Metabolic syndrome D. Alagille syndrome

C Rationale: A cluster of metabolic abnormalities known as metabolic syndrome is a major risk factor for cardiovascular disease. This diagnosis is made when the client has 3 of the 5 risk factors. These factors include a waist circumference of greater than 35.4 inches/89.9 cm, elevated triglycerides, reduced high-density lipoprotein cholesterol, HTN with a systolic blood pressure above 130 mm Hg, and fasting glucose greater than 100 mg/dL or drug treatment for elevated glucose. Adams-Nance syndrome is an inherited disorder characterized by paroxysmal tachycardia, arterial HTN, syncope, and seizures. Alagille syndrome is a rare genetic disorder that can affect multiple organ systems including the liver, heart, skeleton, eyes, and kidneys. Based on the information presented neither of the above syndromes is likely. Postpericardiotomy syndrome may occur to clients days or weeks after surgery, so a possibility exists, but the signs and symptoms are not presented. Postpericardiotomy is characterized by fever, pericardial/pleural/joint pain, friction rub, and dyspnea. PTS: 1 REF: p. 727 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze

Multiple Choice 23. The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs? A. Loop diuretic and antiplatelet aggregator B. Loop diuretic and calcium channel blocker C. Combination of hydralazine and isosorbide dinitrate D. Combination of digoxin and normal saline

C Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed. PTS: 1 REF: p. 801 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a: A. sprain. B. strain. C. contusion. D. dislocation.

C Rationale: A contusion is a soft tissue injury that results in bleeding into soft tissues, creating a hematoma and ecchymosis. A sprain is an injury to ligaments caused by wrenching or twisting. A strain is a "muscle pull" from overuse, overstretching, or excessive stress. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Because the injury is not at the site of a joint, the client has not experienced a sprain, strain, or dislocation. PTS: 1 REF: p. 1153 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the client's commode and supply a bedpan. B. Complete an incident report and submit it to the unit supervisor. C. Have the client assessed by the primary provider due to the risk of internal bleeding. D. Perform a focused abdominal assessment in order to rule out injury.

C Rationale: A fall would necessitate thorough medical assessment due to the client's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate. PTS: 1 REF: p. 1403 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is caring for a client who has been scheduled for a bronchoscopy. How should the nurse prepare the client for this procedure? A. Administer a bolus of IV fluids. B. Arrange for the insertion of a peripherally inserted central catheter. C. Administer nebulized bronchodilators every 2 hours until the test. D. Withhold food and fluids for several hours before the test.

D Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary. PTS: 1 REF: p. 491 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is caring for a client who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response? A. Document the presence of a healthy stoma. B. Assess the client for further signs and symptoms of infection. C. Inform the primary care provider that the vascular supply may be compromised. D. Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.

C Rationale: A healthy stoma is pink or red. A change from this color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma. PTS: 1 REF: p. 1629 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity.

C Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised. PTS: 1 REF: p. 1321 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment? A. A 1.5 L/day fluid restriction B. A high-potassium, low-sodium diet C. A liquid or soft diet D. A high-protein diet

C Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the client's appetite and the degree of discomfort that occurs with swallowing. The client is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber daily B. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

C Rationale: A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given. These foods are important sources of vitamins A and C. Adequate fluid intake is important, but it does not need to be particularly high. High fiber intake would lead to complications. PTS: 1 REF: p. 1323 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 9. A client asks the nurse why an infection in the upper respiratory system is affecting the clarity of the client's speech. The nurse should describe the role of what structure? A. Trachea B. Pharynx C. Paranasal sinuses D. Larynx

C Rationale: A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tube-like structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound. PTS: 1 REF: p. 463 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 5. The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A. Sickle cell disease B. Hemophilia C. Megaloblastic anemia D. Thrombocytopenia

C Rationale: A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms involving the tongue. PTS: 1 REF: p. 912 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 34. A nurse is working with a client who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the client? A. The client will remain on bed rest for 48 to 72 hours after the procedure. B. The client will be given vitamin K infusions to prevent bleeding following PCI. C. A sheath will be placed over the insertion site after the procedure is finished. D. The procedure will likely be repeated in 6 to 8 weeks to ensure success.

C Rationale: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Clients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are given during PCI. PTS: 1 REF: p. 747 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock? A. Elevated systolic blood pressure B. Elevated mean arterial pressure (MAP) C. Shallow, rapid respirations D. Bradycardia

C Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock. PTS: 1 REF: p. 276 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 23. A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A. Serial assessments of hemoglobin levels B. Blood glucose monitoring C. Close monitoring of fluid balance D. Assessment of pain along dermatomes

C Rationale: A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important to monitor the client's intake and output closely. PTS: 1 REF: p. 2093 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A nurse is caring for a client hospitalized with AIDS. A friend comes to visit the client and privately asks the nurse about the risk of contracting HIV when visiting the client. What is the nurse's best response? A. "Do you think that you might already have HIV?" B. "Your immune system is likely very healthy." C. "AIDS isn't transmitted by casual contact." D. "You can't normally contract AIDS in a hospital setting."

C Rationale: AIDS is commonly transmitted by contact with blood and body fluids. Clients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection. PTS: 1 REF: p. 1032 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client? A. Anaphylaxis B. Decreased oxygen consumption C. Abdominal compartment syndrome D. Decreased serum osmolality

C Rationale: Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are given. The scenario does not describe an antigen-antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur. PTS: 1 REF: p. 282 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A nurse is assessing the abdomen of a client just admitted to the unit with suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? A. Abdominal lesions are usually due to age-related skin changes. B. Integumentary diseases often cause GI disorders. C. GI diseases often produce skin changes. D. The client needs to be assessed for self-harm.

C Rationale: Abdominal lesions are of particular importance because GI diseases often produce skin changes. Skin problems do not normally cause GI disorders. Age-related skin changes do not have a pronounced effect on the skin of the abdomen when compared to other skin surfaces. Self-harm is a less likely explanation for skin lesions on the abdomen. PTS: 1 REF: p. 1215 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 9. A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A. Remain NPO for 6 hours postprocedure. B. Administer a Fleet enema to cleanse the bowel of the barium. C. Increase fluid intake to evacuate the barium. D. Avoid dairy products for 24 hours' postprocedure.

C Rationale: Adequate fluid intake is necessary to rid the GI tract of barium. The client must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products. PTS: 1 REF: p. 1219 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning | Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is caring for a client who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A. Assessing the client's mobility B. Facilitating transthoracic echocardiography C. Vigilant monitoring of the client's ECG D. Close monitoring of the client's peripheral perfusion

C Rationale: After a permanent electronic device (pacemaker or ICD) is inserted, the client's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and mobility because the consequences of abnormalities are more serious. Echocardiography is not indicated. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care? A. Teaching the client to self-suction B. Performing chest physiotherapy to promote oxygenation C. Positioning the client to prevent gastric reflux D. Providing a regular diet as tolerated

C Rationale: After recovering from the effects of anesthesia, the client is placed in a low Fowler position, and later in a Fowler position, to help prevent reflux of gastric secretions. The client is observed carefully for regurgitation and dyspnea because a common postoperative complication is aspiration pneumonia. In this period of recovery, self-suctioning is also not likely realistic or safe. Chest physiotherapy is contraindicated because of the risk of aspiration. Nutrition is prioritized, but a regular diet is contraindicated in the immediate recovery from esophageal surgery. PTS: 1 REF: p. 1262 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A. Apply the new ointment without disturbing the existing layer of ointment. B. Apply the ointment using a sterile tongue depressor. C. Apply a layer of ointment approximately 1/16 inch thick. D. Gently irrigate the wound bed after applying the antibiotic ointment.

C Rationale: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment. PTS: 1 REF: p. 1888 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. A client has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this client? A. Placing the client in a left lateral position B. Administering opioids as prescribed C. Placing the client in Fowler position D. Teaching the client to use the client-controlled analgesia (PCA) system

C Rationale: After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the client may be placed in Fowler position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing. PTS: 1 REF: p. 1240 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do? A. Cover the burn with ice and secure with a towel. B. Apply butter to the area that is burned. C. Immerse the child in a cool bath. D. Avoid touching the burned area under any circumstances.

C Rationale: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn. PTS: 1 REF: p. 1874 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select Chapter 62: Management of Patients With Cerebrovascular Disorders 1. A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

C Rationale: Agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile. The client was able to see what was being held but was not recognizing specific garments by just touching them. Because the client was able to see homonymous hemianopsia, which is blindness in half of the visual field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not support these findings. PTS: 1 REF: p. 2033 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? A. As close to the end of the day as possible B. After a meal high in fat C. After a 12-hour fast D. Thirty minutes after a normal meal

C Rationale: Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast. PTS: 1 REF: p. 674 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. The nurse is writing a care plan for a client who has been diagnosed with angina pectoris. The client describes herself as being "distressed" and "shocked" by the new diagnosis. What nursing diagnosis is most clearly suggested by the client's statement? A. Spiritual distress related to change in health status B. Acute confusion related to prognosis for recovery C. Anxiety related to cardiac symptoms D. Deficient knowledge related to treatment of angina pectoris

C Rationale: Although further assessment is warranted, it is not unlikely that the client is experiencing anxiety. In clients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to the client's concerns. Similarly, it is not clear that a lack of knowledge or information is the root of the client's anxiety. PTS: 1 REF: p. 735 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

C Rationale: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions. PTS: 1 REF: p. 1326 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 34. Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication? A. Pulmonary edema B. Pericardiocentesis C. Cardiac tamponade D. Pericarditis

C Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiologic process. PTS: 1 REF: p. 812 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? A. Nerve damage is associated with third-degree strains. B. Compartment syndrome is associated with third-degree strains. C. Avulsion fractures are associated with third-degree strains. D. Greenstick fractures are associated with third-degree strains.

C Rationale: An x-ray should be obtained to rule out bone injury because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. Nerve damage, compartment syndrome, and greenstick fractures are not associated with third-degree strains. PTS: 1 REF: p. 1153 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A. The symptoms indicate angina and should be treated as such. B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C. The symptoms indicate an acute coronary episode and should be treated as such. D. Treatment should be determined pending the results of an exercise stress test.

C Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis. PTS: 1 REF: p. 726 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.

C Rationale: Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia). PTS: 1 REF: p. 2033 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. A 79-year-old client is admitted to the medical unit with digital gangrene. The client reports that the problem first began when the client stubbed the toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the client has a history of which health problem? A. Raynaud phenomenon B. Coronary artery disease (CAD) C. Arterial insufficiency D. Varicose veins

C Rationale: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud disease, CAD, and varicose veins are not the usual causes of digital gangrene in older adults. PTS: 1 REF: p. 857 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 25: Management of Patients with Complications from Heart Disease 1. The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem? A. Pericarditis B. Cardiomyopathy C. Pulmonary edema D. Right ventricular hypertrophy

C Rationale: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production. PTS: 1 REF: p. 798 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A. Obtain an order to reduce the rate of the client's IV fluid infusion. B. Report the client's early signs of acute kidney injury (AKI). C. Recognize that the client is experiencing an expected onset of diuresis. D. Administer sodium chloride as prescribed to compensate for this fluid loss.

C Rationale: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI. PTS: 1 REF: p. 1876 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

C Rationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation. PTS: 1 REF: p. 1872 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the client's previous medication regimen may have contributed to the development of this disorder? A. Calcium carbonate B. Vitamin B12 C. Aspirin D. Vitamin D

C Rationale: Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect. PTS: 1 REF: p. 935 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 11. A client is undergoing testing to assess for a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? A. Increased tactile fremitus, egophony, and the chest wall dull on percussion B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion

C Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion. PTS: 1 REF: p. 484 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A. Administer corticosteroids by metered dose inhaler. B. Administer inhaled anticholinergics. C. Administer an inhaled beta-adrenergic agonist. D. Use a peak flow monitoring device.

C Rationale: Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 5. A client with a total hip replacement has developed decreased breath sounds What is the nurse's best action? A. Place the client on bed rest. B. Request an antitussive medication from the health care provider. C. Encourage use of the incentive spirometer. D. Assess for signs and symptoms of systemic infection.

C Rationale: Atelectasis may occur in the client after surgery and can be prevented with the use of an incentive spirometer. Since bedrest increases the risk for atelectasis and pneumonia after surgery, the client should be encouraged to ambulate and sit up in a chair rather than lie in bed. Since the client should be encouraged to deep breath and cough, requesting an antitussive medication for the client would not be appropriate. Atelectasis is not a clinical manifestation of infection. PTS: 1 REF: p. 1186 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect

C Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure. PTS: 1 REF: p. 794 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 39. Which of the following circumstances would most clearly warrant autologous blood donation? A. The client has type-O blood. B. The client has sickle cell disease or a thalassemia. C. The client has elective surgery pending. D. The client has hepatitis C.

C Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation. PTS: 1 REF: p. 898 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A. Maximizing cardiac output while minimizing heart rate B. Decreasing energy expenditure of the myocardium C. Balancing myocardial oxygen supply with demand D. Increasing the size of the myocardial muscle

C Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium's energy expenditure is often beneficial, but this must be balanced with productivity. PTS: 1 REF: p. 742 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

C Rationale: Because of the early discharge following laparoscopic cholecystectomy, the client needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes. PTS: 1 REF: p. 1425 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 16. An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet. C. Toilet the client on a frequent, scheduled basis. D. Liaise with the primary provider to obtain an order for loperamide.

C Rationale: Because the client's fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this client's health problem. PTS: 1 REF: p. 1293 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for? A. Jugular vein distention B. Right upper quadrant pain C. Bibasilar fine crackles D. Dependent edema

C Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition. PTS: 1 REF: p. 797 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 39. A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

C Rationale: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy. PTS: 1 REF: p. 2037 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 18. A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

C Rationale: Bloody stool is far more common in cases of UC than in Crohn disease. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn) and clients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn disease often has a more prolonged and variable course. PTS: 1 REF: p. 1305 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 28: Assessment of Hematologic Function and Treatment Modalities 1. A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location? A. Spleen B. Kidneys C. Bone marrow D. Liver

C Rationale: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells. However, blood cells are not primarily formed in the spleen, kidneys, or liver. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 6. A nurse is preparing to care for a client with bronchiectasis. The nurse should recognize that this client is likely to experience respiratory difficulties related to what pathophysiologic process? A. Intermittent episodes of acute bronchospasm B. Alveolar distention and impaired diffusion C. Dilation of bronchi and bronchioles D. Excessive gas exchange in the bronchioles

C Rationale: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles that results from destruction of muscles and elastic connective tissue. It is not characterized by acute bronchospasm, alveolar distention, or excessive gas exchange. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A. "The symptoms of pancreatitis mimic those of much less serious illnesses." B. "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C. "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." D. "It's likely that your other organs were compensating for your decreased pancreatic function."

C Rationale: By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions. PTS: 1 REF: p. 1429 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 18. A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? A. Hemodialysis B. Peritoneal dialysis C. Continuous venovenous hemodialysis (CVVHD) D. Plasmapheresis

C Rationale: CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable client. Peritoneal dialysis is not the best choice, as the client may have sustained abdominal injuries during the accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance. PTS: 1 REF: p. 1584 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action? A. Apply a cold pack to the affected area. B. Apply heat to the forehead. C. Perform postural drainage. D. Increase fluid intake.

D Rationale: For a client diagnosed with acute sinusitis, the nurse should instruct the client that increasing fluid intake and elevating the head of the bed can promote drainage. Applying a cold pack to the affected area and applying heat to the forehead will not promote sinus drainage. Postural drainage is used to remove bronchial secretions. PTS: 1 REF: p. 502 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 35. A 40-year-old male client with a history of childhood non-Hodgkin lymphoma and radiation treatment is being admitted for thyroid cancer. The client is a commercial airline pilot, does not smoke, exercises regularly, and eats mostly take-out food. What risk factors are primarily associated with his diagnosis? A. Childhood cancer and physical activity B. Employment and smoking history C. Age and radiation history D. Dietary choices and gender

C Rationale: Cancer of the thyroid is less prevalent than other forms of cancer, but the incidence of the condition is increasing. Thyroid cancer is more likely to develop in clients younger than 50 years old. Exposure to radiation or external radiation of the head, neck or chest in infancy and childhood increases the risk of this condition. Women, not men, are at a greater risk for this condition. Additional risk factors include smoking, low physical activity, unhealthy eating habits, and high stress levels. PTS: 1 REF: p. 1450 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 37. A client with a history of epilepsy is admitted preoperatively for a surgical procedure and dies overnight. The health care provider suspects sudden unexpected death in epilepsy (SUDEP). Which condition is most likely related to SUDEP? A. Brain aneurysm B. Undiagnosed sepsis C. Cardiac abnormalities D. Seizure medication overdose

C Rationale: Cardiac and respiratory abnormalities have been implicated in SUDEP deaths. SUDEP may or may not be related to a seizure event. There have been studies that suggest that clients have an irregular heart rhythm after seizure which causes the death. The client is preoperative, thus there is a low likelihood of undiagnosed sepsis. Clients with epilepsy, especially when their medications are no longer preventing seizures, are at serious risk for SUDEP. SUDEP is defined as nontraumatic, nondrowning unexpected death of a client with epilepsy. These events may be witnessed or unwitnessed and postmortem examination reveals no anatomical or toxicological cause of death. PTS: 1 REF: p. 2021 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A. Administer a PRN dose of pancreatic enzymes as prescribed. B. Teach the client about the importance of abstaining from alcohol. C. Arrange for the client to be transported to the hospital. D. Insert an NG tube, if available, and stay with the client.

C Rationale: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Client education is a later priority that may or may not be relevant. PTS: 1 REF: p. 1433 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. A client is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A. Administration of bronchodilators by nebulizer B. Administration of inhaled corticosteroids by metered dose inhaler (MDI) C. Client's consistent performance of deep-breathing and coughing exercises D. Client's active participation in the cardiac rehabilitation program

C Rationale: Clearance of pulmonary secretions is accomplished by frequent repositioning of the client, suctioning, and chest physical therapy, as well as educating and encouraging the client to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions. PTS: 1 REF: p. 757 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 23. The nurse is teaching a client with allergic rhinitis about the safe and effective use of medications. Which information would be the most essential to give this client about preventing possible drug interactions? A. Prescription medications can be safely supplemented with over-the-counter (OTC) medications. B. Use only one pharmacy so the pharmacist can check drug interactions. C. Read drug labels carefully before taking OTC medications. D. Consult the Internet before selecting an OTC medication.

C Rationale: Client education is essential when assisting the client in the use of all medications. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any OTC medications. Some websites are reliable and valid information sources, but this is not always the case. Clients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C Rationale: Clients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleep most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Clients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and clients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities. PTS: 1 REF: p. 1383 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze

Multiple Choice 37. Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education? A. Infection risks associated with FFP administration B. Physiologic functions of plasma C. Signs and symptoms of a transfusion reaction D. Strategies for managing transfusion-associated anxiety

C Rationale: Clients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some clients, but transfusion reactions are life-threatening and should be addressed first. Teaching about the functions of plasma is not likely a high priority. PTS: 1 REF: p. 903 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 36. A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A. The client will likely require lifelong treatment with anticholinergic medications. B. The client has a disproportionate risk of developing myasthenia gravis later in life. C. The client needs to be assessed for MS. D. The disease is self-limiting and the client will achieve pain relief over time.

C Rationale: Clients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS because trigeminal neuralgia occurs in approximately 5% of clients with MS. Treatment does not include anticholinergics and the disease is not self-limiting. Trigeminal neuralgia is not associated with an increased risk of myasthenia gravis. PTS: 1 REF: p. 2108 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. A client has been scheduled for a bone marrow aspiration and admits to the nurse being worried about the pain involved with the procedure. Which statement by the nurse when providing client education would be most accurate? A. "You'll be given painkillers before the test, so there won't likely be any pain." B. "You'll feel some pain when the needle enters your skin, but none during the aspiration." C. "Most people feel some brief, sharp pain when the marrow is aspirated." D. "I'll be there with you, and I'll try to help you keep your mind off the pain."

C Rationale: Clients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the client should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the client's fears of pain, because this does not help the client know what to expect. Although a local anesthetic agent is administered to the skin, subcutaneous tissue, and periosteum of the bone, it is not possible to anesthetize the bone itself, and the client will most likely experience sharp, brief pain during the actual aspiration. Painkillers are not necessarily given before the test and would not likely block all pain from the aspiration. PTS: 1 REF: p. 894 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem? A. Truncal obesity B. Hypertension C. Muscle weakness D. Moon face

C Rationale: Clients with Addison disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Clients with Cushing syndrome demonstrate truncal obesity, "moon" face, acne, abdominal striae, and hypertension. PTS: 1 REF: p. 1477 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 20. A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intake D. High-protein, low-fat diet

C Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake. PTS: 1 REF: p. 1375 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A 62-year-old client with atrial fibrillation and a CHA2DS2-VASC score of 3 is being discharged home today. Based on this score, which additional medications or medications would be prescribed for this client? A. No antithrombotic therapy, oral anticoagulant or aspirin B. Low molecular weight heparin or intravenous heparin C. Warfarin, direct thrombin inhibitor, or factor Xa inhibitor D. Antiarrhythmic agents and aspirin

C Rationale: Clients with atrial fibrillation are assessed for the risk of stroke using the mnemonic CHA2DS2-VASC with age, sex, and medical history determining a score. With a score of zero, clients may choose no antithrombotic therapy. With a score of 1, the client may choose no therapy, oral anticoagulant or aspirin. With a score of 2 or greater in men or 3 or greater in women, clients may choose warfarin, direct thrombin, or factor Xa inhibitor. Heparin can be used as a short-term or immediate anticoagulation medication and is not used as part of this scoring process. And intravenous heparin is not typically used in a home setting for prevention. The antiarrhythmic medication treats atrial fibrillation and is not part of the scoring process. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A. Glucose in the urine B. Albumin in the urine C. Highly dilute urine D. Leukocytes in the urine

C Rationale: Clients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but if present would indicate a urinary tract infection. PTS: 1 REF: p. 1451 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? A. Initiating a client-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity

C Rationale: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the client's pain. PTS: 1 REF: p. 2092 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 9. A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

C Rationale: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a cerebral spinal fluid (CSF) leak, or an occluded catheter. PTS: 1 REF: p. 2008 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? A. So that the client's functional needs can be met immediately B. So that medications can be given as prescribed and signs of adverse reactions noted C. So that early signs of impending infection can be detected and treated D. So that the nurse's documentation can be thorough and accurate

C Rationale: Continual monitoring of the client's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client's status. Continual monitoring is not primarily motivated by the client's functional needs or medication schedule. The nurse's documentation is important, but less so than infection control. PTS: 1 REF: p. 1007 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 24. When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A. Palpate trapezius muscle while client shrugs shoulders against resistance. B. Administer the whisper or watch tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the client's voice.

C Rationale: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Cranial nerve XI (spinal accessory) does not affect the muscles of the face. Assessing cranial nerve VIII (acoustic) would involve evaluating hearing. Cranial nerve X (vagus) does not affect the face. PTS: 1 REF: p. 1972 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A 30-year-old female client has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse prioritize when planning the client's care? A. Decisional conflict related to treatment options B. Spiritual distress related to changes in cognitive function C. Disturbed body image related to changes in physical appearance D. Powerlessness related to disease progression

C Rationale: Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image. Decisional conflict and powerlessness may exist, but disturbed body image is more likely to be present. Cognitive changes take place in clients with Cushing syndrome, but these may or may not cause spiritual distress. PTS: 1 REF: p. 1479 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. It is cold season, and the school nurse has been asked to provide an educational event for the parent teacher organization of the local elementary school. Which information should the nurse include in education about the treatment of pharyngitis? A. Pharyngitis is more common in children whose immunizations are not up to date. B. There are no effective, evidence-based treatments for pharyngitis. C. Use of warm saline gargles or throat irrigations can relieve symptoms. D. Heat may increase the spasms in pharyngeal muscles.

C Rationale: Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. Applying heat to the throat would reduce, not increase, spasms in the pharyngeal muscles. There is no evidence that pharyngitis is more common in children whose immunizations are not up to date. Warm saline gargles and throat irrigations are evidence-based treatments for pharyngitis. PTS: 1 REF: p. 504 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

C Rationale: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients. PTS: 1 REF: p. 2046 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Understand

Multiple Choice 17. The nurse is assessing a client new to the clinic. Records brought to the clinic show that the client's hypertension has not improved. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? A. Progressive target organ damage B. Possibility of medication interactions C. Lack of adherence to prescribed drug therapy D. Possible heavy alcohol use or use of recreational drugs

C Rationale: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of clients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions. PTS: 1 REF: p. 878 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse caring for a client with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? A. Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours B. Administration of dexamethasone IV, followed by an x-ray of the adrenal glands C. Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning D. Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is given

C Rationale: Dexamethasone (1 mg) is given orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning. This test can be performed on an outpatient basis and is the most widely used and sensitive screening test for diagnosis of pituitary and adrenal causes of Cushing syndrome. PTS: 1 REF: p. 1480 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is caring for a client with epistaxis in the emergency department. Which information should the nurse include in client discharge teaching as a way to prevent epistaxis? A. Keep nasal passages clear. B. Use decongestants regularly. C. Humidify the indoor environment. D. Use a tissue when blowing the nose.

C Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose blowing, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated. PTS: 1 REF: p. 512 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 29. A client has experienced burns to the upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A. Instruct the client to keep the wound site in a dependent position. B. Administer PRN analgesia as prescribed. C. Assess the client's peripheral pulses distal to the dressing. D. Assist with passive range-of-motion exercises to "set" the new dressing.

C Rationale: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be given prior to the dressing change. ROM exercises do not normally follow a dressing change. PTS: 1 REF: p. 1861 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. The nurse is providing education to a client that is to undergo a thyroidectomy. When planning care for this client, the nurse should include which example in their education? A. Pharmacological therapy is not necessary prior to the surgery. B. Symptoms of the disease will disappear immediately after surgery. C. Balance periods of activity and exercise with rest. D. There is no risk for hypothyroidism after the surgery.

C Rationale: Due to the fatigue of the disease process itself and the stress of surgery, there needs to be an even balance of activity and rest for the client. Pharmacological therapy is needed prior to surgery. Symptoms of the disease will gradually taper off after surgery. There is a risk for hypothyroidism after surgery due to the partial or complete removal of thyroid gland. PTS: 1 REF: p. 1465 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 15. A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

D Rationale: For acute gastritis, the nurse provides physical and emotional support and helps the client manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed client; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time. PTS: 1 REF: p. 1268 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 11. The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? A. Increased hunger B. Decreased thirst C. Decreased urinary output D. Increased capillary perfusion

C Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs. PTS: 1 REF: p. 282 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 38. The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment? A. Whether the client and involved family members understand the role of genetics in the etiology of the disease B. Whether the client and involved family members understand dietary changes and the role of nutrition C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately D. Whether the client and involved family members understand the importance of social support and community agencies

C Rationale: During the health history, the nurse needs to determine if the client and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely and appropriate response to a cardiac emergency is paramount. PTS: 1 REF: p. 657 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform? A. Instruct the client to drink 1 L of water before the test. B. Administer intravenous (IV) benzodiazepines and opioids. C. Inform the client that the client will remain on bed rest following the procedure. D. Inform the client that an access line will be initiated in the femoral artery.

C Rationale: During the recovery period, the client must maintain bed rest with the head of the bed elevated to 45 degrees. The client must be NPO 6 hours pre-procedure. The client is sedated to make the client comfortable, but the client will not be heavily sedated and opioids are not necessary. Also, the client will have a peripheral IV line initiated pre-procedure. PTS: 1 REF: p. 681 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 6. A client with a diagnosis of primary immunodeficiency disease informs the nurse that the client has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take? A. Administer a nebulized bronchodilator. B. Perform oral suctioning. C. Assess the client for signs and symptoms of infection. D. Teach the client deep breathing and coughing exercises.

C Rationale: Dyspnea and cough are among the varied signs and symptoms that may suggest infection in an immunocompromised client. There is no indication for suctioning or the use of nebulizers. Deep breathing and coughing exercises do not address the client's complaints or the likely etiology. PTS: 1 REF: p. 1006 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A. Anxiety related to diagnosis of cancer B. Altered nutrition related to swallowing difficulties C. Ineffective airway clearance related to airway alterations D. Impaired verbal communication related to removal of the larynx

C Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions. PTS: 1 REF: p. 516 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? A. Pneumoconiosis B. Pleural effusion C. Acute respiratory failure D. Pneumonia

C Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms. PTS: 1 REF: p. 556 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client is admitted to the ICU with acute pancreatitis. The client's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of clients with acute pancreatitis have what health issue? A. Type 1 diabetes B. An impaired immune system C. Undiagnosed chronic pancreatitis D. An amylase deficiency

C Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These clients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Diabetes, an impaired immune function, and amylase deficiency are not specific precursors to acute pancreatitis. PTS: 1 REF: p. 1429 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment? A. 4 to 6 hours a day for 6 months B. During waking hours for 2 to 3 months after the injury C. Continuously D. At night while sleeping for a year after the injury

C Rationale: Elastic pressure garments are worn continuously (i.e., 24 hours a day). PTS: 1 REF: p. 1889 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis? A. A 45-year-old obese woman with a high-fat diet B. An 18-year-old man who is a weekend binge drinker C. A 39-year-old man with chronic alcoholism D. A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

C Rationale: Excessive and prolonged consumption of alcohol accounts for most cases of chronic pancreatitis in Western societies. PTS: 1 REF: p. 1433 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. A nurse is providing health education to a teenage client newly diagnosed with type 1 diabetes mellitus, as well as the client's family. The nurse teaches the client and family nonpharmacologic measures that will decrease the body's need for insulin. What measure provides the greatest impact on glucose reduction? A. Adequate sleep B. Low stimulation C. Exercise D. Low-fat diet

C Rationale: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not reduce a client's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is as pronounced as that of exercise. PTS: 1 REF: p. 1496 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Select 32. A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? A. Gastroesophageal reflux disease (GERD) B. Peptic ulcers C. Hemorrhoids D. Recurrent nausea and vomiting

C Rationale: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers, and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 39. A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client? A. The client will be started on fluoxetine in 1 month. B. Antiretroviral therapy will begin within 3 months. C. Follow-up testing will be promptly performed to confirm the result. D. The client will be monitored for signs and symptoms of HIV to determine the need for treatment.

C Rationale: Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis. These tests include antibody differentiation tests, which distinguish HIV-1 from antibodies, and HIV-1 nucleic acid tests, which look for the virus RNA directly. Antiretroviral therapy may be needed, but the next step would be to confirm the diagnosis. Fluoxetine, an antidepressant, would be prescribed if the client developed severe depression, which is not evident in this scenario. The client would not simply be monitored for signs and symptoms of HIV to determine treatment; the client would undergo follow-up testing to determine the need for treatment. PTS: 1 REF: p. 1015 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching

C Rationale: Following a Billroth I, the client may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure. PTS: 1 REF: p. 1274 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 22. A client is reporting genitourinary pain shortly after returning to the unit from a scheduled cystoscopy. What intervention should the nurse perform? A. Encourage mobilization. B. Apply topical lidocaine to the client's meatus, as prescribed. C. Apply moist heat to the client's lower abdomen. D. Apply an ice pack to the client's perineum.

C Rationale: Following cystoscopy, moist heat to the lower abdomen and warm sitz baths are helpful in relieving pain and relaxing the muscles. Ice, lidocaine, and mobilization are not recommended interventions. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A. Salmon accompanied by whole milk B. Mixed vegetables and brown rice C. Beef liver accompanied by orange juice D. Yogurt, almonds, and whole grain oats

C Rationale: Food sources high in iron include organ meats, other meats, beans (e.g., black and pinto), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit to iron stores. PTS: 1 REF: p. 914 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home

C Rationale: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation. PTS: 1 REF: p. 2046 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A client newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline should the nurse teach the clients at this class? A. Low fat generally indicates low sugar. B. Protein should constitute 30% to 40% of caloric intake. C. Most calories should be derived from carbohydrates. D. Animal fats should be eliminated from the diet.

C Rationale: For all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet. PTS: 1 REF: p. 1494 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? A. In a knee-chest position (lithotomy position) B. Lying prone with legs drawn toward the chest C. Lying on the left side with legs drawn toward the chest D. In a prone position with two pillows elevating the buttocks

C Rationale: For best visualization, colonoscopy is performed while the client is lying on the left side with the legs drawn up toward the chest. A knee-chest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization. PTS: 1 REF: p. 1223 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A. Administer bronchodilators as ordered. B. Remind the client of the importance of deep breathing and coughing exercises. C. Prepare to assist with intubation. D. Administer supplementary oxygen by nasal cannula.

C Rationale: For the client with Guillain-Barré syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the client's oxygenation needs. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. Which risk factors should the nurse list that can be controlled or modified? A. Gender, obesity, family history, and smoking B. Inactivity, stress, gender, and smoking C. Cholesterol levels, hypertension, and smoking D. Stress, family history, and obesity

C Rationale: Four modifiable risk factors—cholesterol abnormalities, tobacco use, hypertension, and diabetes—are established risk factors for CAD and its complications. Inactivity and obesity are also modifiable risk factors associated with CAD. Stress, although not listed as a direct risk factor for CAD, contributes to hypertension, which is itself a risk factor. Gender and family history are risk factors that cannot be controlled. PTS: 1 REF: p. 730 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 29. The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol." B. "The only time I flush my tube is when I'm putting in medications." C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."

C Rationale: Frequent flushing is needed to prevent occlusion, and should not just be limited to times of medication administration. Alcohol will irritate skin surrounding the insertion site and activity should be maintained as much as possible. PTS: 1 REF: p. 1247 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 32. A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A. "It eliminates the risk for infection." B. "Feeds can be infused at a faster rate." C. "Regurgitation and aspiration are less likely." D. "It allows caregivers to provide personal hygiene more easily."

C Rationale: Gastrostomy is preferred over NG feedings in the client who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care. PTS: 1 REF: p. 1249 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 6. A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

C Rationale: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring. PTS: 1 REF: p. 2022 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 41: Management of Patients with Intestinal and Rectal Disorders 1. A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

C Rationale: Goals for the client include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded. PTS: 1 REF: p. 1289 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A pediatric nurse is working with an interdisciplinary team and parents to care for a 6-month-old client who has recently been diagnosed with severe combined immune deficiency (SCID). Which treatment is likely of most benefit to this client's type of primary immune deficiency disease (PIDD)? A. Combined radiotherapy and chemotherapy B. Antibiotic therapy C. Hematopoietic stem cell transplantation (HSCT) D. Treatment with colony-stimulating factors (CSFs)

C Rationale: HSCT is a curative modality for some PIDDs, such as SCID. The stem cells may be from embryos or adults. SCID's onset is typically manifested by 6 months of age or earlier. SCID causes a child to be born with little or no immune system and historically resulted in frequent deaths due to multiple infections. Newborn screening in recent years has resulted in early inventions with HSCT and gene therapy. Radiation and chemotherapy, antibiotics, and CSF do not provide a cure. PTS: 1 REF: p. 1005 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is caring for a client who had a brush biopsy 12 hours ago. The presence of what assessment finding should prompt the nurse to notify the health care provider? A. Scant hematuria B. Renal colic C. Temperature 37.9°C (100.2°F) orally D. Infiltration of the client's intravenous catheter

C Rationale: Hematuria and renal colic are common and expected findings after the performance of a renal brush biopsy. The health care provider should be notified of the client's body temperature, which likely indicates the onset of an infectious process. IV infiltration does not warrant notification of the primary care provider. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client reports having hereditary angioedema. The nurse should identify which implication of this health condition? A. It will result in increased loss of work days. B. It may cause episodes of weakness due to reduced cardiac output. C. It can cause life-threatening airway obstruction. D. It is a risk factor for ischemic heart disease.

C Rationale: Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work, reduced cardiac function, or ischemic heart disease. PTS: 1 REF: p. 514 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse is planning discharge teaching for a client with a newly inserted permanent pacemaker. What is the priority teaching point for this client? A. Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B. Avoid cooking with a microwave oven. C. Avoid exposure to strong electromagnetic fields D. Avoid walking through store and library antitheft devices.

C Rationale: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows clients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so clients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. A client with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the client? A. Examine feet weekly for redness, blisters, and abrasions. B. Avoid the use of moisturizing lotions. C. Avoid hot-water bottles and heating pads. D. Dry feet vigorously after each bath.

C Rationale: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the client should gently, not vigorously, pat feet dry to avoid injury. PTS: 1 REF: p. 1525 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 20. A pregnant client has been diagnosed with gestational diabetes. The client is shocked by the diagnosis, stating that they are conscientious about their health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor? A. Increased caloric intake during the first trimester B. Changes in osmolality and fluid balance C. The effects of hormonal changes during pregnancy D. Overconsumption of carbohydrates during the first two trimesters

C Rationale: Hyperglycemia and eventual gestational diabetes develop during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality. PTS: 1 REF: p. 1491 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 11. The nurse is caring for a client in acute kidney injury (AKI). Which complication would most clearly warrant the administration of polystyrene sulfonate? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypercalcemia

C Rationale: Hyperkalemia (high potassium) is a common complication of AKI. If the client's potassium is elevated but does not cause ECG (electrocardiography) changes, then polystyrene sulfonate may be administered since it reduces serum potassium levels. It is not recommended for emergency treatment since it takes more than 6 hours to work. Polystyrene sulfonate does not treat low (hypo) magnesium, high sodium (hypernatremia), or high calcium (hypercalcemia). PTS: 1 REF: p. 1568 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. The nurse is providing care for a client with a diagnosis of hypertension. The nurse should consequently assess the client for signs and symptoms of which other health problem? A. Migraines B. Atrial-septal defect C. Atherosclerosis D. Thrombocytopenia

C Rationale: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines. PTS: 1 REF: p. 868 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 5. A 56-year-old client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response? A. "Yes. It is fortunate we caught this during your routine examination." B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." C. "A single elevated blood pressure does not confirm hypertension. Diagnosis requires multiple elevated readings." D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

C Rationale: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the client that there is no need to worry. PTS: 1 REF: p. 866 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. A client has presented with signs and symptoms that are consistent with contact dermatitis. Which aspect of care should the nurse prioritize when working with this client? A. Promoting adequate perfusion in affected regions B. Promoting safe use of topical antihistamines C. Identifying the offending agent, if possible D. Teaching the client to safely use an EpiPen

C Rationale: Identifying the offending agent is a priority in the care of a client with dermatitis. This provides a cure via removal of the offending agent, rather than being limited to treating the symptoms. Topical antihistamines can provide some relief from itching, especially with allergic dermatitis, but identifying and removing the offending agent takes is a higher priority, as it would allow the client to not need to use a topical antihistamine. An epinephrine auto injector (EpiPen) is typically used to treat anaphylaxis, not contact dermatitis. Inadequate perfusion occurs with peripheral artery disease or vasoconstriction but is not associated with contact dermatitis. PTS: 1 REF: p. 1057 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 21. The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Solumedrol B. Dextromethorphan C. Dexamethasone D. Furosemide

C Rationale: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines. PTS: 1 REF: p. 2011 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

C Rationale: If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated. PTS: 1 REF: p. 2042 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is caring for an acutely ill client who is on a factor Xa inhibitor. The client has a comorbidity of renal insufficiency. How will this client's renal status affect this anticoagulant therapy? A. The factor Xa inhibitor is contraindicated in the treatment of this client. B. The factor Xa inhibitor may be given subcutaneously, but not intravenously (IV). C. Lower doses of factor Xa inhibitor are required for this client. D. Warfarin will be substituted for the factor Xa inhibitor.

C Rationale: If renal insufficiency exists, lower doses, not contraindication, of factor Xa inhibitors are needed. Warfarin is not an acceptable substitution for this type of medication. There is no contraindication for IV administration. PTS: 1 REF: p. 848 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A. Ensure that the client knows that he or she will be responsible for care after discharge. B. Reassure the client that many people are fearful after the creation of an ostomy. C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. D. Arrange for the client to be seen by a social worker or spiritual advisor.

C Rationale: If the client is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the client and explore the factors that underlie it. It is presumptive to assume that the client's behavior is motivated by fear. Assessment must precede referrals and emphasizing the client's responsibilities may or may not motivate the client. PTS: 1 REF: p. 1324 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 36. A junior nursing student is having an observation day in the operating room. Early in the day, the student reports eye swelling and dyspnea to the OR nurse. What should the nurse suspect? A. Cytotoxic reaction due to contact with the powder in the gloves B. Immune complex reaction due to contact with anesthetic gases C. Anaphylaxis due to a latex allergy D. Delayed reaction due to exposure to cleaning products

C Rationale: Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction. PTS: 1 REF: p. 1062 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 30. A client has had a indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the client informs the nurse that the client is experiencing urinary urgency resulting in several small-volume voids. What is the nurse's best response? A. Inform the client that urgency and occasional incontinence are expected for the first few weeks post-removal. B. Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C. Inform the client that this is not unexpected in the short term and scan the client's bladder following each void. D. Obtain an order to reinsert the client's urinary catheter and attempt removal in 24 to 48 hours.

C Rationale: Immediately after the indwelling catheter is removed, the client is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the client is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner; if the bladder has not emptied completely, straight catheterization may be performed. An indwelling catheter would not be reinserted to resolve the problem, and diuretics would not be beneficial. Ongoing incontinence is not an expected finding after catheter removal. PTS: 1 REF: p. 1619 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A. Fluid output B. Oral intake C. Blood glucose levels D. BUN and creatinine levels

C Rationale: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A client on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function. PTS: 1 REF: p. 1431 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 24: Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders 1. A client with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the client to exhibit which heart rhythm? A. Ventricular fibrillation (VF) B. Ventricular tachycardia (VT) C. Atrial fibrillation D. Sinus bradycardia

C Rationale: In clients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation caused by strain on the atrium. Bradycardia, VF, and VT are not characteristic of this valvular disorder. PTS: 1 REF: p. 768 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client has been recently diagnosed with myasthenia gravis. Which is indicative of a person diagnosed with myasthenia gravis? A. Excessive serotonin activity in the brain B. Decreased dopamine activity in the brain C. Impairment of acetylcholine binding to muscle cells D. Defects in the expression of acetylcholine receptors

C Rationale: In myasthenia gravis, acetylcholine binding to muscle cells is impaired. A breakdown essentially occurs in the communication between nerves and muscles. This results in weakness of extremities and difficulties with speech and chewing. Many neurologic disorders are due, at least in part, to an imbalance in neurotransmitters. Decreased dopamine activity in the brain is suggestive of Parkinson. Excessive or too much serotonin activity in the brain can cause a variety of mild to severe symptoms. Some of these include high blood pressure, shivering, confusion and/or high fever. Defects in the expression of acetylcholine receptors is more indicative of amyotrophic lateral sclerosis (ALS). ALS affects motor neurons directly. PTS: 1 REF: p. 1968 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 30. The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock? A. Hypertension B. Cool, moist skin C. Bradycardia D. Signs of sympathetic stimulation

C Rationale: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. PTS: 1 REF: p. 296 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction? A. "Skeletal traction temporarily stabilizes the fracture before surgery." B. "Weights are attached to the leg using a boot." C. "Traction involves passing a pin through the bone." D. "Light weights must be used with skeletal traction."

C Rationale: In skeletal traction, a metal pin or wire is passed through the bone and traction is then applied using ropes and weights attached to the pins. Skin traction, not skeletal traction, stabilizes the fracture until surgery is performed and uses a boot or Velcro to attach the ropes and weights to the leg. Skeletal traction is used when greater weight (11 to 18 kg [25 to 40 lb]) is needed to achieve the therapeutic effect. PTS: 1 REF: p. 1176 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A. PP interval and RR interval are irregular. B. PP interval is equal to RR interval. C. Fewer QRS complexes than P waves D. PR interval is constant.

C Rationale: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis. PTS: 1 REF: p. 710 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A. Ineffective breathing pattern related to decreased cardiac output B. Anxiety related to fear of death C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D. Impaired skin integrity related to CAD

C Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina. PTS: 1 REF: p. 742 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

D Rationale: For acute gastritis, the nurse provides physical and emotional support and helps the client manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed client; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time. PTS: 1 REF: p. 1268 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 32. A student with diabetes reports feeling nervous and hungry. The school nurse assesses the student and finds the child has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A. A combination of protein and carbohydrates, such as a small cup of yogurt B. Two teaspoons of sugar dissolved in a cup of apple juice C. Half of a cup of juice, followed by cheese and crackers D. Half a sandwich with a protein-based filling

C Rationale: Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. Initial treatment should be followed with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and the additional sugar may result in a sharp rise in blood sugar that will last for several hours. PTS: 1 REF: p. 1511 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client presents to the walk-in clinic reporting a dry, irritating cough and production of a small amount of mucus-like sputum. The client also reports soreness in the chest in the sternal area. The nurse should suspect that the primary care provider will assess the client for which health problem? A. Pleural effusion B. Pulmonary embolism C. Tracheobronchitis D. Tuberculosis

C Rationale: Initially, the client with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The client may report sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of tuberculosis. PTS: 1 REF: p. 531 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? A. Position the client in a prone position to minimize bleeding. B. Establish IV access for the administration of vitamin K. C. Prepare for the administration of factor VIII. D. Administer a normal saline bolus to increase circulatory volume.

C Rationale: Injuries to clients with hemophilia necessitate prompt administration of clotting factors. Vitamin K is not a treatment modality and a prone position will not be appropriate for all types and locations of wounds. A normal saline bolus is not indicated. PTS: 1 REF: p. 936 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? A. Hyponatremia B. Hypophosphatemia C. Hypocalcemia D. Hypokalemia

C Rationale: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the health care provider immediately because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia. PTS: 1 REF: p. 1471 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises? A. Lie supine to facilitate air entry. B. Avoid pursed-lip breathing unless absolutely necessary. C. Use diaphragmatic breathing. D. Use chest breathing.

C Rationale: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing. PTS: 1 REF: p. 620 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states: A. "I read that a pancreas transplant will provide a cure for my diabetes." B. "I will take my oral antidiabetic agents when my morning blood sugar is high." C. "I will make sure to follow the weight loss plan designed by the dietitian." D. "I will make sure I call the diabetes educator when I have questions about my insulin."

C Rationale: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some clients may require insulin on an ongoing basis, or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes. PTS: 1 REF: p. 1493 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Fill in the Blank Chapter 46: Management of Patients with Diabetes 1. A client with type 1 diabetes has told the nurse that the client's most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? A. The client should withhold the next scheduled dose of insulin. B. The client should promptly eat some protein and carbohydrates. C. The client's insulin levels are inadequate. D. The client would benefit from a dose of metformin.

C Rationale: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia. PTS: 1 REF: p. 1499 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 19. The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess? A. Decreased urine output and hypertension B. Headache and vision changes C. Confusion and lethargy D. Jaundice and elevated liver enzymes

C Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 24. The nurse is collaborating with the dietitian and a client with hypertension to plan dietary modifications. Which modifications should be the priority? A. Reduced intake of protein and carbohydrates B. Increased intake of calcium and vitamin D C. Reduced intake of fat and sodium D. Increased intake of potassium, vitamin B12 and vitamin D

C Rationale: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some clients, but a specific reduction in protein and carbohydrates is not normally indicated. PTS: 1 REF: p. 878 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? A. Diet high in red meat B. Upper GI bleed C. Hemorrhoids D. Use of iron supplements

C Rationale: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood. PTS: 1 REF: p. 1216 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 27. A nurse on a medical unit is caring for a client who has been diagnosed with lymphangitis. When reviewing this client's medication administration record, the nurse should anticipate which type of medication? A. An anticoagulant B. A diuretic C. An antibiotic D. An antiplatelet aggregator

C Rationale: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection. PTS: 1 REF: p. 861 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is creating a plan of care for a client diagnosed with acute laryngitis. Which intervention should be included in the client's plan of care? A. Place warm washcloths on the client's throat, as needed. B. Have the client inhale warm steam three times daily. C. Encourage the client to limit speech whenever possible. D. Limit the client's fluid intake to 1.5 L/day.

C Rationale: Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool, not warm, steam or an aerosol. Fluid intake should be increased, not limited. Warm washcloths on the throat will not help relieve the symptoms of acute laryngitis. PTS: 1 REF: p. 507 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in clients with AIDS by increasing body fat stores? A. Psyllium B. Momordica charantia C. Megestrol D. Ranitidine

C Rationale: Megestrol acetate, a synthetic oral progesterone preparation, promotes significant weight gain. In clients with HIV infection, it increases body weight primarily by increasing body fat stores. Psyllium is a fiber source. Momordica charantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine was previously used to prevent ulcers but was removed from the market in April 2020. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse on the pediatric unit is caring for a 10-year-old child with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis? A. Hypothermia B. Diarrhea C. Ineffective coping D. Imbalanced nutrition: Less than body requirements

C Rationale: Most clients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition. PTS: 1 REF: p. 937 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.

C Rationale: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in clients with a history of consumption of alcohol on a daily basis. PTS: 1 REF: p. 1273 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? A. Teaching focuses on safe and effective use of antibiotics. B. The client should be preliminarily screened for surgery. C. Symptom management is the main focus of medical and nursing care. D. The focus of care is resting the voice to prevent chronic hoarseness.

C Rationale: Nursing care for clients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance. PTS: 1 REF: p. 504 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Response 38. A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A. Document the client's low urine output and monitor closely for the next several hours. B. Contact the dietitian and suggest the need for increased oral fluid intake. C. Contact the client's health care provider and continue to assess fluid balance and renal function. D. Increase the infusion rate of the client's IV fluid to prompt an increase in renal function.

C Rationale: Nursing management includes accurate measurement of urine output. An output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse. PTS: 1 REF: p. 760 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client? A. It promotes coping and slows catecholamine release. B. It stimulates the client so he or she is more alert. C. It decreases gastric secretions. D. It dilates the blood vessels.

D Rationale: For clients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the client's anxiety. Morphine would not be prescribed to promote coping or to stimulate the client. The rationale behind using morphine would not be to decrease gastric secretions. PTS: 1 REF: p. 288 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea

C Rationale: Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock. PTS: 1 REF: p. 283 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 23. A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock? A. Aggressive hypoglycemic control B. Administration of hypertonic IV fluids C. Early provision of nutritional support D. Aggressive antibiotic therapy

C Rationale: Nutritional support is necessary for all clients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many clients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in clients with septic shock. PTS: 1 REF: p. 280 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h

C Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE. PTS: 1 REF: p. 1373 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem? A. Adenoiditis B. Chronic tonsillitis C. Obstructive sleep apnea D. Laryngeal cancer

C Rationale: Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This client's symptoms are not suggestive of laryngeal cancer. PTS: 1 REF: p. 510 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Administration of prophylactic antibiotics B. Total parenteral nutrition (TPN) C. Use of a pressure-relieving mattress D. Use of a Foley catheter until discharge

C Rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure. PTS: 1 REF: p. 1175 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client is scheduled for a skin test. The client informs the nurse that the client used a corticosteroid earlier today to alleviate allergy symptoms. Which nursing intervention should the nurse implement? A. Note the corticosteroid use in the electronic health record and continue with the test. B. Modify the skin test to check for grass, mold, or dust allergies only. C. Administer sodium valproate to reverse the effects of corticosteroid usage. D. Cancel and reschedule the skin test when the client stops taking the corticosteroid.

D Rationale: Corticosteroids and antihistamines, including over-the-counter allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. If the client takes one of these medications within this time frame, the nurse should cancel the skin test and reschedule for a time when the client is not taking it. The nurse should not continue with the test. The nurse should not modify the test. Administration of sodium valproate is used to reverse corticosteroid-induced mania, not to reverse it effects, in general. PTS: 1 REF: p. 1045 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 27: Assessment and Management of Patients with Hypertension 1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. Which topic should the nurse include in health education? A. Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker B. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C. Use of strategies to prevent falls stemming from orthostatic hypotension D. Limiting exercise to avoid injury that can be caused by increased intracranial pressure

C Rationale: Older adults have impaired cardiovascular reflexes and are more sensitive to orthostatic hypotension. The nurse teaches clients to change positions slowly when moving from lying or sitting positions to a standing position and counsels older clients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, are strongly recommended. Increasing fluids in older clients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk, and activity should not normally be limited. PTS: 1 REF: p. 879 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury (AKI)? A. An inability to initiate voiding for 2 days. B. The urine is cloudy and has visible sediment with a foul odor. C. Average urine output has been 10 mL/hr for several hours. D. Client reports left-sided flank pain.

C Rationale: Oliguria (<400 mL/day of urine or 0.5 mL/kg an hour over 6 hours) is the most common clinical situation seen in AKI. The client's inability to void and/or urine hesitancy is typically seen with kidney stones, prostate problems, and/or a urinary tract infection (UTI). Urine that has visible sediment and is cloudy and foul smelling is more suggestive of a UTI. Acute flank pain is sometimes seen in AKI. Generally, flank pain has some connection to a variety of kidney diseases like acute glomerular inflammation and polycystic kidney disease. PTS: 1 REF: p. 1564 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

C Rationale: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A. Respiratory function B. Evidence of decreased tissue perfusion C. Signs and symptoms of infection D. Recent changes in activity tolerance

C Rationale: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance. PTS: 1 REF: p. 889 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. Results of a client's 24-hour urine sample indicate osmolality of 510 mOsm/kg (510 mmol/kg), which is within reference range. What conclusion can the nurse draw from this assessment finding? A. The client's kidneys are capable of maintaining acid-base balance. B. The client's kidneys reabsorb most of the potassium that the client ingests. C. The client's kidneys can produce sufficiently concentrated urine. D. The client's kidneys are producing sufficient erythropoietin.

C Rationale: Osmolality is the most accurate measurement of the kidney's ability to dilute and concentrate urine. Osmolality is not a direct indicator of renal function as it relates to erythropoietin synthesis or maintenance of acid-base balance. It does not indicate the maintenance of healthy levels of potassium, the vast majority of which is excreted. PTS: 1 REF: p. 1548 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A. Sudden increase in random blood glucose readings B. Increased abdominal girth accompanied by decreased level of consciousness C. Fever, increased heart rate and decreased blood pressure D. Abdominal pain unresponsive to analgesics

C Rationale: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis. PTS: 1 REF: p. 1433 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following? A. Organic acids B. Solvents C. Asbestos D. Gypsum

C Rationale: Pneumoconiosis is a general term given to any lung disease caused by dusts that are breathed in and then deposited deep in the lungs causing damage. Pneumoconiosis is usually considered an occupational lung disease, and includes asbestosis, silicosis, and coal workers' pneumoconiosis, also known as "Black Lung Disease." Asbestos is among the more common causes of pneumoconiosis. Organic acids, solvents, and gypsum do not have this effect. PTS: 1 REF: p. 576 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. How should the nurse best position a client who has leg ulcers that are venous in origin? A. Keep the client's legs flat and straight. B. Keep the client's knees bent to a 45-degree angle and supported with pillows. C. Elevate the client's lower extremities. D. Dangle the client's legs over the side of the bed.

C Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With ulcers of venous origin, the lower extremities should be elevated to avoid dependent edema. Simply bending the knees to a 45-degree angle would not prevent dependent edema, as they must be elevated above the level of the heart. Dangling the client's legs and applying pillows may further compromise venous return. PTS: 1 REF: p. 857 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A. Assess ability to clear oral secretions. B. Assess for signs of infection. C. Assess for a patent airway. D. Assess for ability to communicate.

C Rationale: Postoperatively, the nurse assesses for a patent airway. The client's ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period. PTS: 1 REF: p. 1236 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? A. Stool will be yellow for the first 24 hours' postprocedure. B. The barium may cause diarrhea for the next 24 hours. C. Fluids must be increased to facilitate the evacuation of the stool. D. Slight anal bleeding may be noted as the barium is passed.

C Rationale: Postprocedural client education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements. The number of bowel movement is noted because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected. PTS: 1 REF: p. 1219 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for a client with bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this client's care? A. Oral administration of diuretics B. Intravenous fluids to reduce the viscosity of secretions C. Postural chest drainage D. Pulmonary function testing

C Rationale: Postural drainage is part of all treatment plans for bronchiectasis, because draining of the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Diuretics and IV fluids will not aid in the mobilization of secretions. Lung function testing may be indicated, but this assessment will not relieve the client's symptoms. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? A. "No metal objects can enter the procedure room." B. "You need to fast for 8 hours prior to the test." C. "You will need to lie still throughout the procedure." D. "There will be a lot of noise during the test."

C Rationale: Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain. PTS: 1 REF: p. 1990 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 22. A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation? A. "You'll need to fast for at least 18 hours prior to your test." B. "Starting today, take over-the-counter (OTC) stool softeners twice daily." C. "You'll need to have enemas the day before the test." D. "For 24 hours before the test, insert a glycerin suppository every 4 hours."

C Rationale: Preparation of the client includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning. PTS: 1 REF: p. 1220 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 21. The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? A. The breakdown of food particles into cell form for digestion B. The maintenance of fluid and acid-base balance C. The absorption into the bloodstream of nutrient molecules produced by digestion D. The control of absorption and elimination of electrolytes

C Rationale: Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 29. A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform? A. Have the client identify the blood type in writing. B. Ensure that the client has granted verbal consent for transfusion. C. Assess the client's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

C Rationale: Prior to a transfusion, the nurse must take the client's temperature, pulse, respiration, and blood pressure to establish a baseline. Written consent is required, and the client's blood type is determined by type and cross match, not by the client's self-declaration. Peripheral venous access is sufficient for blood transfusion. PTS: 1 REF: p. 900 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? A. All at one time, to provide a longer rest period B. Before meals, to stimulate the client's appetite C. In the morning, with frequent rest periods D. Before bedtime, to promote rest

C Rationale: Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the client may be too exhausted to eat. Procedures should be avoided near bedtime if possible. PTS: 1 REF: p. 2102 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? A. Chronic jaundice B. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly

C Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin. PTS: 1 REF: p. 1371 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months C. Promoting communication with the client and family along with addressing end-of-life issues D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

C Rationale: Promoting communication with the client and family is a critical role of the nurse with a client in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death, and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the client. PTS: 1 REF: p. 297 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 26. The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A. Suctioning secretions B. Facilitating ABG analysis C. Providing ventilatory assistance D. Administering tube feedings

C Rationale: Providing ventilatory assistance takes precedence in the immediate management of the client with myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are not the priority for this client. ABG analysis will be done, but this is also not the priority. PTS: 1 REF: p. 2103 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN

C Rationale: Research findings suggest that low-dose aspirin may lower the risk of stroke in clients who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect. PTS: 1 REF: p. 2035 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A nurse is working with a female client who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment? A. Clearly explain the potential benefits of pelvic floor muscle exercises. B. Ensure the client knows that surgery will be required if the exercises are unsuccessful. C. Arrange for biofeedback when the client is learning to perform the exercises. D. Contact the client weekly to ensure that they are performing the exercises consistently.

C Rationale: Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles involved when performing PME. This objective assessment is likely superior to weekly contact with the client. Surgery is not necessarily indicated if behavioral techniques are unsuccessful. PTS: 1 REF: p. 1614 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 41. The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, the client will receive home care nursing. Which information should the nurse include in discharge teaching for this client? A. Safe technique for self-suctioning of secretions B. Technique for performing postural drainage C. Correct and safe use of oxygen therapy equipment D. How to provide safe and effective tracheostomy care

C Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the client and family in their correct and safe use. The scenario does not indicate the client needs suctioning, postural drainage, or tracheostomy care. PTS: 1 REF: p. 582 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 16. A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A. Expiratory wheezes B. Inspiratory wheezes C. Rhonchi D. Crackles

D Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. The nurse is providing information to a client about neurological disorders associated with genetic defects. The nurse knows which disease is considered an autosomal dominant disorder? A. Duchenne muscular dystrophy B. Parkinson disease C. Huntington disease D. Fragile X syndrome

C Rationale: Several neurologic disorders are associated with genetic abnormalities. These diseases can have distinct inheritance patterns including: autosomal dominant, Autosomal recessive, or X-linked. Autosomal dominant diseases include: familial Alzheimer disease, myotonic dystrophies, Von Hippel-Lindau syndrome, Huntington disease, neurofibromatosis, and cerebral arteriopathy. Duchenne muscular dystrophy and fragile X syndrome are X-linked disorders. Parkinson disease does not have a distinct inheritance pattern. PTS: 1 REF: p. 1979 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 9. A client who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What should the goals of physical therapy for this client include? A. Muscle training to relieve dysphagia B. Relieving nerve paralysis in the cervical plexus C. Promoting maximum shoulder function D. Alleviating achalasia by decreasing esophageal peristalsis

C Rationale: Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the client's neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist. PTS: 1 REF: p. 1242 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 29. A nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the client's aneurysm? A. Sudden increase in blood pressure and a decrease in heart rate B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly C. Sudden onset of severe back or abdominal pain D. New onset of hemoptysis

C Rationale: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis. PTS: 1 REF: p. 842 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 25. A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, which nursing diagnosis is most appropriate? A. Risk for acute pain B. Risk for unilateral neglect C. Risk for activity intolerance D. Risk for fluid volume excess

C Rationale: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 39. During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action? A. Facilitate a referral to a neurologist. B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Follow up by having the client perform the Rinne test.

C Rationale: Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the client's safety. The Rinne test assesses hearing, not balance. PTS: 1 REF: p. 1981 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A. "Have you ever been employed in a factory, smelter, or mill?" B. "Does anyone in your family have any form of lung disease?" C. "Do you currently smoke, or have you ever smoked?" D. "Have you ever lived in an area that has high levels of air pollution?"

C Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors. PTS: 1 REF: p. 474 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the client's chronic kidney disease is at what stage? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C Rationale: Stages of chronic kidney disease are based on the GFR. Stage 3 is defined by a GFR in the range of 30 to 59 mL/min/1.73 m2. This is considered a moderate decrease in GFR. PTS: 1 REF: p. 1557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 32. The nurse is providing health education to an older adult client. What should the nurse teach the client about the relationship between hypertension and age? A. "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up." B. "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in older adults." C. "Structural and functional changes in the cardiovascular system that occur with age contribute to an increase in blood pressure." D. "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure."

C Rationale: Structural and functional changes in the heart and blood vessels contribute to an increase in BP that occurs with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes. PTS: 1 REF: p. 867 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what method? A. Chemotherapy B. Radiation C. Surgical resection D. Bronchoscopic opening of the airway

C Rationale: Surgical resection is the preferred method of treating clients with localized non-small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred. PTS: 1 REF: p. 580 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. Diagnostic testing has revealed that a client's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this client's plan of care will focus on what intervention? A. Cryosurgery B. Liver transplantation C. Lobectomy D. Laser hyperthermia

C Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer. PTS: 1 REF: p. 1406 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 17. A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system? A. Constriction of blood vessels in the heart muscle B. Constriction of bronchioles C. Increase in the secretion of sweat D. Constriction of pupils

C Rationale: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils. PTS: 1 REF: p. 1975 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A trauma client was admitted to the intensive care unit (ICU) with a brain injury that resulted in a change in level of consciousness and altered vital signs. The client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A. Adrenal crisis B. Hypothalamic collapse C. Sympathetic storm D. Cranial nerve deficit

C Rationale: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result. PTS: 1 REF: p. 1975 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? A. Damage to cranial nerve VIII B. Adverse medication effects C. Age-related neurologic changes D. An undiagnosed cerebrovascular disease in early adulthood

C Rationale: Tactile sensation is dulled in the older adult client due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiologic processes. PTS: 1 REF: p. 1984 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (CPP). D. Prepare the client for craniotomy.

C Rationale: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition. PTS: 1 REF: p. 2000 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is preparing to administer warfarin to a client with deep vein thrombophlebitis. Which laboratory value would most clearly indicate that the client's warfarin is at therapeutic levels? A. Partial thromboplastin time (PTT) within normal reference range B. Prothrombin time (PT) 8 to 10 times the control C. International normalized ratio (INR) between 2 and 3 D. Hematocrit of 32%

C Rationale: The INR is most often used to determine whether warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage. PTS: 1 REF: p. 848 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A. P wave B. T wave C. QRS complex D. U wave

C Rationale: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 39. A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? A. Nonrebreathing mask B. Tracheostomy collar C. Venturi mask D. Face tent

C Rationale: The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for clients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The Venturi mask uses the Bernoulli principle of air entrainment (trapping the air like a vacuum), which provides a high airflow with controlled oxygen enrichment. For each liter of oxygen that passes through a jet orifice, a fixed proportion of room air is entrained. Varying the size of the jet orifice and adjusting the flow of oxygen can deliver a precise volume of oxygen. The other methods of oxygen delivery listed, the nonrebreathing mask, tracheostomy collar, and face tent, do not use the Bernoulli principle and thus lack the precision of a Venturi mask. PTS: 1 REF: p. 613 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Emergent B. Immediate resuscitative C. Acute D. Rehabilitation

C Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling. PTS: 1 REF: p. 1873 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis. B. Reduced activity protects the physical integrity of pancreatic cells. C. Bed rest lowers the metabolic rate and reduces enzyme production. D. Inactivity reduces caloric need and gastrointestinal motility.

C Rationale: The acutely ill client is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. Staying in bed does not release energy from the body to fight the disease. PTS: 1 REF: p. 1433 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 5. The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood? A. A capillary blood sample B. Pulse oximetry C. An arterial blood gas (ABG) study D. A complete blood count (CBC)

C Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool, but does not replace ABG measurement because it is not as accurate. A CBC does not indicate the concentration of oxygen. PTS: 1 REF: p. 487 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving birth at home. Which principle should guide the nurse's administration of intravenous fluid? A. 5% albumin is preferred because it is inexpensive and is always readily available. B. Dextran should be given because it increases intravascular volume and counteracts coagulopathy. C. Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency. D. Lactated Ringer solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure.

C Rationale: The best fluid to treat shock remains controversial. In emergencies, the "best" fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids, such as dextran and albumin, should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but it increases the risk for coagulopathy. Lactated Ringer is a good solution choice because it increases volume and buffers acidosis, but it should not be used in clients with liver failure because the liver is unable to convert lactate to bicarbonate. This client does not have liver disease. PTS: 1 REF: p. 287 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse is assessing the respiratory status of a client who is experiencing an exacerbation of emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A. Rhonchi during expiration B. Wheezing with discontinuous breath sounds C. Faint breath sounds with prolonged expiration D. Faint breath sounds with fine crackles

C Rationale: The breath sounds of the client with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged. Fine crackles are soft, high-pitched, discontinuous popping sounds heard in mid to late inspiration that are associated with interstitial pneumonia, restrictive pulmonary disease, or bronchitis. Wheezing is a continuous, musical, high-pitched, shrill sound associated with chronic bronchitis or bronchiectasis. Rhonchi are deep, lower-pitched rumbling sounds, with a snoring quality, that are associated with secretions or a tumor. PTS: 1 REF: p. 482 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

C Rationale: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected. PTS: 1 REF: p. 2051 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 5. A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy? A. The client's diet should be low protein with ample fat. B. The client may experience short-term changes in cognition. C. The client is at an increased risk for developing infection. D. The client is at a decreased risk for development of thrombophlebitis and thromboembolism.

C Rationale: The client is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. The diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects. PTS: 1 REF: p. 1487 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 49: Management of Patients with Urinary Disorders 1. A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client? A. Bathe daily and keep the perineal region clean. B. Avoid voiding immediately after sexual intercourse. C. Drink liberal amounts of fluids. D. Void at least every 6 to 8 hours.

C Rationale: The client is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The client should be encouraged to shower rather than bathe. PTS: 1 REF: p. 1609 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 5. A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The client will obtain measurement of drainage from the T-tube. B. The client will exercise three times a week. C. The client will take immunosuppressive agents as required. D. The client will monitor for signs of liver dysfunction.

C Rationale: The client is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The client is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the client to measure drainage from a T-tube as the client wouldn't go home with a T-tube. The nurse may teach the client about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen. PTS: 1 REF: p. 1410 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 6. A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Allow the client to gently scratch inside the cast with a pencil. B. Give the client a sterile tongue depressor to use for scratching instead of the pencil. C. Provide a fan to blow cool air into the cast to relieve itching, D. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

C Rationale: The client may receive relief from itching by using a fan or hair dryer to blow cool air into the cast. Scratching should be discouraged using a pencil or a sterile tongue depressor because of the risk for skin breakdown or damage to the cast. Benzodiazepines would not be given for this purpose. PTS: 1 REF: p. 1170 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client who underwent percutaneous (endourologic) lithotripsy earlier in the day. What instruction should the nurse give the client? A. Limit oral fluid intake for 1 to 2 days. B. Report the presence of fine, sand-like particles through the nephrostomy tube. C. Notify the health care provider about cloudy or foul-smelling urine. D. Report any pink-tinged urine within 24 hours after the procedure.

C Rationale: The client should report the presence of foul-smelling or cloudy urine since this is suggestive of a urinary tract infection (UTI). Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal due to residual stone products. Hematuria is common after lithotripsy. PTS: 1 REF: p. 1621 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. A client has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this client's discharge education? A. Resumption of activities of daily living B. Pain control C. Promotion of adequate nutrition D. Strategies for promoting communication

C Rationale: The client who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the client's nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery. PTS: 1 REF: p. 1234 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 33. A client with a recent history of nephrolithiasis has presented to the ED. After determining that the client's cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A. IV fluid administration B. Insertion of an indwelling urinary catheter C. Pain management D. Assisting with aspiration of the stone

C Rationale: The client with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the client's need for IV fluids or for catheterization. Kidney stones cannot be aspirated. PTS: 1 REF: p. 1621 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client? A. Oxycodone B. Warfarin C. Morphine D. Acetaminophen

C Rationale: The client with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta-blocker, and other medications as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used. PTS: 1 REF: p. 740 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A client presents to the clinic reporting the inability to grasp objects with the right hand. The client's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with the left arm. The nurse should expect that the primary provider may diagnose the client with which health problem? A. Lymphedema B. Raynaud phenomenon C. Upper extremity arterial occlusive disease D. Upper extremity venous thromboembolism (VTE)

C Rationale: The client with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud disease or lymphedema. The upper extremities are rare sites for VTE. PTS: 1 REF: p. 833 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A. Educating the client about expectations and care following surgery B. Educating the client about the management of blood glucose after discharge C. Educating the client about postdischarge lifestyle modifications D. Educating the client about the potential benefits of pancreatic transplantation

C Rationale: The client's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery, and blood sugar monitoring is not necessarily indicated for every client after hospital treatment. Transplantation is not an option. PTS: 1 REF: p. 1433 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.

C Rationale: The client's symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the client's symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the client's surgery. PTS: 1 REF: p. 1279 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A 35-year-old client with a history of traumatic brain injury has been admitted to the emergency department for a recent change in cognition. The client is steadily walking across the room, intermittently laughing loudly, and crying hysterically. What is the most likely condition associated with these signs? A. Dementia B. Status epilepticus C. Pseudobulbar affect D. Absence seizure

C Rationale: The condition known as pseudobulbar affect involves inappropriate or exaggerated emotional expression, usually episodes of laughing or crying. It is associated with brain injury (e.g., stroke, traumatic brain injury, multiple sclerosis [MS], amyotrophic lateral sclerosis [ALS], AD, and Parkinson disease). The client's age, gait, and new onset of symptoms make dementia an unlikely choice. Even new onset dementia typically occurs in a client over the age of 40 with a progressive /slow onset of symptoms which could impair their gait. Status epilepticus (acute prolonged seizure activity) can be defined as a seizure lasting 5 minutes or longer or serial seizures occurring without full recovery of consciousness between attacks. The client's symptoms do not support this finding. Absence seizures usually involve staring episodes. PTS: 1 REF: p. 2017 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? A. The circumference of the stoma B. The length, then double it C. The widest part of the stoma D. Half the width of the stoma

C Rationale: The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage. PTS: 1 REF: p. 1630 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is performing a focused genitourinary and renal assessment of a client. Where should the nurse assess for pain at the costovertebral angle? A. At the umbilicus and the right lower quadrant of the abdomen B. At the suprapubic region and the umbilicus C. At the lower border of the 12th rib and the spine D. At the 7th rib and the xiphoid process

C Rationale: The costovertebral angle is the angle formed by the lower border of the 12th rib and the spine. Renal dysfunction may produce tenderness over the costovertebral angle. PTS: 1 REF: p. 1544 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The nurse should closely monitor the client for what complication during this phase? A. Hypokalemia B. Hypocalcemia C. Dehydration D. Acute flank pain

C Rationale: The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The client must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. Excessive losses of potassium and calcium are not typical during this phase, and diuresis does not normally result in pain. PTS: 1 REF: p. 1565 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is admitting a client with a diagnosis of left ventricular hypertrophy. The client reports dyspnea on exertion, as well as fatigue. Which diagnostic tool would be most helpful in diagnosing this type of myopathy? A. Cardiac catheterization B. Arterial blood gases C. Echocardiogram D. Exercise stress test

C Rationale: The echocardiogram (ECG) is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily. The ECG is also important, and can demonstrate arrhythmias and changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing is not normally used to differentiate cardiomyopathy from other cardiac pathologies. PTS: 1 REF: p. 770 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. The health care provider has explained to a client that the client has developed diabetic neuropathy in the right foot. Later that day, the client asks the nurse what causes diabetic neuropathy. What would be the nurse's best response? A. "Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years." B. "The cause is not known for sure but it is thought to have something to do with ketoacidosis." C. "The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years." D. "Research has shown that diabetic neuropathy is caused by a combination of elevated glucose and ketone levels."

C Rationale: The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugar (rather than fluctuations or variations in blood sugars) is thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies. PTS: 1 REF: p. 1523 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. A client is undergoing diagnostic testing for mitral stenosis. What statement by the client during the nurse's interview is most suggestive of this valvular disorder? A. "I get chest pain from time to time, but it usually resolves when I rest." B. "Sometimes when I'm resting, I can feel my heart skip a beat." C. "Whenever I do any form of exercise I get terribly short of breath." D. "My feet and ankles have gotten terribly puffy the last few weeks."

C Rationale: The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension. Clients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. Palpitations occur in some clients, but dyspnea is a characteristic early symptom. Peripheral edema and chest pain are atypical. PTS: 1 REF: p. 768 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select Chapter 60: Assessment of Neurologic Function 1. A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect? A. Parietal lobe B. Temporal lobe C. Frontal lobe D. Occipital lobe

C Rationale: The frontal lobe is the largest lobe located in front of the brain. It is responsible in large part for a person's affect, judgment, personality, and inhibitions. The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The temporal lobe plays a role in memory of sound and understanding of language and music. The occipital lobe is responsible for visual interpretation and memory. PTS: 1 REF: p. 1968 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 19. A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas? A. Cerebellum B. Thalamus C. Hypothalamus D. Midbrain

C Rationale: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation. PTS: 1 REF: p. 1969 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric need B. Calorie deficit and muscle wasting combined with low electrolyte levels C. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

C Rationale: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral. PTS: 1 REF: p. 1313 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. The nurse is caring for a client in the emergency department who was admitted for a hypertensive emergency. The nurse knows the goal of intravenous vasodilator therapy for a hypertensive emergency would be which outcome? A. Lower the blood pressure to reduce the onset of neurological changes B. Decrease the blood pressure to a normal level based on the client's age C. Decrease the systolic blood pressure by no more than 25% within the first hour D. Decrease the blood pressure to less than or equal to 120/80 as quickly as possible

C Rationale: The initial treatment for hypertensive crisis is to decrease the systolic blood pressure by no more than 25% within the first hour of treatment. Lowering the blood pressure too fast may cause hypotension in a client whose body has adjusted to hypertension and could cause a stroke, myocardial infarction, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning. PTS: 1 REF: p. 880 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated A. 635241 B. 352416 C. 236145 D. 162534

C Rationale: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function. PTS: 1 REF: p. 2032 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse's assessment reveals a blood pressure (BP) of 98/52 mm Hg. The nurse should recognize that the client's kidneys will compensate by secreting what substance? A. Antidiuretic hormone (ADH) B. Aldosterone C. Renin D. Angiotensin

C Rationale: The kidneys have an important function in the autoregulation of BP. When the vasa recta detects a decrease in BP, specialized juxtaglomerular cells near the afferent arteriole, distal tubule, and efferent arteriole secrete the hormone renin. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II. The vasoconstriction causes the BP to increase. The adrenal cortex secretes aldosterone in response to stimulation by the pituitary gland, which in turn is in response to poor perfusion or increasing serum osmolality. The result is an increase in BP. Aldosterone and angiotensin are part of this complex process but renin is required to start this process. ADH is a hormone and vasopressin can increase the BP but is secreted by the pituitary gland, not the kidneys. PTS: 1 REF: p. 1539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Decreased breath sounds B. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomen D. Acute pain with movement

C Rationale: The location of the subcostal incision will likely cause the client to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind clients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be given for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the health care provider, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure. PTS: 1 REF: p. 1427 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

C Rationale: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA. PTS: 1 REF: p. 2040 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 6. The nurse in the intensive care unit is caring for a client with pulmonary hypertension. Which finding should the nurse expect to assess? A. Pulmonary artery pressure greater than 20 mm Hg B. Flat neck veins C. Dyspnea at rest D. Enlarged spleen

C Rationale: The main symptom in pulmonary hypertension is dyspnea. At first dyspnea occurs with exertion, then eventually at rest. A client with pulmonary hypertension will have a pulmonary artery pressure greater than 25 mm Hg at rest and distended neck veins secondary to right-sided heart failure. The nurse would expect the liver, not the spleen, to be enlarged secondary to engorgement in pulmonary hypertension. PTS: 1 REF: p. 575 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The critical care nurse is caring for a client just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A. Warfarin B. Furosemide C. Sodium nitroprusside D. Ramipril

C Rationale: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside, nicardipine hydrochloride, clevidipine, fenoldopam mesylate, enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is given orally and would not meet the client's immediate need for BP management. Diuretics, such as furosemide, are not used as initial treatments and there is no indication for anticoagulants such as warfarin. PTS: 1 REF: p. 880 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to which area of the heart? A. Endocardium B. Pericardium C. Myocardium D. Visceral pericardium

C Rationale: The middle layer of the heart, or myocardium, is made up of muscle fibers and is responsible for the pumping action. The inner layer, or endocardium, consists of endothelial tissue and lines the inside of the heart and valves. The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Adhering to the epicardium is the visceral pericardium. Enveloping the visceral pericardium is the parietal pericardium, a tough fibrous tissue that attaches to the great vessels, diaphragm, sternum, and vertebral column and supports the heart in the mediastinum. PTS: 1 REF: p. 660 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 34. Which factor is the most common cause of mitral valve regurgitation in developing countries? A. A decrease in gamma globulins B. An insect bite C. Rheumatic heart disease and its sequelae D. Sepsis and its sequelae

C Rationale: The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease and its sequelae, not a decrease in gamma globulins, an insect bite, or sepsis and its sequelae. PTS: 1 REF: p. 767 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Select 14. A client is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. Which food items would the nurse inform the client are common allergens? A. Citrus fruits and rice B. Root vegetables and tomatoes C. Eggs and wheat D. Hard cheeses and vegetable oils

C Rationale: The most common food allergens are seafood (lobster, shrimp, crab, clams, fin fish), peanuts, tree nuts, eggs, wheat, milk, and soy. Citrus fruits, rice, root vegetables, tomatoes, hard cheeses, and vegetable oils are not common allergens. PTS: 1 REF: p. 1061 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 16. A nurse should prioritize and closely monitor a client for a potentially severe anaphylactic reaction after the client has received which medical intervention? A. Measles-mumps-rubella vaccine B. Rapid administration of intravenous fluids C. Computed tomography with contrast solution D. Nebulized bronchodilator

C Rationale: The most severe anaphylaxis, sometimes referred to as anaphylactic shock, is caused by antibiotics and radiocontrast agents. The computed tomography scan with contrast dye uses these agents. Vaccines can produce an anaphylactic reaction but are usually localized and not severe. Intravenous fluid and bronchodilators may be used to manage anaphylaxis in clients with symptoms of bronchospasm or hypotension, but they are not typically associated with triggering anaphylactic shock themselves. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's health care provider because these symptoms are suggestive of what issue? A. Pneumothorax B. Lung tumors C. Infection D. Pulmonary edema

C Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum. PTS: 1 REF: p. 473 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 30. The nurse is caring for a client who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action? A. Arrange for continuous cardiac monitoring and reposition the client. B. Remove the CVP catheter and apply an occlusive dressing. C. Assess the client for fluid overload and inform the health care provider. D. Raise the head of the client's bed and have the client perform deep breathing exercises, if possible.

C Rationale: The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is due to hypervolemia. Assessing the client and informing the health care provider are the most prudent actions. Repositioning the client is ineffective and removing the device is inappropriate. PTS: 1 REF: p. 684 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A. Increased blood pressure B. Bounding peripheral pulses C. Changes in level of consciousness D. Skin flushing

C Rationale: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected. PTS: 1 REF: p. 710 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A nurse is aware of the high incidence and prevalence of fluid volume deficit among older adults. What related health education should the nurse provide to an older adult? A. "If possible, try to drink at least 4 liters of fluid daily." B. "Ensure that you avoid replacing water with other beverages." C. "Remember to drink frequently, even if you don't feel thirsty." D. "Make sure you eat plenty of salt in order to stimulate thirst."

C Rationale: The nurse emphasizes the need to drink throughout the day even if the client does not feel thirsty because the thirst stimulation is decreased. Four liters of daily fluid intake is excessive, and fluids other than water are acceptable in most cases. Additional salt intake is not recommended as a prompt for increased fluid intake. PTS: 1 REF: p. 1541 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

C Rationale: The nurse encourages the client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated. PTS: 1 REF: p. 1427 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action? A. Remove the client's drain and apply pressure with a sterile gauze. B. Assess the client, reposition the client supine, and apply wall suction to the drain. C. Rapidly assess the client and notify the surgeon about the client's bleeding. D. Administer a STAT dose of vitamin K to aid coagulation.

C Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be given without an order. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A. "Complementary therapies generally have not been approved, so clients are usually discouraged from using them." B. "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C. "Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks." D. "You'll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach."

C Rationale: The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment. PTS: 1 REF: p. 1026 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. The nurse is creating an education plan for a client who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan? A. The importance of increased fluid intake B. Signs and symptoms of rejection C. Inspection and care of the incision D. Techniques for preventing metastasis

C Rationale: The nurse teaches the client to inspect and care for the incision and perform other general postoperative care, including activity and lifting restrictions, driving a vehicle, and pain management. There would be no need to teach the signs or symptoms of rejection as there has been no transplant. Increased fluid intake is not normally recommended and the client has minimal control on the future risk for metastasis. PTS: 1 REF: p. 1565 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 18. While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A. Eupnea B. Apnea C. Biot respiration D. Cheyne-Stokes

C Rationale: The nurse will document that the client is demonstrating a Biot respiration pattern. Biot respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. PTS: 1 REF: p. 477 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 4. A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color. D. Limit foods high in fiber due to the risk for diarrhea.

C Rationale: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy. PTS: 1 REF: p. 915 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 61: Management of Patients With Neurologic Dysfunction 1. A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D. Spironlactone

C Rationale: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema. PTS: 1 REF: p. 2012 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse is creating a plan of care for a client with cardiomyopathy. Which goal would be a priority for the client? A. Absence of complications B. Adherence to the self-care program C. Improved cardiac output D. Increased activity tolerance

C Rationale: The priority nursing diagnosis of a client with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output. PTS: 1 REF: p. 782 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. This is known as what physiologic state? A. Static stage B. Latent stage C. Viral set point D. Window period

C Rationale: The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though they are infected. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine.

C Rationale: The services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists are made available, and can reduce the client's anxiety. This is preferable to antianxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach. PTS: 1 REF: p. 1281 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 23. A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? A. Decisional conflict B. Deficient knowledge C. Death anxiety D. Disturbed thought processes

C Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the client's likely fear of death, which is a realistic possibility. For most clients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The client may or may not experience disturbances in thought processes. PTS: 1 REF: p. 1378 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 19. Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? A. A client who skips breakfast when the glucose reading is greater than 220 mg/dL (12.3 mmol/L) B. A client who never deviates from the prescribed dose of insulin C. A client who adheres closely to a meal plan and meal schedule D. A client who eliminates carbohydrates from the daily intake

C Rationale: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes. PTS: 1 REF: p. 1494 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 9. A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A. Shallow respirations B. Increased anterior-posterior (AP) diameter C. Bilateral wheezes D. Bradypnea

C Rationale: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's AP diameter does not normally change. PTS: 1 REF: p. 633 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure? A. Cerebellum B. Hypothalamus C. Pituitary gland D. Pineal gland

C Rationale: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus. PTS: 1 REF: p. 2016 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 38. The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment? A. The client desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B. The client requires a high-flow system for use with a tracheostomy collar. C. The client desires a portable oxygen delivery system that can deliver 2 L/min. D. The client's respiratory status requires a system that provides an FiO2 of 65%.

C Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The client desiring a portable oxygen delivery system of 2 L/min will benefit from the use of an oxygen concentrator. PTS: 1 REF: p. 630 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 11. The nurse is caring for a client suspected of having renal dysfunction. When reviewing laboratory results for this client, the nurse interprets the presence of which substances in the urine as most suggestive of pathology? A. Potassium and sodium B. Bicarbonate and urea C. Glucose and protein D. Creatinine and chloride

C Rationale: The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Within the tubule, some of these substances are selectively reabsorbed into the blood. Glucose is completely reabsorbed in the tubule and normally does not appear in the urine. However, glucose is found in the urine if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. Protein molecules are also generally not found in the urine because amino acids are also filtered at the level of the glomerulus and reabsorbed so that they are not excreted in the urine. PTS: 1 REF: p. 1537 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. PTS: 1 REF: p. 596 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care? A. Risk for disuse syndrome related to ineffective peripheral circulation B. Functional urinary incontinence related to urethral occlusion C. Ineffective tissue perfusion related to thrombosis D. Ineffective thermoregulation related to hypothalamic dysfunction

C Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis. PTS: 1 REF: p. 920 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat diet B. Annual screening endoscopy for clients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy foods

C Rationale: There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history. PTS: 1 REF: p. 1257 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse on a nephrology unit is caring for a diverse group of clients. For which client would a kidney biopsy most likely be contraindicated? A. A 64-year-old client with chronic glomerulonephritis B. A 57-year-old client with proteinuria C. A 42-year-old client with morbid obesity D. A 16-year-old client with signs of kidney transplant rejection

C Rationale: There are several contraindications to a kidney biopsy, including bleeding tendencies, uncontrolled hypertension, a solitary kidney, and morbid obesity. Indications for a kidney biopsy include unexplained acute kidney injury, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 35. A newly diagnosed client with hypertension is prescribed a thiazide diuretic. What client education should the nurse provide to this client? A. "Eat a banana every day because this medication causes moderate hyperkalemia." B. "Take over-the-counter potassium pills because this medication causes your kidneys to lose potassium." C. "This medication can cause low blood pressure and dizziness, especially when you get up suddenly." D. "This medication increases sodium levels in your blood, so cut down on your salt."

C Rationale: Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids, or hot weather. Thiazide diuretics do not cause either moderate hyperkalemia or severe hypokalemia and they do not result in hypernatremia. PTS: 1 REF: p. 871 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 32. A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching? A. Increased respiratory secretions B. Bradycardia C. Oral candidiasis D. Decreased level of consciousness

C Rationale: Thrush or oral candidiasis is a fungal infection that presents with white lesions on the tongue and/or inner cheeks of the mouth. Clients should rinse their mouth after administration or use a spacer to prevent thrush, a common complication associated with use of inhaled corticosteroids. Increased respiratory secretions normally do not occur, although a cough may develop. Tachycardia, or a fast heart rate, rather than bradycardia, or a slow heart rate, is listed as an adverse effect. A decreased level of consciousness is not associated with this medication because it does not cause sedation nor is it an opiate. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 7. A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

C Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 12. The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? A. Monitor and record blood pressure daily. B. Monitor and record radial pulses daily. C. Monitor weight daily. D. Monitor bowel movements.

C Rationale: To assess fluid balance at home, the client should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance. PTS: 1 REF: p. 809 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse is caring for a client with acute pericarditis. Which nursing management would be instituted to minimize complications? A. The nurse keeps the client isolated to prevent nosocomial infections. B. The nurse encourages coughing and deep breathing. C. The nurse helps the client with activities until the pain and fever subside. D. The nurse encourages increased fluid intake until the infection resolves.

C Rationale: To minimize complications, the nurse helps the client with activity restrictions until the pain and fever subside. As the client's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the client isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary. PTS: 1 REF: p. 789 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degrees to right side of the abdomen and push down firmly.

C Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant. PTS: 1 REF: p. 1369 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action? A. Housing the resident in a private room B. Implementing a passive ROM program C. Implementing of a plan for fall prevention D. Providing the client with a high-fiber diet

C Rationale: To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake. PTS: 1 REF: p. 931 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification

C Rationale: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification. PTS: 1 REF: p. 1888 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. The nurse is caring for a client with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a client with an indwelling catheter? A. Vigorously clean the meatus area daily. B. Apply powder to the perineal area twice daily. C. Empty the drainage bag at least every 8 hours. D. Irrigate the catheter every 8 hours with normal saline.

C Rationale: To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine. Vigorous cleaning of the meatus while the catheter is in place is discouraged, because the cleaning action can move the catheter, increasing the risk of infection. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Irrigation of the catheter opens the closed system, increasing the likelihood of infection. PTS: 1 REF: p. 1619 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

C Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A nurse is admitting a client to the medical unit who has a history of peripheral artery disease (PAD). While providing the health history, the client reports smoking about two packs of cigarettes a day, having a history of alcohol abuse, and not exercising. Which topic would be the priority health education for this client? A. The lack of exercise, which is the main cause of PAD B. The likelihood that heavy alcohol intake is a significant risk factor for PAD C. The nicotine in cigarettes, which is a powerful vasoconstrictor and may cause or aggravate PAD D. Alcohol, which suppresses the immune system, creates high glucose levels, and may cause PAD

C Rationale: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and clients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks. PTS: 1 REF: p. 828 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 24. The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants' risks of renal carcinoma? A. Avoiding heavy alcohol use B. Control of sodium intake C. Smoking cessation D. Adherence to recommended immunization schedules

C Rationale: Tobacco use is a significant risk factor for renal cancer, surpassing the significance of high alcohol and sodium intake. Immunizations do not address an individual's risk of renal cancer. PTS: 1 REF: p. 1563 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. Which form of alaryngeal communication is generally most preferred? A. Esophageal speech B. Electric larynx C. Tracheoesophageal puncture D. American sign language (ASL)

C Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, electric larynx, and ASL. PTS: 1 REF: p. 517 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Response 28. A client has just been diagnosed with lung cancer. After the health care provider discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response? A. "The type of treatment depends on the client's age and health status." B. "The type of treatment depends on what the client wants when given the options." C. "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status." D. "The type of treatment depends on the discussion between the client and the health care provider of which treatment is best."

C Rationale: Treatment of lung cancer depends on the cell type, the stage of the disease, and the client's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the client's age or the client's preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the client and the health care provider of which treatment is best, though this discussion will take place. PTS: 1 REF: p. 580 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding? A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury. C. This is an accurate indicator of myocardial injury. D. This result indicates muscle injury, but does not specify the source.

C Rationale: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury. PTS: 1 REF: p. 672 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 3. At a blood pressure screening, the nurse learns that a client has a family history of hypertension, high cholesterol, and elevated lipid levels. The client says reports smoking one pack of cigarettes daily and drinking "about a pack of beer" every day. The nurse notes which nonmodifiable risk factor for hypertension? A. Hyperlipidemia B. Excessive alcohol intake C. A family history of hypertension D. Closer adherence to medical regimen

C Rationale: Unlike cholesterol levels, alcohol intake, and adherence to treatment, family history is not modifiable. PTS: 1 REF: p. 867 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 28. A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young, I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? A. "Newer antihistamines are combined with a stimulant that offsets drowsiness." B. "Most people find that they develop a tolerance to sedation after a few months." C. "The newer antihistamines are different than in years past, and cause less sedation." D. "Have you considered taking them at bedtime instead of in the morning?"

C Rationale: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if any at all. Tolerance to sedation did not usually occur with first-generation drugs, and newer antihistamines are not combined with a stimulant. Although taking an antihistamine at bedtime may be a suitable option for the client, it is not the nurse's best response because it does not inform the client of the newer antihistamines, which cause little or no sedation and thus could be taken any time of day. PTS: 1 REF: p. 1050 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. A client admitted to the medical unit with impaired renal function reports severe, stabbing pain in the flank and lower abdomen. The client is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location? A. Meatus B. Bladder C. Ureter D. Urethra

C Rationale: Ureteral pain is characterized as a dull, continuous pain that may be intense with voiding. The pain may be described as sharp or stabbing if the bladder is full. This type of pain is inconsistent with a stone being present in the bladder. Stones are not normally situated in the urethra or meatus. PTS: 1 REF: p. 1541 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 21. The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

C Rationale: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care. PTS: 1 REF: p. 2092 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote? A. Intravenous immunoglobulins (IVIG) B. Factor IX C. Vitamin K D. Factor VIII

C Rationale: Vitamin K is given as an antidote for warfarin toxicity. IVIG is a form of immunosuppressive therapy given to treat immune thrombocytopenic purpura and to counteract hemolytic transfusion reaction and neutralizing antibodies (inhibitors) that develop in response to factor replacement therapy in clients with hemophilia. IVIG is not used as an antidote for warfarin toxicity. Factors VIII and IX are clotting factors that are deficient in clients with hemophilia due to a genetic defect; these clients may receive recombinant forms of these factors to treat their condition. PTS: 1 REF: p. 945 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. The triage nurse in the emergency department is assessing a client who reports pain and swelling in the right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago, and it has been sore ever since." The client has a history of chronic venous insufficiency. Which intervention should the nurse anticipate for this client? A. Platelet transfusion to treat thrombocytopenia B. Warfarin to treat arterial insufficiency C. Antibiotics to treat cellulitis D. Intravenous heparin to treat venous thromboembolism (VTE)

C Rationale: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The client may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a client's risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This client does not have signs and symptoms of VTE. PTS: 1 REF: p. 861 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a client's plan of care. The presence of which chronic health problem would most likely prompt this diagnosis? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Spina bifida D. Hypogammaglobulinemia

C Rationale: Clients with spina bifida are at a particularly high risk for developing a latex allergy. Clients with spina bifida are at high risk because they have had multiple surgeries, multiple urinary catheterization procedures, and other treatments involving use of latex products, and latex allergy develops as a result of repeated exposure to the proteins and polypeptides in natural rubber latex. Clients with herpes simplex, HIV, or hypogammaglobulinemia (decreased level of gamma immunoglobulins) are less likely than clients with spina bifida to have as many surgeries or other treatments that would expose them to latex. PTS: 1 REF: p. 1062 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen

C Rationale: Emotional support from the family is key to the client's coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the client's health status. It is highly beneficial if the family is willing and able to accommodate the client's dietary needs, but emotional support is paramount and cannot be solely provided by the client alone. PTS: 1 REF: p. 1311 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze

Multiple Choice 2. A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse would discuss the importance of antibiotic prophylaxis prior to which event? A. Exposure to immunocompromised individuals B. Future hospital admissions C. Dental procedures D. Live vaccinations

C Rationale: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed. PTS: 1 REF: p. 786 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

C Rationale: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures. PTS: 1 REF: p. 2019 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client? A. Signs of oxygen toxicity B. A moon face C. A barrel chest D. Long, thin fingers

C Rationale: In chronic obstructive pulmonary disease (COPD) clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The client with COPD is more likely to have finger clubbing, which is an abnormal rounded appearance of the fingertips, rather than long, thin fingers. Clubbed fingers are the result of chronically low blood levels of oxygen. A moon face is swelling of the face due to increased fat deposits. This may be a sign of Cushing syndrome or a side effect of steroid use. Signs of oxygen toxicity, such as facial pallor or behavioral changes, may be possible but are not the most likely physical findings for this client. PTS: 1 REF: p. 606 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A medical nurse has admitted four clients over the course of a 12-hour shift. For which client would assessment of ankle-brachial index (ABI) be most clearly warranted? A. A client who has peripheral edema secondary to chronic heart failure B. An older adult client who has a diagnosis of unstable angina C. A client with poorly controlled type 1 diabetes who is a smoker D. A client who has community-acquired pneumonia and a history of COPD

C Rationale: Nurses should perform a baseline ABI on any client with decreased pulses or any client 50 years of age or older with a history of diabetes or smoking. The other answers do not apply. PTS: 1 REF: p. 824 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 34. The nurse is caring for a client who had a low-profile gastrostomy device placed. Which instruction should the nurse give the client and family? A. Wear the tubing outside of clothing. B. Use tape to secure the device. C. Bring the connection tubing if going to the hospital. D. Change the wet-to-dry dressing daily.

C Rationale: To administer a feeding with a low-profile feeding device, special tubing is connected to the device. This client needs to be instructed to take this tubing to the hospital and when traveling. A low-profile gastrostomy device sits flush with the skin so it is easily concealed under clothes. The device does not require tape or other type of securement system. This device also does not require any type of dressing, including a wet-to-dry dressing. PTS: 1 REF: p. 1250 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care? A. Hematemesis and persistent sensation of fullness B. Abdominal bloating and recurrent constipation C. Intermittent pain and bloody stool D. Unexplained bowel incontinence and fatty stools

C Rationale: When the client is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors. PTS: 1 REF: p. 1283 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 20. An older adult client diagnosed with cancer is admitted to the oncology unit for surgical treatment. The client has been on chemotherapeutic agents to decrease tumor size prior to the planned surgery. The nurse caring for the client is aware that what precipitating factors in this client may contribute to acute kidney injury (AKI)? Select all that apply. A. Anxiety and agitation B. Low body mass index (BMI) C. Age-related physiologic changes D. Chronic systemic disease E. Nothing by mouth (NPO) status

C, D, E Rationale: Changes in kidney function with normal aging increase the susceptibility of older clients to kidney dysfunction and kidney injury. In addition, the presence of chronic, systemic diseases increases the risk of AKI. This client was on chemotherapeutic agents that frequently cause nausea and vomiting, which contribute to dehydration. Older adult clients taking medications may cause alterations in renal flow and clearance. The client was made NPO prior to surgery, making them more susceptible to AKI even with parenteral fluids. A low BMI and anxiety are not risk factors for acute renal disease. PTS: 1 REF: p. 1567 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 35. A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. A. Systemic infection B. Complex regional pain syndrome C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism

C, D, E Rationale: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures. PTS: 1 REF: p. 1161 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the client's admission assessment, the nurse should be aware that what signs and symptoms are characteristic of this diagnosis? Select all that apply. A. Diarrhea B. High fever C. Hematuria D. Urinary frequency E. Acute pain

C, D, E Rationale: Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the client has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation, and a fever is usually absent due to the noninfectious nature of the health problem. PTS: 1 REF: p. 1621 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 11. A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A. Antihypertensives B. Penicillins C. Sulfa-containing medications D. Aspirin-based drugs E. NSAIDs

C, D, E Rationale: The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function. PTS: 1 REF: p. 934 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse is caring for a client with a duodenal ulcer and is relating the client's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A. Secretion of hydrochloric acid (HCl) B. Reabsorption of water C. Secretion of mucus D. Absorption of nutrients E. Movement of nutrients into the bloodstream

C, D, E Rationale: The small intestine folds back and forth on itself, providing a very large surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. Water reabsorption primarily takes place in the large bowel. HCl is secreted by the stomach. PTS: 1 REF: p. 1209 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 30. A client has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. A. Pupillary response B. Creatinine and BUN levels C. Potassium level D. Peripheral pulses E. Blood pressure

C, E Rationale: Clients with primary aldosteronism (Conn syndrome) exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected. PTS: 1 REF: p. 1483 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client had a lumbar puncture performed at the outpatient clinic and the nurse phoned the client and family that evening. What does this phone call enable the nurse to determine? Select all that apply. A. What the client's and family's expectations of the test are. B. Whether the client's family had any questions about why the test was necessary. C. Whether the client has had any complications from the test. D. Whether the client understood accurately why the test was done. E. The necessary steps for the client and family to take should complications arise.

C, E Rationale: Contacting the client and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure, whether the client had any untoward results, and what to do should complications arise. Since the test was done as an outpatient; monitoring and care are being provided by the family. The health of the client becomes a team effort so any communication by the nurse should include both parties. The other listed information should have been elicited from the client and family prior to the test. PTS: 1 REF: p. 1991 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 14. A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What are the current recommendations that the nurse would describe? A. 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B. 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C. 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D. 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

D Rationale: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet. PTS: 1 REF: p. 1494 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Response 31. A nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD) admitted to the hospital for the second time this year with pneumonia. Which nursing diagnoses would be appropriate for this client? Select all that apply. A. Ineffective airway clearance related to inhalation of toxins B. Activity intolerance related to oxygen supply and demand C. Impaired gas exchange related to ventilation-perfusion inequality D. Ineffective health management related to fatigue E. Deficient knowledge regarding self-care related to preventable complications

C, E Rationale: Impaired gas exchange and deficient knowledge are the appropriate diagnoses for this client based on the information provided. Pneumonia is an acute infection of the parenchyma whose pathophysiology typically triggers an inflammatory response in the lung. In a client with COPD who already has chronic inflammation, gas exchange becomes further compromised. Areas of the lung receive either oxygen but no blood flow or blood flow but no oxygen (ventilation/perfusion inequality). Because this was the second admission for the same diagnosis, deficient knowledge of prevention strategies should be included for this client. Although ineffective airway clearance is a possibility, not enough information is provided to conclude that it was a result of toxins such as cigarette smoke. Activity intolerance and health management should be addressed as a risk because pneumonia and COPD impact activity and cause fatigue, but not enough information was provided to make these a problem. PTS: 1 REF: p. 620 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Drag and Drop 35. A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), and assessment reveals a client with a newly delayed and shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital and has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs and symptoms? A. Cryptococcal meningitis B. Cytomegalovirus retinitis C. Peripheral neuropathy D. Subcortical neurodegenerative disease

D Rationale Subcortical neurodegenerative disease is known as HIV-associated neurocognitive disorder (HAND). Signs can be subtle and include changes in language, memory, and problem solving, as well as slowing psychomotor skills. Early identification is important as HAND can be treated by changing antiretroviral medications. Cryptococcal meningitis is a form of subacute meningitis. Signs include fever, malaise, and headache. Retinitis caused by cytomegalovirus retinitis is the leading cause of blindness in clients with acquired immunodeficiency syndrome. Peripheral neuropathy is a common neurological symptom at any stage of HIV infection. Signs and symptoms are pain in the feet and functional impairment. PTS: 1 REF: p. 1023 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 37: Management of Patients with Musculoskeletal Trauma 1. A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client? A. The cast will feel cool to touch for the first 30 minutes. B. The cast should be wrapped snuggly with a towel until the client gets home. C. The cast should be supported on a board while drying. D. The cast will only have full strength when dry.

D Rationale: A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped. PTS: 1 REF: p. 1167 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching.

D Rationale: A client diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The client should participate in daily muscle stretching to help alleviate and relax muscle spasms. PTS: 1 REF: p. 2098 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A. Assessment of body image B. Assessment of jugular venous pressure C. Assessment of carotid pulse D. Assessment of swallowing ability

D Rationale: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client's body image should be assessed, but dysphagia has the potential to affect the client's airway, and is a consequent priority. PTS: 1 REF: p. 520 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. The nurse is caring for a client who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the client to tilt the head forward, and the nurse applies pressure to the nose, but the client's nose continues to bleed. Which intervention should the nurse next implement? A. Apply ice to the bridge of the nose. B. Lay the client down. C. Arrange for transfer to the local emergency department. D. Insert a cotton tampon in the affected nare.

D Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down could block the client's airway. Transfer to the emergency department is necessary only if the bleeding becomes serious. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. An older adult client has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A. Use of supplementary oxygen to aid tissue oxygenation B. Daily use of normal saline compresses on the lower limbs C. Daily administration of prophylactic antibiotics D. A high-protein diet that is rich in vitamins

D Rationale: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation. PTS: 1 REF: p. 858 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A nurse is providing health education to the family of a client with bronchiectasis. Which technique should the nurse prioritize teaching the client's family members? A. The correct technique for chest palpation and auscultation B. Techniques for assessing the client's fluid balance C. The technique for providing deep nasotracheal suctioning D. The correct technique for providing postural drainage

D Rationale: A focus of the care of bronchiectasis is helping clients clear pulmonary secretions; consequently, clients and families are taught to perform postural drainage. Chest palpation and auscultation and assessment of fluid balance are not prioritized over postural drainage. Nasotracheal suctioning is not normally necessary. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice Chapter 57: Management of Patients with Burn Injury 1. A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness

D Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the client will report pain and sensitivity to cold air. Full partial thickness is not a depth of burn. PTS: 1 REF: p. 1867 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 33. A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A. The client should not undergo the normal bowel cleansing protocol prior to the procedure. B. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. C. The client should be admitted to the surgical unit on the day before the procedure. D. The client should be given necessary clotting factors before the procedure.

D Rationale: A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive procedure to prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not reduce the client's risk of bleeding. There may or may not be a need for preprocedure hospital admission. PTS: 1 REF: p. 939 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

D Rationale: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition. PTS: 1 REF: p. 2049 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? A. Taking prophylactic antibiotics as prescribed B. Adhering to the treatment regimen in order to cure the disease C. Avoiding airplanes, buses, and other crowded public places D. Setting realistic short- and long-term goals

D Rationale: A major area of teaching involves setting and accepting realistic short-term and long-term goals. Emphysema is not considered curable and antibiotics are not used on a preventative basis. The client does not normally need to avoid public places. PTS: 1 REF: p. 608 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is planning the care of a client who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, which blood pressure would be the goal of treatment? A. 160/90 mm Hg or lower B. 100/80 mm Hg or lower C. Average of two BP readings of 150/80 mm Hg D. 130/80 mm Hg or lower

D Rationale: A pressure of 130/80 mm Hg or less is the goal for clients. All other readings are out of range or not appropriate. PTS: 1 REF: p. 870 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 35. A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? A. Cranial arteritis B. Cluster headache C. Paroxysmal hemicranias D. Secondary headache

D Rationale: A secondary headache is a symptom associated with other causes, such as a brain tumor, an aneurysm, or lumbar puncture. Cranial arteritis is a cause of headache in the older population, reaching its greatest incidence in those older than 70 years of age. Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. A cluster headache is usually chronic and occurs more frequently in the male population. Paroxysmal hemicrania is a rare form of a primary headache that usually begins as an adult. It is usually severe, sudden, and can be linked to women with conditions like head trauma or a tumor on the pituitary gland. PTS: 1 REF: p. 2026 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia? A. Venous ulcers and visual disturbances B. Fever and signs of hyperkalemia C. Epistaxis and gastroesophageal reflux D. Shortness of breath and peripheral edema

D Rationale: A significant complication of anemia is heart failure from chronic diminished blood volume and the heart's compensatory effort to increase cardiac output. Clients with anemia should be assessed for signs and symptoms of heart failure, including dyspnea and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure. PTS: 1 REF: p. 912 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention? A. Hepatectomy B. Vitamin K administration C. Platelet transfusion D. Splenectomy

D Rationale: A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to conservative treatment. Vitamin K administration is treatment for vitamin K deficiency and does not resolve anemia. Platelet transfusion may be the course of treatment for some bleeding disorders. Hepatectomy would not help the client. PTS: 1 REF: p. 927 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate? A. Position the client in the high Fowler position whenever possible. B. Temporarily eliminate animal protein from the client's diet. C. Make sure the client eats at least two servings of raw fruit each day. D. Obtain a stool culture to identify possible pathogens.

D Rationale: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Clients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the bed. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. B. Provide the client with educational materials that match the client's learning style. C. Encourage the client to write down these concerns and questions to bring forward to the surgeon. D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

D Rationale: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the client's psychosocial and learning needs. Reassurance does not address the client's questions, and education may or may not alleviate anxiety. PTS: 1 REF: p. 1321 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action? A. Palpate the client's carotid pulse. B. Illuminate the client's call light. C. Begin performing chest compressions. D. Activate the Emergency Response System (ERS).

D Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response. PTS: 1 REF: p. 813 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The critical care nurse is caring for a client who is receiving cyclosporine postoperative heart transplant. What outcome represents a therapeutic outcome of this pharmacologic treatment? A. The client remains free of thrombus formation. B. The client maintains adequate cardiac output. C. The client has an increase in white cell count. D. The client does not experience organ rejection.

D Rationale: After heart transplant, clients are constantly balancing the risk of rejection with the risk of infection. Most commonly, clients receive medications such as cyclosporine to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance cardiac output, or increase white cell counts. PTS: 1 REF: p. 779 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response? A. Educate the client about the link between alcohol use and pancreatitis. B. Ensure that the client knows the importance of attending follow-up appointments. C. Refer the client to social work or spiritual care. D. Encourage the client to connect with a community-based support group.

D Rationale: After the acute attack has subsided, some clients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous as appropriate or other support groups is essential. The client already has an understanding of the effects of alcohol, and follow-up appointments will not necessarily result in lifestyle changes. Social work and spiritual care may or may not be beneficial. PTS: 1 REF: p. 1433 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect the client's busy work schedule. Which guidance would the nurse provide to the client? A. "Clients generally stay in the hospital for 6 to 8 days." B. "Clients are kept in the hospital until they are independent with all aspects of their care." C. "Clients need to stay in the hospital until they regain normal heart function for their age." D. "Clients usually remain at the hospital for 24 to 48 hours."

D Rationale: After undergoing percutaneous balloon valvuloplasty, the client usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the client does not need to be wholly independent prior to discharge. PTS: 1 REF: p. 775 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 9. A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

D Rationale: Alcohol must be avoided when taking metronidazole and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the client. PTS: 1 REF: p. 1269 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D Rationale: All of the listed focuses of care are important for the client with a small bowel obstruction. However, the client's risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions. PTS: 1 REF: p. 1304 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse working on the coronary care unit is caring for a client with ACS. How can the nurse best meet the client's psychosocial needs? A. Reinforce the fact that treatment will be successful. B. Facilitate a referral to a chaplain or spiritual leader. C. Increase the client's participation in rehabilitation activities. D. Directly address the client's anxieties and fears.

D Rationale: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the client's psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some clients, but it may exacerbate it for others. PTS: 1 REF: p. 741 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy? A. Persistently cold feet B. Pain that does not respond to analgesia C. Acute pain, unrelieved by rest D. The presence of a tingling sensation

D Rationale: Although approximately half of clients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication. PTS: 1 REF: p. 1522 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A 72-year-old man has been brought to his primary care provider by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client? A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B. Lapses in memory in older adults are considered benign unless they have negative consequences. C. Gradual increases in confusion accompany the aging process. D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

D Rationale: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging. PTS: 1 REF: p. 1985 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. A client with a history of rheumatic heart disease knows that the client is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which drug? A. Enoxaparin B. Metoprolol C. Azathioprine D. Amoxicillin

D Rationale: Although rare, bacterial endocarditis may be life threatening. A key strategy is primary prevention in high-risk clients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic. PTS: 1 REF: p. 785 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. An ECG has been ordered for a newly admitted client. What should the nurse do prior to electrode placement? A. Clean the skin with povidone-iodine solution. B. Ensure that the area for electrode placement is dry. C. Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D. Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

D Rationale: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used. PTS: 1 REF: p. 692 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client with end stage renal disease (ESKD) is being treated for a right ankle fracture unrelated to a fall. The client's lab values show high phosphate levels, low calcium levels, and low vitamin D levels. What is the most likely reason for this client's fracture? A. Osteoporosis B. Codman triangle C. Hypertrophic osteoarthropathy D. Renal osteodystrophy

D Rationale: An abnormality seen in ESKD is called renal osteodystrophy or uremic bone disease. It is a disease that involves complex changes in calcium, phosphate, and parathormone balances. Damage seen in ESKD results in an increase in phosphate and a decrease in calcium (reciprocal relationship), which causes increased production from the parathyroid. Clients with ESKD cannot handle these increases, effectively resulting in bone changes and bone disease. All of the other choices can cause fractures but are not typically suspected in a client with ESRD with the presented lab values. Osteoporosis, where bone becomes brittle and fragile, is usually diagnosed with a bone density scan. Codman triangle is a radiologic sign seen commonly on x-rays. It is usually an indication of bone tumors. Hypertrophic osteoarthropathy (HOA) is characterized by abnormal proliferation (growth) of skin and periosteal tissue involving the extremities. Diagnosis is typically from x-rays and physical findings. PTS: 1 REF: p. 1571 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

D Rationale: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. PTS: 1 REF: p. 2021 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? A. Prednisone B. Dexamethasone C. Cafergot D. Phenytoin

D Rationale: Anticonvulsant medication (phenytoin, levetiracetam) is often prescribed prophylactically for clients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines. PTS: 1 REF: p. 2011 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. Graduated compression stockings have been prescribed to treat a client's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the client? A. The need to take anticoagulants concurrent with using compression stockings B. The need to wear the stockings on a "one day on, one day off" schedule C. The importance of wearing the stockings around the clock to ensure maximum benefit D. The importance of ensuring the stockings are applied evenly with no pressure points

D Rationale: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory clients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in clients who are using compression stockings. PTS: 1 REF: p. 853 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A. Radiation therapy often results in secondary brain tumors. B. Surgical complications are exceedingly common. C. Diagnosis rarely occurs until the cancer is end stage. D. Metastases are common and respond poorly to treatment.

D Rationale: Deaths from malignancies of the head and neck are primarily attributable to local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by way of the lymphatics before the primary lesion has been treated. This local-regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. This high mortality rate is not related to surgical complications, late diagnosis, or the development of brain tumors. PTS: 1 REF: p. 1236 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 34. The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring? A. Urinary output increases B. Skin becomes warm and dry C. Adventitious lung sounds occur in the upper airway D. Heart and respiratory rates are elevated

D Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs. PTS: 1 REF: p. 293 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 8. The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first? A. Check for a carotid pulse. B. Apply supplemental oxygen. C. Give two full breaths. D. Gently shake and shout, "Are you OK?"

D Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery. PTS: 1 REF: p. 813 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select Chapter 43: Assessment and Management of Patients with Hepatic Disorders 1. A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K

D Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin. PTS: 1 REF: p. 1366 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 2. A client with a family history of allergies has experienced an allergic response based on a genetic predisposition. This atopic response is usually mediated by which immunoglobulin (Ig)? A. IgA B. IgM C. IgG D. IgE

D Rationale: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions. IgE (0.004% of total Ig) appears in serum; takes part in allergic and some hypersensitivity reactions; and combats parasitic infections. IgA (15% of total Ig) appears in body fluids (blood, saliva, tears, and breast milk, as well as pulmonary, gastrointestinal, prostatic, and vaginal secretions); protects against respiratory, gastrointestinal, and genitourinary infections; prevents absorption of antigens from food; and passes to neonate in breast milk for protection. IgM (10% of total Ig) appears mostly in intravascular serum; appears as the first Ig produced in response to bacterial and viral infections; and activates the complement system. IgG (75% of total Ig) appears in serum and tissues (interstitial fluid); assumes a major role in bloodborne and tissue infections; activates the complement system; enhances phagocytosis; and crosses the placenta. PTS: 1 REF: p. 1039 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A nurse is educating a client about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A. Stem cell differentiation B. Cytokine production C. Phagocytosis D. Antibody production

D Rationale: B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production. PTS: 1 REF: p. 889 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 14. A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider? A. Large, wide stools B. Milky white stools C. Three stools during an 8-hour period of time D. Streaks of blood present in the stool

D Rationale: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the client to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify accordingly. PTS: 1 REF: p. 1214 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A. Impaired skin integrity B. Cognitive deficits C. Hemorrhage D. Autonomic dysfunction

D Rationale: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-Barré syndrome. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention? A. Positioning the client supine B. Administering diuretics C. Oxygen by nasal cannula D. Administering volume expanders

D Rationale: Because clients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. Supine positioning could exacerbate bleeding because of the effects of gravity. Nasal cannula are unlikely to meet the client's oxygenation needs. PTS: 1 REF: p. 1377 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. The nurse is assessing a client who had a pacemaker implanted 4 weeks ago. During the client's most recent follow-up appointment, the nurse identifies data that suggest the client may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A. Decisional conflict related to pacemaker implantation B. Deficient knowledge related to pacemaker implantation C. Spiritual distress related to pacemaker implantation D. Ineffective coping related to pacemaker implantation

D Rationale: Depression and isolation may be symptoms of ineffective coping with the implantation. These psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be needed to determine a spiritual component to the client's challenges. PTS: 1 REF: p. 721 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A client is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The client is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response? A. Report this finding promptly to the primary care provider. B. Obtain a sterile urine sample and send it for culture. C. Obtain a urine sample and check it for pH. D. Reassure the client that this is an expected phenomenon.

D Rationale: Because mucous membrane is used in forming the conduit, the client may excrete a large amount of mucus mixed with urine. This causes anxiety in many clients. To help relieve this anxiety, the nurse reassures the client that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required. PTS: 1 REF: p. 1629 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 26. The nurse is caring for a client with right ventricular hypertrophy and, consequently, decreased right ventricular function. What valvular disorder may have contributed to this client's diagnosis? A. Mitral valve regurgitation B. Aortic stenosis C. Aortic regurgitation D. Mitral valve stenosis

D Rationale: Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails. None of the other listed valvular disorders has this pathophysiological effect. PTS: 1 REF: p. 771 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A female client's most recent urinalysis results are suggestive of bacteriuria. When assessing this client, the nurse's data analysis should be informed by what principle? A. Most UTIs in female clients are caused by viruses and do not cause obvious symptoms. B. A diagnosis of bacteriuria requires three consecutive positive results. C. Urine contains varying levels of healthy bacterial flora. D. Urine samples are frequently contaminated by bacteria normally present in the urethral area.

D Rationale: Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does not require three consecutive positive results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology. PTS: 1 REF: p. 1606 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

D Rationale: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure may not be accurate since the client is often still confused during the postictal period. PTS: 1 REF: p. 2012 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 31. A client has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the client and will implement a program of health education. What is the nurse's priority action? A. Ensure that the client understands the basic pathophysiology of diabetes. B. Identify the client's body mass index. C. Teach the client "survival skills" for diabetes. D. Assess the client's readiness to learn.

D Rationale: Before initiating diabetes education, the nurse assesses the client's (and family's) readiness to learn. This must precede other physiologic assessments (such as BMI) and providing health education. PTS: 1 REF: p. 1508 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 10. A kidney biopsy has been scheduled for a client with a history of acute kidney injury. The client asks the nurse why this test has been scheduled. What is the nurse's best response? A. "A biopsy is routinely ordered for all clients with renal disorders." B. "A biopsy is generally ordered following abnormal x-ray findings of the renal pelvis." C. "A biopsy is often ordered for clients before they have a kidney transplant." D. "A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease."

D Rationale: Biopsy of the kidney is used in diagnosing and evaluating the extent of kidney disease. Indications for biopsy include unexplained acute kidney injury, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time? A. Only when needed B. Daily at bedtime C. First thing in the morning D. With each meal

D Rationale: Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate-binding medications must be given with food to be effective. PTS: 1 REF: p. 1570 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure? A. "Do not breastfeed your baby for two weeks after the procedure as recommended by your provider." B. "Limit your intake of water and alcohol following the procedure." C. "Do not eat or cook any shellfish prior to the procedure." D. "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

D Rationale: Breastfeeding women are instructed by the nuclear medicine department to stop for a certain time period when undergoing nuclear medicine/CT scan treatment. Clients are assessed to see if an allergy to shellfish/iodine exists prior to the procedure. Clients are encouraged to drink plenty of fluids after the procedure to help the kidneys clear the dye out of the body. PTS: 1 REF: p. 1985 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe? A. The entire peritoneal cavity can be visualized. B. The test allows for painless biopsy collection. C. The capsule is endoscopically placed in the intestine. D. The test is noninvasive.

D Rationale: Capsule endoscopy allows for the noninvasive visualization of the mucosa of the small intestine. This procedure allows visualization of the GI tract, but not the peritoneal cavity. The capsule consists of a chip video camera without a mechanism to obtain a biopsy. The capsule is swallowed and is not endoscopically placed in the small intestine. PTS: 1 REF: p. 1224 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 18. The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm? A. Pulseless electrical activity (PEA) B. Ventricular fibrillation C. Ventricular tachycardia D. Asystole

D Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm. PTS: 1 REF: p. 813 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember

Multiple Choice 38. The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? A. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. B. Elicit the client's response to a hypothetical problem. C. Ask the client to close his or her eyes and discern between hot and cold stimuli. D. Guide the client through the performance of rapid, alternating movements.

D Rationale: Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the client perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment. PTS: 1 REF: p. 1981 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

D Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure. PTS: 1 REF: p. 596 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 16. What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus

D Rationale: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension. PTS: 1 REF: p. 2008 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 36. A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include? A. Check the gastric residual volume every 4 hours. B. Hold the tube feeding if the gastric residual volume is greater than 200 mL. C. Position client flat in bed during feedings. D. Use client assessment findings to determine tolerance of feedings.

D Rationale: Client indicators of tolerance to tube feedings include abdominal distention, client report of discomfort, vomiting, hypoactive bowel sounds, and diarrhea. Previously, gastric residual volume (GRV) was checked as an indicator of tube feeding tolerance. Professional organizations such as the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) no longer advocate using GRVs to monitor tolerance of enteral feedings. Therefore, unless policy states otherwise, GRV should not be checked every 4 hours and the feeding should not be held for a GRV greater than 250 mL. The head of the bed should be elevated 30 degrees while a tube feeding is being administered to reduce the risk for aspiration. PTS: 1 REF: p. 1246 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is providing care to a client who has just undergone an electrophysiologic (EP) study. The client reports being nervous about "things going wrong" during the procedure. What is the nurse's best response? A. "This is basically a risk-free procedure." B. "Thousands of clients undergo EP every year." C. "Remember that this is a step that will bring you closer to enjoying good health." D. "The whole team will be monitoring you very closely for the entire procedure."

D Rationale: Clients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the client, the family, and the electrophysiologist usually occurs to ensure that the client can give informed consent and to reduce the client's anxiety about the procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not necessarily relieve the client's anxiety. Characterizing EP as a step toward good health does not directly address the client's anxiety. PTS: 1 REF: p. 711 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 34. A client has sought care, stating that the client developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the client developed? A. Type I B. Type II C. Type III D. Type IV

A Rationale: Type I hypersensitivity reactions are unanticipated severe allergic reactions that are rapid in onset, characterized by edema in many tissues, including the larynx, and often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Urticaria (hives) is a type I hypersensitive allergic reaction of the skin that is characterized by the sudden appearance of intensely pruritic pink or red discrete papules that progress to wheals of variable size. Type II, or cytotoxic, hypersensitivity reactions occur when antibodies are directed against antigens on cells or basement membranes of tissues. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia. Type III, or immune complex, hypersensitivity reactions are damaging inflammatory reactions caused by the insoluble immune complexes formed by antigens that bind to antibodies. Examples of type III reactions include systemic lupus erythematosus, serum sickness, nephritis, and rheumatoid arthritis. Type IV, or delayed, hypersensitivity reactions are T cell-mediated immune reactions that typically occur 24 to 48 hours after exposure to an antigen. Examples of type IV reactions include contact dermatitis, graft-versus-host disease, Hashimoto's thyroiditis, and sarcoidosis. PTS: 1 REF: p. 1057 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 20. A nurse is planning discharge health education for a client who will soon undergo placement of a mechanical valve prosthesis. Which topic would the nurse prioritize? A. The need for long-term antibiotics B. The need for 7 to 10 days of bed rest C. Strategies for preventing atherosclerosis D. Strategies for infection prevention

D Rationale: Clients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials used in valvuloplasty) require education to prevent infective endocarditis. Despite these infection risks, antibiotics are not used long term. Activity management is important, but extended bed rest is unnecessary. Valve replacement does not create a heightened risk for atherosclerosis. PTS: 1 REF: p. 775 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment? A. Hypovolemia B. Vitamin B12 deficiency C. Thrombocytopenia D. Iron overload

D Rationale: Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels. PTS: 1 REF: p. 905 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is providing preprocedure teaching about an ultrasound. The nurse informs the client that in preparation for an ultrasound of the lower urinary tract the client will require what action? A. Increased fluid intake to produce a full bladder B. IV administration of radiopaque contrast agent C. Sedation and intubation D. Injection of a radioisotope

A Rationale: Ultrasonography requires a full bladder; therefore, fluid intake should be encouraged before the procedure. The administration of a radiopaque contrast agent is required to perform IV urography studies, such as an IV pyelogram. Ultrasonography is a quick and painless diagnostic test and does not require sedation or intubation. The injection of a radioisotope is required for nuclear scan and ultrasonography is not in this category of diagnostic studies. PTS: 1 REF: p. 1549 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. On admission to a medical unit, a client with human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result? A. Efavirenz B. Doravirine C. Nevirapine D. Etravirine

A Rationale: Use of efavirenz, even as part of a combination drug, may lead to false-positive results with cannabinoid and benzodiazepine screening assays. Efavirenz, doravirine, nevirapine and etravirvine are all non-nucleoside reverse transcriptase inhibitors that bind and block the HIV enzyme and prevent replication in the body. Doravirine, nevirapine, and etravirvine do not have the adverse side effect of false-positives for cannabinoid and benzodiazepine. PTS: 1 REF: p. 1019 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 36. A 55-year-old female client with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A. Destruction of the client's liver tumor B. Restoration of portal vein patency C. Destruction of a liver abscess D. Reversal of metastasis

A Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis. PTS: 1 REF: p. 1406 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. The nurse is planning care for a client with venous insufficiency. Which nursing intervention would be appropriate for this client's plan of care? A. Elevate lower extremities. B. Educate on decreased protein. C. Apply compression only at night. D. Teach frequent rest periods due to pain.

A Rationale: Venous insufficiency is lack of blood flow back to the heart. Elevation of lower extremities will assist the peripheral blood vessels in returning stasis of blood. Increased protein should be taught. Compression therapy should be used but not only at night. Pain is not usually assessed in clients with venous insufficiency but with arterial insufficiency. PTS: 1 REF: p. 853 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing the face B. Exposing the skin to sunlight C. Using artificial tears D. Drinking large amounts of fluids

A Rationale: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a client with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this client. Temperature extremes in beverages should be avoided. PTS: 1 REF: p. 2108 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? A. Bronchoconstriction B. Pneumonia C. Hemoptysis D. Hemothorax

A Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from the respiratory tract), or hemothorax (a collection of blood in the space between the chest wall and the lung). PTS: 1 REF: p. 473 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? A. Maintain firm contact between paddles and the client's skin. B. Apply a layer of water as a conducting agent. C. Call "all clear" once before discharging the defibrillator. D. Ensure the defibrillator is in the sync mode.

A Rationale: When defibrillating an adult client, the nurse should maintain good contact between the paddles and the client's skin. To prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear'' should be called three times before discharging the paddles. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse would anticipate which potential treatment? A. Heart transplantation B. Balloon valvuloplasty C. Cardiac catheterization D. Stent placement

A Rationale: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy. PTS: 1 REF: p. 779 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? A. Inspection, auscultation, percussion, and palpation B. Inspection, palpation, auscultation, and percussion C. Inspection, percussion, palpation, and auscultation D. Inspection, palpation, percussion, and auscultation

A Rationale: When performing a focused assessment of the client's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation. PTS: 1 REF: p. 1215 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

A Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened. PTS: 1 REF: p. 1303 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider will use to drain the client's bladder? A. Insertion of a suprapubic catheter B. Scheduling the client immediately for a prostatectomy C. Application of warm compresses to the perineum to assist with relaxation D. Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours

A Rationale: When the client cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm. PTS: 1 REF: p. 1616 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium? A. It may have developed an increased area of infarction during the time without treatment. B. It will probably not have more damage than if the client came in immediately. C. It may be responsive to restoration of the area of dead cells with proper treatment. D. It has been irreparably damaged, so immediate treatment is no longer necessary.

A Rationale: When the client experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means. PTS: 1 REF: p. 737 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 9. A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing which health problem? A. Chronic kidney disease B. Right ventricular hypertrophy C. Glaucoma D. Anemia

A Rationale: When uncontrolled hypertension is prolonged, it can result in chronic kidney disease, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension. PTS: 1 REF: p. 867 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? A. Through a central venous line B. By a gravity infusion IV set C. By IV push for rapid onset of action D. Mixed with parenteral feedings to balance osmosis

A Rationale: Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition. PTS: 1 REF: p. 283 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiologic state? A. The client's tissue demands may be met, but the client will be unable to respond to physiological stressors. B. The client's short-term oxygen needs will be met, but the client will be unable to expel sufficient CO2. C. The client will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D. The client will experience respiratory alkalosis with no ability to compensate.

A Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiologic stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results. PTS: 1 REF: p. 470 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? A. Acute pulmonary edema B. Right-sided heart failure C. Right ventricular hypertrophy D. Left-sided heart failure

A Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The client quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not directly occur. PTS: 1 REF: p. 809 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse is caring for a client with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A. Provide a high-calorie, high-protein diet. B. Apply a clean occlusive dressing once daily and whenever soiled. C. Abstain from wearing graduated compression stockings. D. Apply an antibiotic ointment on the surrounding skin with each dressing change.

A Rationale: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Compression therapy should be implemented with venous ulcers but not arterial ulcers. PTS: 1 REF: p. 858 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A female client has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the client, the nurse should address what topic? A. The risk of developing a vaginal yeast infection as a consequence of antibiotic therapy B. The need to expect a heavy menstrual period following the course of antibiotics C. The risk of developing antibiotic resistance after the course of antibiotics D. The need to undergo a series of three urine cultures after the antibiotics have been completed

A Rationale: Yeast vaginitis occurs in many clients treated with antimicrobial agents that affect vaginal flora. Antibiotics do not affect menstrual periods and serial urine cultures are not normally necessary. Resistance is normally a result of failing to complete a prescribed course of antibiotics. PTS: 1 REF: p. 1607 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A. A 4-year-old scald victim burned over 24% of the body B. A 27-year-old male burned over 36% of his body in a car accident C. A 39-year-old female client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire

A Rationale: Young children and older adults continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the client. PTS: 1 REF: p. 1867 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 8. A nurse is preparing a client diagnosed with benign prostatic hyperplasia (BPH) for a lower urinary tract cystoscopic examination. The nurse should caution the client about what common temporary complication of this procedure? A. Urinary retention B. Bladder perforation C. Hemorrhage D. Nausea

A Rationale: After a cystoscopic examination, the client with obstructive pathology may experience urine retention if the instruments used during the examination cause edema. The nurse will carefully monitor the client with prostatic hyperplasia for urine retention. Postprocedure, the client will experience some hematuria, but is not at great risk for hemorrhage. Unless the condition is associated with another disorder, nausea is not commonly associated with this diagnostic study. Bladder perforation is rare. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A. Ischemia B. Referred pain C. Cellulitis D. Venous thromboembolism (VTE)

A Rationale: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site. PTS: 1 REF: p. 1871 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. A client with Wiskott-Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention? A. Protective isolation B. Fresh-frozen plasma (FFP) administration C. Chest physiotherapy D. Nutritional supplementation

A Rationale: Clients with WAS are at a grave risk for infection; infection prevention is a priority aspect of nursing care. Nutritional supplementation may be necessary, but infection prevention is paramount. Chest physiotherapy and FFP administration are not indicated. PTS: 1 REF: p. 1006 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

A Rationale: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The client should be encouraged to eat on the unaffected side due to swallowing difficulties. Analgesics are used to control the facial pain. The client should continue to provide self-care including oral hygiene. PTS: 1 REF: p. 2110 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit

A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit. PTS: 1 REF: p. 1871 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 39. A client on the medical unit reports experiencing significant dyspnea, despite not having recently performed any physical activity. What assessment question should the nurse ask the client while preparing to perform a physical assessment? A. "On a scale from 0 to 10, how bad would you rate your shortness of breath?" B. "When was the last time you ate or drank anything?" C. "Are you feeling any nausea along with your shortness of breath?" D. "Do you think that some medication might help you catch your breath?"

A Rationale: Gauging the severity of the client's dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication. PTS: 1 REF: p. 471 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 14. The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A. Emphysema B. Pulmonary fibrosis C. Pleural effusion D. Acute respiratory distress syndrome (ARDS)

A Rationale: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, such as in emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS. PTS: 1 REF: p. 466 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client? A. "Take no NSAIDs within 72 hours of the test." B. "Take prescribed medications as usual." C. "Avoid over-the-counter (OTC) vitamin C supplements." D. "Do not use fiber supplements before the test."

A Rationale: In the past, clients were advised to avoid ingesting red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish for 72 hours prior to the study because it was thought that these were associated with false-positive results; likewise, clients were advised to avoid ingesting vitamin C from supplements or foods as it was believed that this was associated with false-negative results. However, these restrictions are no longer advised as their actual effects on test results have not been established; plus, they unnecessarily restricted client participation in screening. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A. Stool for occult blood B. Bone marrow biopsy C. Lumbar puncture D. Urinalysis

A Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat." B. "The pain begins right after I eat." C. "I know that my father and my grandfather both had ulcers." D. "I seem to have bowel movements more often than I usually do."

A Rationale: Pain relief after eating is associated with duodenal ulcers. This type of ulcer is not associated with family history or increased frequency of bowel movements. Pain immediately after eating is typical of gastric ulcers, not duodenal. PTS: 1 REF: p. 1272 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 34. A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem? A. A GI malignancy B. Dumping syndrome C. Peptic ulcer disease D. Esophageal/gastric obstruction

A Rationale: Palpable nodules around the umbilicus, called Sister Mary Joseph nodules, are a sign of a GI malignancy, usually a gastric cancer. This would not be a sign of dumping syndrome, peptic ulcer disease, or esophageal/gastric obstruction. PTS: 1 REF: p. 1278 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 14. A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? A. Inform the health care provider and assess the client for signs of infection. B. Flush the peritoneal catheter with normal saline. C. Remove the catheter promptly and have the catheter tip cultured. D. Administer a bolus of IV normal saline as prescribed.

A Rationale: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection. PTS: 1 REF: p. 1586 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? A. Severed blood vessels constrict. B. Thromboplastin is released. C. Prothrombin is converted to thrombin. D. Fibrin is lysed.

A Rationale: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed. PTS: 1 REF: p. 890 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? A. In a high Fowler position B. On the left side-lying position C. In a flat, supine position D. In the Trendelenburg position

A Rationale: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation. PTS: 1 REF: p. 806 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. The nurse on a urology unit is working with a client who has been diagnosed with calcium oxalate renal calculi. When planning this client's health education, what nutritional guidelines should the nurse provide? A. Restrict protein intake as prescribed. B. Increase intake of potassium-rich foods. C. Follow a low-calcium diet. D. Encourage intake of food containing oxalates.

A Rationale: Protein is restricted to 60 g/day, while sodium is restricted to 3 to 4 g/day. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The client should avoid intake of oxalate-containing foods and there is no need to increase potassium intake. PTS: 1 REF: p. 1621 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 3. A medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client? A. Indicates acceptance of altered appearance and demonstrates positive self-image B. Freely expresses needs and concerns related to postoperative pain management C. Compensates effectively for alteration in ability to communicate related to dysarthria D. Demonstrates effective stress management techniques to promote muscle relaxation

A Rationale: Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the client's appearance is visibly altered. The face generally appears asymmetric, with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Clients who have had head and neck surgery generally report less pain as compared with other postoperative clients; however, the nurse must assess each individual client's level of pain and response to analgesics. Clients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation. PTS: 1 REF: p. 1241 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 40. A client is scheduled to undergo a bone marrow aspiration. When preparing the client for the procedure, which action would the nurse do first? A. Ensure informed consent has been obtained. B. Cleanse the skin with an antiseptic. C. Administer a local anesthetic. D. Cover the area with a sterile drape.

A Rationale: The first step in the procedure is ensuring that informed consent has been obtained by the health care provider, nurse practitioner, or health care provider assistant performing the procedure and includes the reason the procedure is being performed, alternatives, and risks of the procedure. Risks include infection, bleeding, and pain. After informed consent is obtained, the client is assisted to either a prone or lateral decubitus position. The skin is cleansed using aseptic technique and either a chlorhexidine-based solution or povidone-iodine. A sterile drape is applied, and the skin is numbed using local anesthesia. PTS: 1 REF: p. 894 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes which type of impairment? A. Impaired gas exchange B. Collapsed bronchial structures C. Necrosis of the alveoli D. Closed bronchial tree

A Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues. PTS: 1 REF: p. 464 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A nurse has asked the nurse educator if there is any way to predict the severity of a client's anaphylactic reaction. Which response by the nurse educator would be best? A. "The faster the onset of symptoms, the more severe the reaction." B. "The reaction will be about one-third more severe than the client's last reaction to the same antigen." C. "There is no way to gauge the severity of a client's anaphylaxis, even if it has occurred repeatedly in the past." D. "The reaction will generally be slightly less severe than the last reaction to the same antigen."

A Rationale: The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 21. A nurse is caring for a client who has had surgery for oral cancer. When addressing the client's long-term needs, the nurse should prioritize interventions and referrals with what goal? A. Enhancement of verbal communication B. Enhancement of immune function C. Maintenance of adequate social support D. Maintenance of fluid balance

A Rationale: Verbal communication may be impaired by radical surgery for oral cancer. Addressing this impairment often requires a long-term commitment. Immune function, social support, and fluid balance are all necessary, but communication is a priority issue for clients recovering from this type of surgery. PTS: 1 REF: p. 1239 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 20. A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a fever and a new onset of fine crackles on lung auscultation. Which action by the nurse would be the most appropriate? A. Apply supplementary oxygen by nasal cannula. B. Administer bronchodilators by nebulizer. C. Liaise with the respiratory therapist and consider high-flow oxygen. D. Inform the health care provider that the client may have an infection.

D Rationale: Clients with sickle cell disease are highly susceptible to infection, thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated. PTS: 1 REF: p. 924 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.

A, B Rationale: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Providing small frequent meals during recovery will decrease the likelihood of aspiration. Dietary restrictions are based on individual client needs, and fiber, carbohydrates, and sugars are not typically restricted. Urinary catheters should be discontinued as soon as possible to prevent the increased risk of catheter associated urinary tract infections (CAUTI). It is also important to get the client out of bed as soon as possible to prevent pressure ulcers and encourage mobility. PTS: 1 REF: p. 2036 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunization B. Use of standard precautions C. Consumption of a vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections

A, B Rationale: People who are at high occupational risk for contracting hepatitis B, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV. PTS: 1 REF: p. 1389 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 41. A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion D. Teaching the client to flush the line with sterile water E. Teaching the client when it is safe to leave the access site open to air

A, B, C Rationale: An effective home care teaching program prepares the client to store solutions, set up the infusion, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Tap water is never used for flushes and the access site must never be left open to air. PTS: 1 REF: p. 1316 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 25. The client has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse would assess for indications of which potential complications? Select all that apply. A. Emboli B. Mitral valve damage C. Ventricular dysrhythmia D. Atrial-septal defect E. Plaque formation

A, B, C Rationale: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty. PTS: 1 REF: p. 772 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. A. Transient ischemic attacks (TIAs) B. Cerebrovascular disease C. Retinal hemorrhage D. Venous insufficiency E. Right ventricular hypertrophy

A, B, C Rationale: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks; cerebrovascular disease; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension. PTS: 1 REF: p. 878 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 26. The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. A. Transcranial Doppler flow study B. Cerebral angiography C. MRI D. Cranial radiography E. Electromyography (EMG)

A, B, C Rationale: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass. PTS: 1 REF: p. 2011 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A client has been brought to the emergency department after being found unresponsive, and anaphylaxis is suspected. The care team should attempt to assess for which potential causes of anaphylaxis? Select all that apply. A. Foods B. Medications C. Insect stings D. Autoimmunity E. Environmental pollutants

A, B, C Rationale: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities. PTS: 1 REF: p. 1047 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 20. The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. A. Splenic vein B. Inferior mesenteric vein C. Gastric vein D. Inferior vena cava E. Saphenous vein

A, B, C Rationale: This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg. PTS: 1 REF: p. 1209 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. The nurse is caring for a client who has just returned to the postsurgical unit following renal surgery. When assessing the client's output from surgical drains, the nurse should physically assess what parameter(s)? Select all that apply. A. Quantity of output B. Color of the output C. Visible characteristics of the output D. Specific gravity of the output E. Potential hydrogen (pH) of the output

A, B, C Rationale: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage from the surgical drains are reported and may indicate obstruction. Specific gravity and pH are not normally assessed at the bedside but are sent to the lab if needed. Those two tests are not part of the recommendations. PTS: 1 REF: p. 1594 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. The nurse is assessing a client admitted with renal stones. During the admission assessment, what parameters should the nurse address? Select all that apply. A. Dietary history B. Family history of renal stones C. Medication history D. Surgical history E. Vaccination history

A, B, C Rationale: Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the client to stone formation. When caring for a client with renal stones, it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones. PTS: 1 REF: p. 1622 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the client should be informed that this procedure will involve the removal of which of the following? Select all that apply. A. Gallbladder B. Part of the stomach C. Duodenum D. Part of the common bile duct E. Part of the rectum

A, B, C, D Rationale: A pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas. This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct. The rectum is not affected. PTS: 1 REF: p. 1441 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 39. A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question(s) addresses likely etiologic factors? Select all that apply. A. "How many alcoholic drinks do you typically consume in a week?" B. "Have you ever been tested for diabetes?" C. "Have you ever been diagnosed with gallstones?" D. "Would you say that you eat a particularly high-fat diet?" E. "Does anyone in your family have cystic fibrosis?"

A, B, C, D Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes and high-fat consumption are also associated with pancreatitis. Cystic fibrosis is not a noted etiologic factor for pancreatitis. PTS: 1 REF: p. 1429 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is providing education to the family of a client beginning peritoneal dialysis. The family ask questions concerning catheter placement and stabilization. Which information will the nurse provide about the cuffs? Select all that apply. A. The cuffs are constructed of Dacron polyester material. B. The cuffs will help stabilize the catheter. C. The cuffs prevent the dialysate from leaking. D. The cuffs provide a barrier against microorganisms. E. The cuffs will absorb the dialysate.

A, B, C, D Rationale: Most catheters used for peritoneal dialysis have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. They do not absorb dialysate. PTS: 1 REF: p. 1586 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 36. The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply. A. Specific gravity of the client's urine B. Testing for the presence of glucose in the client's urine C. Microscopic examination of urine sediment for RBCs D. Microscopic examination of urine sediment for casts E. Testing for BUN and creatinine in the client's urine

A, B, C, D Rationale: Urine testing includes testing for specific gravity, glucose, RBCs, and casts. BUN and creatinine are components of serum, not urine. PTS: 1 REF: p. 1548 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. The nurse is caring for a client's status after a motor vehicle accident. The client has developed AKI. What are the nurse's roles in caring for this client? Select all that apply. A. Providing emotional support for the family B. Monitoring for complications C. Participating in emergency treatment of fluid and electrolyte imbalances D. Providing nursing care for primary disorder (trauma) E. Directing nutritional interventions

A, B, C, D Rationale: The nurse has an important role in caring for the client with AKI. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the client's progress and response to treatment, and provides physical and emotional support. Additionally, the nurse keeps family members informed about the client's condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract). The nurse does not direct the client's nutritional status; the dietitian and the health care provider normally collaborate on directing the client's nutritional status. PTS: 1 REF: p. 1569 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A. Current medication regimen B. Identification of client's support system C. Immune system function D. Genetic risk factors for HIV E. History of sexual practices

A, B, C, E Rationale: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function, and sexual history. HIV does not have a genetic component. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply. A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure D. Causes the coronary arteries to dilate E. Increases the blood carbon monoxide level

A, B, C, E Rationale: Nicotinic acid in tobacco triggers the release of catecholamines (hormones that are released due to stress), which raise the heart rate and blood pressure and cause coronary arteries to constrict. This increases the risk of CAD and sudden cardiac death. Tobacco use also increases oxidation of low-density lipoprotein (good) cholesterol, which results in increased platelet adhesion and thrombus formation. Ischemia and reduced contractility can result in the increase in carbon monoxide levels and decreased oxygenation of the myocardium. PTS: 1 REF: p. 730 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 38. A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. A. Blood urea nitrogen (BUN) level B. Urine specific gravity C. Alkaline phosphatase level D. Creatinine level E. Serum albumin level

A, B, D Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function. PTS: 1 REF: p. 279 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the client's gastrointestinal function? Select all that apply. A. Decreased motility B. Increased sphincter tone C. Increased enzyme release D. Inhibition of secretions E. Increased peristalsis

A, B, D Rationale: Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes. PTS: 1 REF: p. 1211 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. A. Decreased protein intake B. Decreased sodium intake C. Increased potassium intake D. Fluid restriction E. Vitamin D supplementation

A, B, D Rationale: Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium intake is usually limited, not increased, and there is no particular need for vitamin D supplementation. PTS: 1 REF: p. 1583 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A. Dyspnea B. Unusual fatigue C. Hypotension D. Syncope E. Peripheral cyanosis

A, B, D Rationale: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS. PTS: 1 REF: p. 738 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. When hemodynamic monitoring is ordered for a client, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a client who has such a device in place, the nurse should check which of the following components? Select all that apply. A. A transducer B. A flush system C. A leveler D. A pressure bag E. An oscillator

A, B, D Rationale: To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial catheter is introduced into the appropriate blood vessel or heart chamber. It is connected to a pressure monitoring system that has several components. Included among these are a transducer, a flush system, and a pressure bag. A pressure monitoring system does not have a leveler or an oscillator. PTS: 1 REF: p. 684 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. The occupational health nurse is assessing an employee who has just had respiratory exposure to a toxin. What should the nurse assess? Select all that apply. A. Time frame of exposure B. Type of respiratory protection used C. Immunization status D. Breath sounds E. Intensity of exposure

A, B, D, E Rationale: Key aspects of any assessment of clients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The client's current respiratory status would also be a priority. Occupational lung hazards are not normally influenced by immunizations. PTS: 1 REF: p. 577 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A nurse is completing the nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Serum albumin level B. Weight history C. White blood cell count D. Body mass index E. Blood urea nitrogen (BUN) level

A, B, D, E Rationale: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the client's ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment. PTS: 1 REF: p. 1032 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 28. A female client who is HIV negative arrives for a gynecologist appointment and reports that her husband, who is HIV positive, no longer wants to wear a latex condom. Which alternative treatments would the nurse recommend to reduce the likelihood of HIV transmission? Select all that apply. A. Dental dam B. Polyurethane female condom C. Microbicidal vaginal suppository D. Non-latex male condoms E. Pre-exposure prophylaxis

A, B, E Rationale: A dental dam, which is a flat piece of latex, can be used for oral contact with the vagina or penis. A polyurethane female condom is an effective contraceptive and also effective in preventing the transmission of HIV. Pre-exposure prophylaxis involves one pill containing 2 HIV medications daily to prevent HIV conversion. A microbicidal vaginal suppository is currently not a reality, although clinical trials are occurring. Non-latex/lambskin male condoms will not protect the client from HIV due to permeability. Breakage is usually related to polyurethane condoms, which are more effective than lambskin. PTS: 1 REF: p. 1011 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. A. Pneumothorax B. Infection C. Atelectasis D. Bronchospasm E. Air embolism

A, B, E Rationale: Complications from use of hemodynamic monitoring systems are uncommon, but can include pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring systems do not include atelectasis or bronchospasm. PTS: 1 REF: p. 684 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. The nurse is caring for a client with mitral valve prolapse. Which symptoms would be consistent with this diagnosis? Select all that apply. A. Anxiety B. Fatigue C. Shoulder pain D. Tachypnea E. Palpitations

A, B, E Rationale: Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse. PTS: 1 REF: p. 767 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 32. An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcohol B. Adopt a low-residue diet C. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery

A, C Rationale: Clients with chronic gastritis are encouraged to avoid alcohol and NSAIDs. Calcium gluconate is not a common treatment and the condition is not normally treated with surgery. Dietary modifications are usually recommended, but this does not necessitate a low-residue diet. PTS: 1 REF: p. 1268 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 33. The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). Which statement(s) by the client indicates effective knowledge of the procedure? Select all that apply. A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." B. "It is likely that I will need to receive nutrition directly into my veins." C. "One of my nerves, the vagus nerve, may be cut during the surgery." D. "I can eat a normal diet again after 3 to 5 weeks." E. "This surgery will remove part of my stomach and colon."

A, C Rationale: This surgery carries a risk for dumping syndrome and may be performed with a truncal vagotomy, in which the vagus nerve is severed. Dumping syndrome is a condition in which food empties rapidly from the stomach to the duodenum, resulting in diarrhea, nausea, and feeling light-headed after eating a meal. Parenteral nutrition is not expected, though life-long dietary modifications will be necessary. A portion of the duodenum is removed, but not the colon. PTS: 1 REF: p. 1279 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 27. The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. A. Hepatitis B. Acute kidney injury C. HIV D. Malignant melanoma E. Cholecystitis

A, C Rationale: Viral illnesses have the potential to cause ITP. Acute kidney injury, malignancies, and gallbladder inflammation are not typical causes of ITP. PTS: 1 REF: p. 933 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 26. A client with Cushing syndrome has been hospitalized after a fall. The dietitian works with the client to improve the client's nutritional intake. What foods should a client with Cushing syndrome eat to optimize health? Select all that apply. A. Foods high in vitamin D B. Foods high in calories C. Foods high in protein D. Foods high in calcium E. Foods high in sodium

A, C, D Rationale: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the client in selecting appropriate foods that are also low in sodium and calories. PTS: 1 REF: p. 1481 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. The client has a homocysteine level ordered. What aspects of this test should inform the nurse's care? Select all that apply. A. A 12-hour fast is necessary before drawing the blood sample. B. Recent inactivity can depress homocysteine levels. C. Genetic factors can elevate homocysteine levels. D. A diet low in folic acid elevates homocysteine levels. E. An ECG should be performed immediately before drawing a sample.

A, C, D Rationale: Genetic factors and a diet low in folic acid, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. An ECG is unnecessary and recent inactivity does not influence the results of the test. PTS: 1 REF: p. 674 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 19. A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

A, C, D Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel. PTS: 1 REF: p. 1369 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

A, C, D Rationale: Older adult clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite. PTS: 1 REF: p. 2096 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A 45-year-old client has been admitted to the hospital for a hypertensive crisis. The health care provider (HCP) has ruled out a cerebrovascular accident (CVA) but suspects pheochromocytoma. What additional signs and symptoms would further confirm this diagnosis as correct? Select all that apply. A. hypermetabolism B. hyperkalemia C. hyperglycemia D. hyperhidrosis E. hyperpigmentation

A, C, D Rationale: Pheochromocytoma is suspected if the client has hypertension along with signs of nervous system overactivity. The five signs of this condition are: hypertension, headache, hyperhidrosis, hypermetabolism and hyperglycemia. Pheochromocytoma is a rare tumor of the adrenal medulla. The tumor is the cause of hypertension and is usually fatal if undetected and untreated. While this condition can happen at any age, it usually occurs between ages 40 and 50. A client with this condition typically has hypokalemia (low potassium). Hyperpigmentation is associated with Addison disease. PTS: 1 REF: p. 1475 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 30. The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A. Facilitate the presence of friends and family whenever possible. B. Teach the client about the harmful effects of anxiety on cardiac function. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety. E. Administer benzodiazepines two to three times daily.

A, C, D Rationale: The nurse should empathically validate the client's sensations of anxiety. The presence of friends and family is frequently beneficial, and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some clients, but alternative methods of relief should be prioritized. As well, medications are given on a PRN basis. Teaching the client about the potential harms of anxiety is likely to exacerbate, not relieve, the problem. PTS: 1 REF: p. 806 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 26. The nurse has performed a thorough nursing assessment of the care of a client with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A. Location and type of pain B. Apical heart rate C. Bilateral comparison of peripheral pulses D. Comparison of temperature in the client's legs E. Identification of mobility limitations

A, C, D, E Rationale: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. It is not likely that there is any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed. PTS: 1 REF: p. 857 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

A, C, D, E Rationale: Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function PTS: 1 REF: p. 1993 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply. A. Abrupt closure of the coronary artery B. Venous insufficiency C. Bleeding at the insertion site D. Retroperitoneal bleeding E. Arterial occlusion

A, C, D, E Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute kidney injury. Venous insufficiency is not a postprocedure complication of a PTCA. PTS: 1 REF: p. 747 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A nurse is assessing a client with acromegaly. Which finding(s) would the nurse most likely assess? Select all that apply. A. Enlarged feet B. Height greater than 7 feet C. Broad nose D. Enlarged tongue E. Carpal tunnel syndrome

A, C, D, E Rationale: With acromegaly, the excessive skeletal growth occurs only in the feet, the hands, and the superciliary ridge (bony ridge located above the eye sockets). Facial features (nose, lips, ears, and forehead) become broader and larger, the tongue enlarges, the space between the teeth increases, and the lower jaw grows, resulting in an underbite and extended lower jaw. Enlargement also can involve all tissues and organs of the body. As an example, because of soft tissue enlargement, carpal tunnel syndrome can also occur. Height over 7 feet is associated with gigantism, which occurs in children. PTS: 1 REF: p. 1450 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply A. The procedure generally takes 45 to 60 minutes. B. Please remove all jewelry and any metal objects prior to the procedure C. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo D. If you feel nervous about the test I can provide you a light sedative medication to ease your anxiety E. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure F. It is required that you withhold taking your anticonvulsant medication 72 hours before the procedure.

A, C, E Rationale: A standard EEG usually takes 45 to 60 minutes. Typically, a water-soluble lubricant is used to aid electrode contact. This lubricant is easily removed with shampoo. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. Sedation is not considered because it may lower the seizure threshold in clients and it may alter brain activity. Stimulants, tranquilizers, anticonvulsants, and depressants are advised to be held 24 to 48 hours, not 72 hours, prior to the procedure because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The client is instructed to eat before the test because keeping the client NPO (nothing by mouth) can alter blood glucose levels and cause changes in brain wave patterns. The client can wear jewelry during the test, although some facilities will request that earrings be removed. PTS: 1 REF: p. 1988 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing client positioning

A, C, E Rationale: Administering diuretics, implementing fluid restrictions, and enhancing client positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem. PTS: 1 REF: p. 1399 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) of this stage of the disease? Select all that apply. A. Perforation into the mediastinum B. Development of an esophageal lesion C. Erosion into the great vessels D. Painful swallowing E. Obstruction of the esophagus

A, C, E Rationale: In the later stages of esophageal cancer, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Painful swallowing and the emergence of a lesion are early signs of esophageal cancer. PTS: 1 REF: p. 1261 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Select 35. During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

A, C, E Rationale: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome. PTS: 1 REF: p. 2041 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 13. A client has been diagnosed with Stevens-Johnson syndrome. Which factors are common triggers of this condition? Select all that apply. A. Tamoxifen and vemurafenib B. Exposure to cold objects, cold fluids, or cold air C. Allopurinol and nevirapine D. Wearing clothing washed in a detergent E. Radiation in combination with phenytoin

A, C, E Rationale: Stevens-Johnson syndrome is a severe reaction commonly triggered by medication. The syndrome can evolve into extensive epidermal necrosis and become life-threatening. Among the many medications that trigger this condition are tamoxifen, vemurafenib, allopurinol and nevirapine. The combination of radiation and antiepileptic drugs such as phenytoin can also trigger this condition. Exposure to cold objects, cold fluids, or cold air can trigger cold urticaria, resulting in wheals (hives) or angioedema, but would not trigger Steven-Johnson syndrome. Wearing clothing washed in a detergent can trigger contact dermatitis but would not trigger Steven-Johnson syndrome. PTS: 1 REF: p. 1058 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply. A. Displacing or shifting cerebral spinal fluid (CSF) B. Decreasing cerebral perfusion C. Increasing the absorption of CSF D. Shifting brain tissue E. Decreasing cerebral blood volume

A, C, E Rationale: The Monro-Kellie hypothesis explains the dynamic equilibrium of cranial contents. This hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. The brain typically compensates for these changes by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral blood volume. Without such changes, ICP begins to rise. A decrease in cerebral perfusion and shifting brain tissue are not normal compensatory events. An increase in ICP can occur because of a brain tumor. Increased ICP from any cause would result in a decrease in cerebral perfusion which stimulates further edema and may shift brain tissue. A shift in brain tissue results in herniation which is a dire and frequently fatal event. PTS: 1 REF: p. 2000 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. A. Potential drug toxicities B. Needed dietary changes C. Potential drug interactions D. Sleep pattern disturbances E. Adherence requirements

A, C, E Rationale: The health care provider will need to understand potential drug toxicities, such as rashes and hypersensitivity reactions, which could imitate acute HIV seroconversion and require monitoring. The health care provider will also need to understand potential drug interactions, such as with supplements and vitamins, which could change the effectiveness of PEP. The health care provider will also need to understand adherence requirements, as adherence to the daily use of the PEP is paramount to its effectiveness. Typically, for most of PEP, there are no specific dietary changes needed. Sleep pattern disturbances generally do not happen with administration of these medications. PTS: 1 REF: p. 1012 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A. Promote truthful communication. B. Avoid asking the client to make decisions. C. Teach the client coping strategies. D. Administer benzodiazepines as prescribed. E. Provide positive reinforcement.

A, C, E Rationale: The nurse can assist the client to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the client practice appropriate strategies, and giving positive reinforcement when appropriate. The client may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping. PTS: 1 REF: p. 1886 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Choice 9. The nurse is performing a shift assessment of a client with aldosteronism. What priority assessment(s) should the nurse include that relate to this condition? Select all that apply. A. Urine output B. Signs or symptoms of venous thromboembolism C. Peripheral pulses D. Blood pressure E. Skin integrity

A, D Rationale: The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and blood pressure (BP). Hypertension is the most prominent and almost universal sign of primary aldosteronism. The client's peripheral pulses, risk of venous thromboembolism (VTE), and skin integrity are not typically affected by aldosteronism. PTS: 1 REF: p. 1482 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A nurse is implementing the care plan of diarrhea related to enteric pathogens of human immunodeficiency virus infections. Which interventions are needed to reach the goal of resuming usual bowel habits? Select all that apply. A. Administer antimicrobials. B. Restrict fluid to 1500 mL/50.7 fl oz daily. C. Implement a BRAT diet. D. Administer antitussives. E. Establish normal bowel pattern.

A, D, E Rationale: After establishing the client's normal pattern of bowel habits (i.e., frequency, time, consistency, color) and current problems (i.e., diarrhea, constipation, abdominal cramps/pain), a stool sample is then collected to identify any pathogenic organisms and any antimicrobial therapy needed. The BRAT (bananas, rice, applesauce, tea, and toast) diet is a type of bland diet that reduces stimulation/hyperactivity of the bowels. It is a temporary step. Unless contraindicated, clients are encouraged to maintain a fluid intake of 3L/0.793GL (3000 mL/1014 fl oz) daily to prevent hypovolemia. Antitussives are medications used to suppress cough and are not used to restore normal bowel patterns. PTS: 1 REF: p. 1027 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply. A. Chest tightness B. Crackles C. Bradypnea D. Wheezing E. Cough

A, D, E Rationale: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma. PTS: 1 REF: p. 632 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 9. Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A. Leukocytes B. Natural killer cells C. Cytokines D. Platelets E. Erythrocytes

A, D, E Rationale: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. A. Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines B. Hypotension that responds to bolus fluid resuscitation C. Exaggerated response to vasoactive medications D. Serum lactate greater than 4 mmol/L E. Mean arterial pressure (MAP) of less than 65 mm Hg

A, D, E Rationale: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted. PTS: 1 REF: p. 294 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 5. The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A. Using appropriate personal protective equipment B. Placing clients in negative pressure isolation rooms C. Placing clients in positive pressure isolation rooms D. Using safe injection practices E. Performing hand hygiene

A, D, E Rationale: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions. PTS: 1 REF: p. 1011 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Chapter 21: Assessment of Cardiovascular Function 1. A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this as what action? A. Systole B. Diastole C. Repolarization D. Ejection fraction

A. Systole Rationale: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxation), ejection fraction (the amount of blood expelled), or repolarization (electrical charging). PTS: 1 REF: p. 651 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 3. A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

B Rationale. In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke. PTS: 1 REF: p. 2035 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A 67-year-old client with severe bilateral arthritis of the hands has been diagnosed with chronic obstructive pulmonary disease. Which inhalation delivery method is best for the bronchodilator ordered for this client? A. A conventional pressurized metered-dose inhaler (pMDI) B. A small-volume nebulizer (SVN) C. A breath-actuated pressurized metered-dose inhaler (pMDI) D. A dry-powder inhaler (DPI)

B Rationale: A SVN is the best choice for the client with severe arthritis in both hands. The SVN is a machine that mixes the medication and turns it into a mist. The client then uses a handheld apparatus or mask and just breathes in the treatment. Any pMDI requires dexterity between inspiration and the mechanics of the inhaler to be effective. Although DPIs rely solely on inspiration for medication delivery, they still require the user to press a button or lever to dispense the medication. Poor inhaler technique has been linked to a lack of symptom control. PTS: 1 REF: p. 616 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 14. The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? A. A reduced calorie diet, high in nutrients B. Small, frequent meals, high in protein and calories C. Three large, bland meals a day D. A diet high in fiber and plant-sourced fat

B Rationale: A client with hyperthyroidism has an increased appetite. The client should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged. A clear liquid diet would not satisfy the client's caloric or hunger needs. A diet rich in fiber and fat should be avoided because these foods may lead to GI upset or increase peristalsis. PTS: 1 REF: p. 1465 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. Open B. Comminuted C. Intra-articular D. Greenstick

B Rationale: A comminuted fracture has more than two bone fragments. An open fracture has a bone end which breaks through the skin surface. An intra-articular fracture extends into the joint surface of a bone. A greenstick fracture refers to a partial break of a bone. PTS: 1 REF: p. 1157 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A. Compression B. Compound C. Impacted D. Transverse

B Rationale: A compound fracture involves damage to the skin or mucous membranes and is also called an open fracture. A compression fracture involves compression of bone and is seen in vertebral fractures. An impacted fracture occurs when a bone fragment is driven into another bone fragment. A transverse fracture occurs straight across the bone shaft. PTS: 1 REF: p. 1157 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The nurse is caring for a client with a severe nosebleed. The health care provider inserts a nasal sponge. What should the nurse teach the client about this intervention? A. The sponge creates a risk for viral sinusitis B. The sponge can stay in place for 3 to 4 days if needed C. The client should remain supine while the sponge is in place D. NSAIDs are contraindicated while the sponge is in place

B Rationale: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 3 or 4 days if necessary to control bleeding. This does not require the client to be supine or to avoid all NSAIDs. Packing does not increase the risk for sinusitis. PTS: 1 REF: p. 512 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client's sternum. This client's health record should note the presence of what chest deformity? A. A barrel chest B. A funnel chest C. A pigeon chest D. Kyphoscoliosis

B Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax. PTS: 1 REF: p. 477 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A nurse is caring for a client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action? A. Document the findings as being consistent with a viable graft. B. Promptly report these indications of venous congestion. C. Closely monitor the client and reassess in 30 minutes. D. Reposition the client to promote peripheral circulation.

B Rationale: A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary. PTS: 1 REF: p. 1236 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? A. Computed tomography (CT) scan B. Lumbar puncture C. Magnetic resonance imaging (MRI) D. Venous Doppler studies

B Rationale: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself. PTS: 1 REF: p. 2001 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. A nurse is developing a teaching plan for a client with chronic obstructive pulmonary disease. What should the nurse include as the most important area of teaching? A. Avoiding extremes of heat and cold B. Setting and accepting realistic short- and long-term goals C. Adopting a lifestyle of moderate activity D. Avoiding emotional disturbances and stressful situations

B Rationale: A major area of teaching involves setting and accepting realistic short- and long-term goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals. PTS: 1 REF: p. 629 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 34. A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? A. As soon as the client's pain becomes unbearable B. As soon as the client senses the onset of symptoms C. Twenty to 30 minutes after the onset of symptoms D. When the client senses his or her symptoms peaking

B Rationale: A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain. PTS: 1 REF: p. 2029 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response Chapter 26: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation 1. The nurse is taking a health history of a new client who reports pain in the left lower leg and foot when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address which health problem? A. Coronary artery disease (CAD) B. Intermittent claudication C. Arterial embolus D. Raynaud disease

B Rationale: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of these health problems produce this cluster of signs and symptoms. PTS: 1 REF: p. 822 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 40. The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs? A. Nonrebreathing mask B. Nasal cannula C. Venturi mask D. Partial-rebreathing mask

B Rationale: A nasal cannula is used when the client requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for clients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The client's respiratory status does not require a partial- or non-rebreathing mask. PTS: 1 REF: p. 613 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 40: Management of Patients with Gastric and Duodenal Disorders 1. A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

B Rationale: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics. PTS: 1 REF: p. 1270 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 37. The nurse is auscultating the breath sounds of a client with pericarditis. Which finding is most consistent with this diagnosis? A. Wheezes B. Friction rub C. Fine crackles D. Coarse crackles

B Rationale: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis. PTS: 1 REF: p. 789 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. Which action should the nurse suggest as a preventive measure for varicose veins? A. Sit with crossed legs for a few minutes each hour to promote relaxation. B. Walk for several minutes every hour to promote circulation. C. Elevate the legs when tired. D. Wear snug-fitting ankle socks to decrease edema.

B Rationale: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for clients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for clients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return the socks simply capture the blood and promote venous stasis. PTS: 1 REF: p. 859 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 22. A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury? A. A first-degree strain B. A second-degree strain C. A first-degree sprain D. A second-degree sprain

B Rationale: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this client states a loss of function. A sprain normally involves twisting, which is inconsistent with the client's overuse injury. PTS: 1 REF: p. 1153 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders 1. A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism

B Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing. PTS: 1 REF: p. 527 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the client begins to exhibit signs and symptoms of a transfusion reaction. The client is suffering from which type of hypersensitivity? A. Anaphylactic (type 1) B. Cytotoxic (type II) C. Immune complex (type III) D. Delayed type (type IV)

B Rationale: A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions. This type of reaction does not result from types I, III, or IV reactions. PTS: 1 REF: p. 1041 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment finding? A. Assess the client's use of over-the-counter dietary supplements. B. Implement interventions relevant to arterial narrowing. C. Encourage the client to increase intake of foods high in vitamin K. D. Adjust the client's activity level to accommodate decreased coronary output.

B Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and over-the-counter (OTC) medications are not likely causative. PTS: 1 REF: p. 824 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is performing a respiratory assessment of a client who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A. An appropriate perfusion-diffusion ratio B. An adequate ventilation-perfusion ratio C. Adequate diffusion of gas in shunted blood D. Appropriate blood nitrogen concentration

B Rationale: Adequate gas exchange depends on an adequate ventilation-perfusion ratio. There is no perfusion-diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen. PTS: 1 REF: p. 468 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 26. A client with a diagnosis of colon cancer is 2 days' postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperature B. Frequent abdominal auscultation C. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

B Rationale: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse. Obstruction can develop more quickly than infection in most cases. PTS: 1 REF: p. 1330 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep client NPO until the results of test are known. B. Keep client NPO until the client's gag reflex returns. C. Administer analgesia until post-procedure tenderness is relieved. D. Give the client a cold beverage to promote swallowing ability.

B Rationale: After the examination, fluids are not given until the client's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the client's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns. PTS: 1 REF: p. 1376 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. Which other supportive measure should be initiated in this client? A. Psychological counseling B. Nutritional support C. High-protein oral diet D. Occupational therapy

B Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS. PTS: 1 REF: p. 572 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? A. Alcohol causes hormone fluctuations. B. Alcohol causes vasodilation of the blood vessels. C. Alcohol has an excitatory effect on the CNS. D. Alcohol diminishes endorphins in the brain.

B Rationale: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain. PTS: 1 REF: p. 2028 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 19. A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? A. Beginning immunotherapy B. Carrying an epinephrine pen C. Maintaining the child's immunization status D. Avoiding all foods that have a high potential for allergies

B Rationale: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies. PTS: 1 REF: p. 1063 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 39. A client has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the client's body image? A. Emphasize that the diversion is an integral part of successful cancer treatment. B. Encourage the client to speak openly and frankly about the diversion. C. Allow the client to initiate the process of providing care for the diversion. D. Provide the client with detailed written materials about the diversion at the time of discharge.

B Rationale: Allowing the client to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the client is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the client's body image. PTS: 1 REF: p. 1633 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

B Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke. PTS: 1 REF: p. 2051 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptom resolution. B. Adhere to dosing recommendations of over-the-counter analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.

B Rationale: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis. PTS: 1 REF: p. 1392 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? A. The client will be given a low dose of epinephrine before the treatment. B. The client will remain in the clinic to be monitored for 30 minutes following the injection. C. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months. D. The allergen will be given by the peripheral intravenous (IV) route.

B Rationale: Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. Because of this risk, the client must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. Therapeutic failure is evident when a client does not experience a decrease in symptoms within 12 to 24 months. Epinephrine is not given prior to treatment and the IV route is not used. PTS: 1 REF: p. 1053 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 10. A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication? A. Aortitis B. Deep vein thrombosis C. Thoracic aortic aneurysm D. Raynaud disease

B Rationale: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. This client has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aortitis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues. PTS: 1 REF: p. 846 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 29. A 76-year-old client with ESKD has been told by the health care provider that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse about feeling unsure about undergoing a kidney transplant. What would be an appropriate response for the nurse to make? A. "The decision is certainly yours to make, but be sure not to make a mistake." B. "Kidney transplants in peoples your age are as successful as they are in younger clients." C. "I understand your hesitancy to commit to a transplant surgery. Success is relatively rare." D. "Have you talked this over with your family?"

B Rationale: Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the older adult. However, the success rate of the surgery is comparable to that for younger clients. The other listed options either belittle the client or give the client misinformation. PTS: 1 REF: p. 1570 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 33. A client has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the client for this test, what action should the nurse perform? A. Keep the client NPO for at least 6 hours prior to the test. B. Establish peripheral IV access. C. Limit the client's activity for 2 hours before the test. D. Teach the client to perform incentive spirometry.

B Rationale: An IV is necessary if contrast is to be used to enhance the images of the CT. The client does not need to fast or limit activity. Incentive spirometry is not relevant to this diagnostic test. PTS: 1 REF: p. 679 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? A. Antibodies to donor leukocytes remained in the blood. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. The blood was infused too quickly and overwhelmed the client's circulatory system.

B Rationale: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 25. The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why they have to take an aspirin every day if they don't have any pain. Which rationale for this intervention would be the best? A. To help restore the normal function of the heart B. To help prevent blockages that can cause chest pain or heart attacks C. To help the blood penetrate the heart more freely D. To help the blood carry more oxygen than it would otherwise

B Rationale: An aspirin a day is a common nonprescription medication that improves outcomes in clients with coronary artery disease due to its antiplatelet action, which helps to prevent clots that can lead to chest pain or heart attacks. It does not affect oxygen-carrying capacity or perfusion. Aspirin does not restore cardiac function. PTS: 1 REF: p. 660 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? A. Burning pain on swallowing B. Regurgitation of undigested food C. Symptoms mimicking a myocardial infarction D. Chronic parotid abscesses

B Rationale: An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the client assumes a recumbent position. The client may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum. PTS: 1 REF: p. 1255 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

B Rationale: An extremely tender and rigid (board-like) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer. PTS: 1 REF: p. 1276 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. The nurse caring for a client with suspected renal dysfunction calculates that the client's weight has increased by 5 pounds (2.27 kg) in the past 24 hours. The nurse estimates that the client has retained approximately how much fluid? A. 1,300 mL/ 43.9 fl oz. of fluid in 24 hours B. 2,270 mL/76.7 fl oz. of fluid in 24 hours C. 3,100 mL/104.8 fl oz. of fluid in 24 hours D. 5,000 mL/169.0 fl oz. of fluid in 24 hours

B Rationale: An increase in body weight commonly accompanies edema. To calculate the approximate weight gain from fluid retention, the nurse should remember that 1 kg of weight gain equals approximately 1,000 mL of fluid. Five pounds = 2.27 kg = 2,270 mL. PTS: 1 REF: p. 1546 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 18. A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical débridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed. C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.

B Rationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform débridement. PTS: 1 REF: p. 1882 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client? A. A client who has previously been treated for tuberculosis B. A client who is at 30 weeks' gestation C. A client who is on estrogen-replacement therapy D. A client with a severe allergy to eggs

B Rationale: Antihistamines are contraindicated during the third trimester of pregnancy. Previous tuberculosis, hormone therapy, and food allergies do not contraindicate the use of antihistamines. PTS: 1 REF: p. 1051 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 32. A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old child, who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother? A. "I will relay your request promptly to the doctor, but I suspect that the doctor won't get back to you if it's a cold." B. "I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus." C. "I'll phone in the prescription for you since it can be prescribed by the pharmacist." D. "Amoxicillin is not likely the best antibiotic, but I'll call in the right prescription for you."

B Rationale: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the client that the health care provider will not respond to the request. PTS: 1 REF: p. 504 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? A. Cyclosporine B. Acyclovir C. Cyclobenzaprine D. Ampicillin

B Rationale: Antiviral agents, acyclovir and ganciclovir, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses. PTS: 1 REF: p. 2092 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 23. A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor? A. Recent blood donation B. Evidence of lung disease C. A history of venous thromboembolism D. Impaired renal function

B Rationale: Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia. Blood donation does not precipitate this problem and impaired renal function typically causes anemia, not polycythemia. A history of venous thromboembolism is not a likely contributor. PTS: 1 REF: p. 929 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation, the educator describes what consequence of this disorder? A. Cardiac tamponade B. Left ventricular hypertrophy C. Right-sided heart failure D. Ventricular insufficiency

B Rationale: Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency. PTS: 1 REF: p. 766 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

B Rationale: Aspirin and other NSAIDs are implicated in chronic gastritis because of their irritating effect on the gastric mucosa. Organic foods and vitamins confer no protection. Exercise and a healthy body weight are beneficial to overall health but do not prevent gastritis. PTS: 1 REF: p. 1267 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 10. A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? A. Review images from the client's portable chest x-ray. B. Turn the client to enable assessment of all lung fields. C. Assess the breath sounds accessible from the anterior chest wall. D. Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.

B Rationale: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. A chest x-ray does not allow assessment of breath sounds. Assessment of only breath sounds accessible from the anterior chest wall neglects breath sounds that can only be assessed in other lung fields. All lung fields need to be assessed whether oxygen saturation is low or not. PTS: 1 REF: p. 483 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients? A. Encouraging clients to carry a corticosteroid rescue inhaler at all times B. Educating clients about recognizing and avoiding asthma triggers C. Teaching clients to utilize alternative therapies in asthma management D. Ensuring that clients keep their immunizations up to date

B Rationale: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate clients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations. PTS: 1 REF: p. 641 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 14. The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be: A. drug therapy and smoking cessation. B. diet and drug therapy. C. diet therapy only. D. diet therapy and smoking cessation.

D Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms. PTS: 1 REF: p. 731 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

B Rationale: Baclofen, a -aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities. PTS: 1 REF: p. 2097 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A. Right-sided heart failure B. Acute pulmonary edema C. Pneumonia D. Cardiogenic shock

B Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia PTS: 1 REF: p. 809 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address what topic? A. The possibility of precipitous weight gain B. The need for lifelong steroid replacement C. The need to match the daily steroid dose to immediate symptoms D. The importance of monitoring liver function

B Rationale: Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the client and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects. PTS: 1 REF: p. 1477 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. C. Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

B Rationale: Because of the risk of increased bacterial proliferation in the PRBCs and subsequent infection in the client, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route. PTS: 1 REF: p. 901 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse has taken on the care of a client who had a coronary artery stent placed yesterday. When reviewing the client's daily medication administration record, the nurse should anticipate administering what drug? A. Ibuprofen B. Clopidogrel C. Dipyridamole D. Acetaminophen

B Rationale: Because of the risk of thrombus formation within the stent, the client receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement. PTS: 1 REF: p. 747 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency? A. The client has irregular menstrual periods. B. The client is a vegan. C. The client donated blood 60 days ago. D. The client frequently smokes marijuana.

B Rationale: Because vitamin B12 is found only in foods of animal origin, vegans may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is performing the health interview of a client with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the client about the current medication regimen. Which medication would put the client at a higher risk for recurrent epistaxis? A. Oxymetazoline nasal B. Beclomethasone C. Levothyroxine D. Albuterol

B Rationale: Beclomethasone should be avoided in clients with recurrent epistaxis because it is a risk factor. The other listed medications do not increase the risk for epistaxis. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 24. The nurse is caring for a client scheduled for renal angiography following a motor vehicle accident. What client preparation should the nurse most likely provide before this test? A. Administration of IV potassium chloride B. Administration of a laxative C. Administration of Gastrografin D. Administration of a 24-hour urine test

B Rationale: Before the procedure, a laxative may be prescribed to evacuate the colon so that unobstructed x-rays can be obtained. A 24-hour urine test is not necessary prior to the procedure. Gastrografin and potassium chloride are not given prior to renal angiography. PTS: 1 REF: p. 1551 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B Rationale: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. PTS: 1 REF: p. 569 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A. Tinnitus B. Facial paralysis C. Pain at the base of the tongue D. Diplopia

B Rationale: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus. PTS: 1 REF: p. 2109 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the health care provider immediately for what finding? A. Presence of small blood clots in the drainage B. 60 mL of milky or cloudy drainage C. Spots of drainage on the dressings surrounding the drain D. 120 mL of serosanguinous drainage

B Rationale: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt treatment. PTS: 1 REF: p. 1240 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client? A. Chest pain B. Bleeding at the implantation site C. Malignant hyperthermia D. Bradycardia

B Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration. PTS: 1 REF: p. 717 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which action? A. Measuring the BP after the client has been seated quietly for more than 5 minutes B. Taking the BP 10 minutes after nicotine or coffee ingestion C. Using a cuff with a bladder that encircles at least 80% of the limb D. Using a bare forearm supported at heart level on a firm surface

B Rationale: Blood pressures should be taken with the client seated with arm bare, supported, and at heart level. The client should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement. PTS: 1 REF: p. 869 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A. Sigmoid colon B. Upper GI tract C. Large intestine D. Anus or rectum

B Rationale: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue. PTS: 1 REF: p. 1214 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 24. Results of a client's preliminary assessment prompted an examination of the client's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding? A. Perform a focused abdominal assessment. B. Prepare to meet the client's psychosocial needs. C. Liaise with the nurse practitioner to perform an anorectal examination. D. Encourage the client to adhere to recommended screening protocols.

B Rationale: CEA is a protein that is normally not detected in the blood of a healthy person; therefore, when detected it indicates that cancer is present, but not what type of cancer is present. The client would likely be learning that he or she has cancer, so the nurse must prioritize the client's immediate psychosocial needs, not abdominal assessment. Future screening is not a high priority in the short term. PTS: 1 REF: p. 1217 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A. Use clean technique and wear a mask during dressing changes. B. Change the dressing no more than weekly. C. Apply antibiotic ointment around the site with each dressing change. D. Irrigate the insertion site with sterile water during each dressing change.

B Rationale: CVAD dressings are changed every 7 days unless the dressing is damp, bloody, loose, or soiled, in which case they should be changed more often. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not normally used. PTS: 1 REF: p. 1316 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. The critical care nurse is caring for a client with a central venous pressure (CVP) monitoring system. The nurse notes that the client's CVP is increasing. This may indicate: A. psychosocial stress. B. hypervolemia. C. dislodgment of the catheter. D. hypomagnesemia.

B Rationale: CVP is a useful hemodynamic parameter to observe when managing an unstable client's fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgment of the catheter, and low magnesium levels would not typically result in increased CVP. PTS: 1 REF: p. 685 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 30. The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

B Rationale: Cardiogenic embolic strokes are associated with cardiac arrhythmias, which is usually atrial fibrillation. Absence of a regular contraction of the fibrillating atria leads to an increase of atrial pressure and dilation, which together with hemoconcentration, endothelial dysfunction, and a prothrombotic state are prerequisites for thrombus formation. In other words, the irregularity of the heartbeat caused by atrial fibrillation makes the heart more likely to form clots. Studies have shown that strokes that are caused by atrial fibrillation have an increased poor outcome in terms of severity and resulting disability. The other listed arrhythmias are less commonly associated with this type of stroke. PTS: 1 REF: p. 2032 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock? A. The client admitted with acute renal failure B. The client admitted following an MI C. The client admitted with malignant hypertension D. The client admitted following a stroke

B Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and clients experiencing a stroke are at risk for thrombus formation, the client admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses. PTS: 1 REF: p. 811 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 8. A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

B Rationale: Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. Interventions during this period include measures to reduce ICP. Other treatment measures include: Providing supplemental oxygen if saturation is below 95% and monitoring of blood glucose and management. Intubation is used only if necessary to establish a patent airway. For this client, a more expedient and less invasive measure would be supplemental oxygen. Urinary catheter placement is not a priority measure for this client. It is important to monitor for febrile events, but there is no protocol in place to keep the client hypothermic. Antihypertensive medication goals for blood pressure in the first 24 hours after a stroke remain controversial for a client who has not received thrombolytic therapy; antihypertensive treatment may be given to lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg. Vital signs for this client would be monitored closely and continuously until stable. PTS: 1 REF: p. 2039 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 24. A client is scheduled for catheter ablation therapy. When describing this procedure to the client's family, the nurse should address which aspect of the treatment? A. Resetting of the heart's contractility B. Destruction of specific cardiac cells C. Correction of structural cardiac abnormalities D. Clearance of partially occluded coronary arteries

B Rationale: Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It does not "reset" the heart's contractility and it does not address structural or vascular abnormalities. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Response 29. A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock? A. Acute hypertension B. Respiratory distress C. Neurologic compensation D. Cardiac arrest

B Rationale: Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur later if prompt treatment is not provided. PTS: 1 REF: p. 296 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A resident of a long-term care facility has reported chest pain to the nurse. What aspect of the resident's pain would be most suggestive of angina as the cause? A. The pain is worse when the resident inhales deeply. B. The pain occurs immediately following physical exertion. C. The pain is worse when the resident coughs. D. The pain is most severe when the resident moves the upper body.

B Rationale: Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies. PTS: 1 REF: p. 659 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 28. The nurse is caring for a client with lung metastases who just underwent a mediastinotomy. What is the nurse's priority postprocedure care? A. Assisting with pulmonary function testing (PFT) B. Maintaining the client's chest tube C. Administering oral suction as needed D. Performing chest physiotherapy

B Rationale: Chest tube drainage is required after mediastinotomy. PFT may be needed, but it would be a lower priority than maintaining the chest tube. The client would need chest tube drainage after a mediastinotomy, not oral suctioning. Given that the client is healing from the incision made during the procedure, chest physiotherapy would be inappropriate at this time. PTS: 1 REF: p. 492 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinence B. Drug-drug interactions C. Abdominal pain D. Heat intolerance

B Rationale: Cimetidine is associated with several drug-drug interactions. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance. PTS: 1 REF: p. 1269 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes? A. "I've always been a fan of sweet foods, but lately I'm turned off by them." B. "Lately, I drink and drink and can't seem to quench my thirst." C. "No matter how much sleep I get, it seems to take me hours to wake up." D. "When I went to the washroom the last few days, my urine smelled odd."

B Rationale: Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes. PTS: 1 REF: p. 1491 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 32. A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

B Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery. PTS: 1 REF: p. 1886 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 29. A client is scheduled for a diagnostic MRI of the lower urinary system. What preprocedure education should the nurse include? A. The need to be NPO for 12 hours prior to the test B. Relaxation techniques to use during the test C. The need for conscious sedation prior to the test D. The need to limit fluid intake to 1 liter in the 24 hours before the test

B Rationale: Client preparation should include teaching relaxation techniques because the client needs to remain still during an MRI. The client does not normally need to be NPO or fluid-restricted before the test and conscious sedation is not usually implemented. PTS: 1 REF: p. 1549 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A client is scheduled for a splenectomy. During discharge education, which teaching point should the nurse prioritize? A. Adhering to prescribed immunosuppressant therapy B. Reporting any signs or symptoms of infection promptly C. Ensuring adequate folate, iron, and vitamin B12 intake D. Limiting activity postoperatively to prevent hemorrhage

B Rationale: Clients face an increased risk for infection following splenectomy; therefore, long-term use of antibiotic therapy is indicated. After splenectomy, the client is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, clients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary, and immunosuppressants would be strongly contraindicated. PTS: 1 REF: p. 895 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 19. A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A. "The client is on a calorie-restricted diet in order to divert energy to wound healing." B. "The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." C. "The client actually hasn't lost weight. Instead, there's been a change in the distribution of body fat." D. "The client lost many fluids while being treated in the emergency phase of burn care."

B Rationale: Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are not placed on a calorie restriction during recovery, and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur. PTS: 1 REF: p. 1884 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A nurse on a busy medical unit provides care for many clients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which client? A. A client whose diagnosis of chronic kidney disease requires a fluid restriction B. A client who has Alzheimer disease and who is acutely agitated C. A client who is on bed rest following a recent episode of venous thromboembolism D. A client who has decreased mobility following a transmetatarsal amputation

B Rationale: Clients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated. Recent VTE, amputation, and fluid restriction do not directly create a risk for injury or trauma associated with indwelling catheter use. PTS: 1 REF: p. 1619 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 24. A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A. Preventing skin breakdown B. Maintaining spinal alignment C. Maximizing function D. Preventing increased intracranial pressure

B Rationale: Clients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing skin breakdown, even though these are both valid considerations. Increased ICP is not a high risk. PTS: 1 REF: p. 1193 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. A nurse is providing discharge education to a client who has recently been diagnosed with a bleeding disorder. Which topic should the nurse prioritize when teaching this client? A. Avoiding buses, subways, and other crowded, public sites B. Avoiding activities that carry a risk for injury C. Keeping immunizations current D. Avoiding foods high in vitamin K

B Rationale: Clients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some clients. Clients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may be beneficial, not detrimental. PTS: 1 REF: p. 931 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A client newly diagnosed with type 2 diabetes has been told by their family that they can no longer consume alcohol. The client asks the nurse if abstaining from all alcohol is necessary. What is the nurse's best response? A. "You should stop all alcohol intake. Alcohol is absorbed by your body before other important nutrients and may lead to very high blood glucose levels." B. "You do not need to give up alcohol entirely but there are potential side effects specific to clients with diabetes that you should consider." C. "You should no longer consume alcohol since it causes immediate low blood glucose levels in diabetic clients." D. "You can still consume alcohol, but limit your consumption to no more than 3 glasses of wine or beer daily because of the high sugar content of alcohol."

B Rationale: Clients with diabetes do not need to give up alcoholic beverages entirely. Moderation is the key. Moderate intake is no more than 1 alcoholic beverage (light beer, wine) for women and 2 drinks for men daily. Recommendations include avoiding mixed drinks and liqueurs because of the possibility of excessive weight gain, elevated glucose levels, and hyperlipidemia. Clients should be aware of potential side effects of alcohol consumption. These include diabetic ketoacidosis and hypoglycemia To combat possible hypoglycemia, clients with diabetes should not consume alcohol on an empty stomach. PTS: 1 REF: p. 1496 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. A client with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the client's symptoms, the nurse would teach the client to take which action? A. Eat a high-protein, low-carbohydrate diet. B. Avoid activities that cause an increased heart rate. C. Avoid large crowds and public events. D. Perform deep breathing and coughing exercises.

B Rationale: Clients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary. PTS: 1 REF: p. 770 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice Chapter 64: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies 1. A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

B Rationale: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis. PTS: 1 REF: p. 2089 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A client states that the client's family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to which factor? A. Cold viruses are increasingly resistant to common antibiotics. B. The virus is shed for 2 days prior to the emergence of symptoms. C. A genetic predisposition to viral rhinitis has recently been identified. D. Overuse of over-the-counter (OTC) cold remedies creates a "rebound" susceptibility to future colds.

B Rationale: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses, and OTC medications do not have a "rebound" effect. Genetic factors do not exist for viral rhinitis. PTS: 1 REF: p. 497 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 11. The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? A. Carboxyhemoglobin level B. Brain natriuretic peptide (BNP) level C. C-reactive protein (CRP) level D. Complete blood count

B Rationale: Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem. PTS: 1 REF: p. 572 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following? A. Peripheral edema B. Bleeding at insertion site C. Left ventricular hypertrophy D. Pulmonary edema

B Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include left ventricular hypertrophy because this problem takes an extended time to develop and is not emergent. Bleeding is a more likely and more serious complication than edema. PTS: 1 REF: p. 747 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 35. A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

B Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration. PTS: 1 REF: p. 2102 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? A. Obtain a sputum sample. B. Perform a swallowing assessment. C. Inspect the client's tongue and mouth. D. Assess the client's nutritional status.

B Rationale: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the client's tongue, mouth, and nutrition is not directly relevant to the problem of aspiration. PTS: 1 REF: p. 472 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is reviewing the echocardiography results of a client who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure is this client experiencing? A. Dilated ventricles with atrophy of the ventricles B. Dilated ventricles without hypertrophy of the ventricles C. Dilation and hypertrophy of all four heart chambers D. Dilation of the atria and hypertrophy of the ventricles

B Rationale: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in clients with DCM. PTS: 1 REF: p. 776 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 22. The community health nurse cares for many clients who have hypertension. What nursing diagnosis is most common among clients who are being treated for this health problem? A. Deficient knowledge regarding the lifestyle modifications for management of hypertension B. Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C. Deficient knowledge regarding BP monitoring D. Noncompliance with treatment regimen related to medication costs

B Rationale: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many clients, this is related to adverse effects of medications. Medication cost is relevant for many clients, but adverse effects are thought to be a more significant barrier. Many clients are aware of necessary lifestyle modification, but do not adhere to them. Most clients are aware of the need to monitor their BP. PTS: 1 REF: p. 878 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 18. A nurse is performing an admission assessment on a client with stage 3 human immunodeficiency virus (HIV). After assessing the client's gastrointestinal system and analyzing the data, which nursing diagnosis is most likely to be the priority? A. Acute abdominal pain B. Diarrhea C. Bowel incontinence D. Constipation

B Rationale: Diarrhea is a problem in many clients with HIV and acquired immunodeficiency syndrome. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply. PTS: 1 REF: p. 1025 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 6. The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? A. Temporal lobe B. Parietal-occipital area C. Inferior-posterior frontal areas D. Posterior frontal area

B Rationale: Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area. PTS: 1 REF: p. 1983 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. A client being treated in the hospital has been experiencing occasional urinary retention. What voiding trigger technique would help this client? A. Using a bedpan instead of a commode B. Dipping the client's hands in warm water C. Performing a bladder scan after voiding D. Encouraging male clients to use a urinal in bed

B Rationale: Dipping the client's hands in warm water is a urinary trigger technique that helps encourage clients to start voiding. Other trigger techniques include turning on the faucet while the client is attempting to void and stroking the abdomen or inner thighs. Using a commode instead of a bedpan is a nursing measure to encourage normal voiding patterns. Encouraging a male client to use a urinal while standing is more natural and comfortable and is also linked to voiding patterns. Bladder scanning after voiding will assess whether the client is retaining urine but is not a trigger technique. PTS: 1 REF: p. 1616 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? A. Monitoring liver function studies B. Blood pressure C. Vitamin D intake D. Monitoring potassium levels

B Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant. PTS: 1 REF: p. 800 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds? A. Normal B. Hypoactive C. Hyperactive D. Paralytic ileus

B Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis. PTS: 1 REF: p. 1216 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related? A. Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B. Older adults are less able to increase blood cell production when demand suddenly increases. C. Stem cells in older adults eventually lose their ability to differentiate. D. The ratio of plasma to erythrocytes and lymphocytes increases with age.

B Rationale: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease, and the relative volume of plasma does not change significantly. PTS: 1 REF: p. 891 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.

B Rationale: During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic. PTS: 1 REF: p. 2042 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A client has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the client knows to take what action? A. Take the drug concurrent with levothyroxine. B. Take each dose of prednisone with a dose of calcium chloride. C. Gradually replace the prednisone with an over-the-counter (OTC) alternative. D. Slowly taper down the dose of prednisone, as prescribed.

D Rationale: Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. There are no over-the-counter (OTC) substitutes for prednisone, and neither calcium chloride nor levothyroxine addresses the risk of adrenal insufficiency. PTS: 1 REF: p. 1484 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 23. A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what factor most likely caused this short-term change in treatment? A. Alterations in bile metabolism and release have likely caused hyperglycemia. B. Stress has likely caused an increase in the client's blood sugar levels. C. The client's efforts did not control the diabetes using nonpharmacologic measures. D. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

B Rationale: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The client's need for insulin is unrelated to the action of bile. The client's normal routine of nonpharmacological strategies of diet and exercise have been changed due to the client's admission to the hospital. Therefore, the client cannot overestimate what they cannot control. Electrolyte/ fluid balances may have some bearing on glucose levels, but stress is the most impactful cause of the change happening to this client.- PTS: 1 REF: p. 1526 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 29. A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? A. Integration B. Attachment C. Cleavage D. Budding

B Rationale: During the process of attachment, glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle. PTS: 1 REF: p. 1014 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

B Rationale: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends. PTS: 1 REF: p. 2051 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

B Rationale: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary. PTS: 1 REF: p. 2039 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. Which of the following actions is most likely to accomplish this? A. The nurse gauges the client's response to hypothetical outcomes. B. The client is encouraged to express fears openly. C. The nurse provides detailed and accurate information about the disease. D. The nurse closely observes the client's body language.

B Rationale: Encouraging the client to discuss his or her fears and anxieties is usually the best way to assess a client's anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some clients, but it is not an assessment. PTS: 1 REF: p. 1283 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 22. A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

B Rationale: Esophageal varices are a major cause of mortality in clients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed. PTS: 1 REF: p. 1375 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 37. The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise? A. "Do not exercise unsupervised." B. "Eventually aim to work up to 30 minutes of exercise each day." C. "Keep exercising but slow down if you get dizzy or short of breath." D. "Start your exercise program with high-impact activities."

B Rationale: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms, such as dizziness or shortness of breath, should prompt the client to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized. PTS: 1 REF: p. 806 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 22. A client with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this client's hematologic disorder? A. "When did you last have a blood transfusion?" B. "What medications have you taken recently?" C. "Have you been under significant stress lately?" D. "Have you suffered any recent injuries?"

B Rationale: Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by medications. Blood transfusions, stress, and injury are less common triggers. PTS: 1 REF: p. 926 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

B Rationale: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 35. A client has come to the clinic reporting blood in the stool. A fecal occult blood test is performed but is negative. Based on the client's history, the health care provider suggests a colonoscopy, but the client refuses, citing a strong aversion to the invasive nature of the test. What other test might the provider order to check for blood in the stool? A. A laparoscopic intestinal mucosa biopsy B. A fecal immunochemical test (FIT) C. Computed tomography (CT) D. Magnetic resonance imagery (MRI)

B Rationale: Fecal immunochemical tests (FIT) may be more accurate than guaiac testing and useful for clients who refuse invasive testing. CT or MRI cannot detect blood in stool. Laparoscopic intestinal mucosa biopsy is not performed. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? A. Impaired physical mobility related to presence of an indwelling urinary catheter B. Risk for infection related to presence of an indwelling urinary catheter C. Deficient knowledge regarding indwelling urinary catheter care D. Disturbed body image related to urinary catheterization

B Rationale: Fifty percent of all hospital-acquired infections are urinary tract infections (UTI), with a large number being associated with indwelling urinary catheters. This adverse infection is frequently referred to as a CAUTI (catheter associated urinary tract infection) and considered in the United States as a "never event". According to the National Quality Forum (NQF), never events are errors in health care that are identifiable, preventable, and serious for clients. Since the risk of infection is substantial; it is prioritized over functional and psychosocial diagnosis of mobility, knowledge deficits, and disturbed body image for this client. PTS: 1 REF: p. 1617 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitis B. Bleeding and perforation C. Acidosis and hypoglycemia D. Gangrene of the gallbladder and hyperglycemia

B Rationale: Following ERCP removal of gallstones, the client is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar alterations, gangrene, peritonitis, and acidosis are less likely complications. PTS: 1 REF: p. 1422 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A client has sustained a cut to the hand, immediately initiating the process of hemostasis. Following vasoconstriction, which event in the process of hemostasis will take place? A. Fibrin will be activated at the bleeding site. B. Platelets will aggregate at the injury site. C. Thromboplastin will form a clot. D. Prothrombin will be converted to thrombin.

B Rationale: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action. PTS: 1 REF: p. 890 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? A. Core body temperature B. Heart rate and rhythm C. Blood pressure D. Oxygen saturation level

B Rationale: For clients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 20. A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B Rationale: For many clients, being able to dialogue frankly about the effect of the ostomy with a nonjudgmental nurse is helpful. Emphasizing the benefits of the intervention is unlikely to improve the client's body image, since the benefits are likely already known. Online research is not likely to enhance the client's body image and some ostomies are permanent. PTS: 1 REF: p. 1319 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood? A. A client who is 81 years of age B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago D. A client who has type 1 diabetes

B Rationale: For potential blood donors, systolic arterial blood pressure should be 80 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation (donors are only required to wait at least 8 weeks between donations), and diabetes is not a contraindication. PTS: 1 REF: p. 897 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 36. An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication? A. Osteomyelitis B. Avascular necrosis C. Phantom pain D. Septicemia

B Rationale: Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in clients with femoral neck fractures. Infections are not immediate complications and phantom pain applies to clients with amputations, not hip fractures. PTS: 1 REF: p. 1165 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. The nurse is caring for an acutely ill client who has central venous pressure monitoring in place. What intervention should be included in the care plan of a client with CVP in place? A. Apply antibiotic ointment to the insertion site twice daily. B. Change the site dressing whenever it becomes visibly soiled. C. Perform passive range-of-motion exercises to prevent venous stasis. D. Aspirate blood from the device once daily to test pH.

B Rationale: Gauze dressings should be changed every 2 days or transparent dressings at least every 7 days and whenever dressings become damp, loosened, or visibly soiled. Passive ROM exercise is not indicated and it is unnecessary and inappropriate to aspirate blood to test it for pH. Antibiotic ointments are contraindicated. PTS: 1 REF: p. 685 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. The nurse is conducting a presurgical interview for a client with laryngeal cancer. The client reports drinking approximately 20 oz (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for risk of which condition? A. Increased risk for infection B. Delirium tremens C. Depression D. Nonadherence to postoperative care

B Rationale: Given the client's reported alcohol intake and considering that alcoholism is a known risk factor for cancer of the larynx, it is essential to assess the client for risk of delirium tremens, which occurs among clients with alcohol use disorder during withdrawal from alcohol, such as would occur in the hospital following surgery. Infection is a risk in the postoperative period, but not an appropriate answer based on the client's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments. PTS: 1 REF: p. 518 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A client's health history reveals daily consumption of two to three bottles of wine. The nurse would consider increased risk for which hematologic disorder when planning assessments and interventions for this client? A. Leukemia B. Anemia C. Thrombocytopenia D. Lymphoma

B Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; Red blood cell levels are typically affected more than platelet levels (i.e., thrombocytopenia). PTS: 1 REF: p. 893 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. The perioperative nurse has admitted a client who has just undergone a tonsillectomy. The nurse's postoperative assessment should prioritize which potential complication of this surgery? A. Difficulty ambulating B. Hemorrhage C. Infrequent swallowing D. Bradycardia

B Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a client after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does. PTS: 1 REF: p. 506 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intake C. Daily use of OTC glycerin suppositories D. Use of an NSAID to reduce inflammation

B Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem. PTS: 1 REF: p. 1335 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 8. A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per day B. A pregnant woman at 28 weeks' gestation C. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

B Rationale: Hemorrhoids commonly affect 50% of clients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids. PTS: 1 REF: p. 1335 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. The health care provider has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a client. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis? A. Immunosuppression B. Inflammation C. Infection D. Hemostasis

B Rationale: High-sensitivity CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis. PTS: 1 REF: p. 674 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. The nurse in an allergy clinic is educating a new client about the pathology of the client's health problem. What response should the nurse describe as a possible consequence of histamine release? A. Constriction of small venules B. Contraction of bronchial smooth muscle C. Dilation of large blood vessels D. Decreased secretions from gastric and mucosal cells

B Rationale: Histamine's effects during the immune response include contraction of bronchial smooth muscle, resulting in wheezing and bronchospasm, dilation of small venules, constriction of large blood vessels, and an increase in secretion of gastric and mucosal cells. PTS: 1 REF: p. 1040 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. The nurse caring for a client whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this client? A. Implanted pacemaker B. Transcutaneous pacemaker C. ICD D. Asynchronous defibrillator

B Rationale: If a client suddenly develops bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief. PTS: 1 REF: p. 716 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize? A. Establishing central venous access and beginning fluid resuscitation B. Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR) C. Establishing peripheral intravenous (IV) access and administering IV epinephrine D. Performing a comprehensive assessment and initiating rapid fluid replacement

B Rationale: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. A patent airway is also an immediate priority. Epinephrine is not withheld pending IV access, and fluid resuscitation is not a priority. PTS: 1 REF: p. 297 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

B Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding. PTS: 1 REF: p. 1425 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition

B Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice. PTS: 1 REF: p. 1372 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? A. Assess the client's vital signs and correlate these with the client's baselines. B. Assess the client's eye opening and response to stimuli. C. Document that the client currently lacks a level of consciousness. D. Facilitate diagnostic testing in an effort to obtain objective data.

B Rationale: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness. PTS: 1 REF: p. 1979 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 21. A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? A. Imbalanced nutrition: More than body requirements B. Excess fluid volume C. Sedentary lifestyle D. Adult failure to thrive

B Rationale: If the client with AKI gains or does not lose weight, fluid retention should be suspected. Short-term weight gain is not associated with excessive caloric intake or a sedentary lifestyle. Failure to thrive is not associated with weight gain. PTS: 1 REF: p. 1568 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 38. A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client's abdomen is increasing in girth. What is the nurse's most appropriate action? A. Advance the catheter 2 to 4 cm further into the peritoneal cavity. B. Reposition the client to facilitate drainage. C. Aspirate from the catheter using a 60-mL syringe. D. Infuse 50 mL of additional dialysate.

B Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate. PTS: 1 REF: p. 1588 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A client is being discharged home after a heart transplant. The nurse is preparing to provide medication education on cyclosporine and tacrolimus. Which nursing diagnosis would be prioritized for this client? A. Risk for injury B. Risk for infection C. Risk for peripheral neurovascular dysfunction D. Risk for unstable blood glucose

B Rationale: Immunosuppressants decrease the body's ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels. PTS: 1 REF: p. 779 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? A. Monitoring the client for dysrhythmias B. Maintaining and monitoring the client's fluid balance C. Assessing the client's level of consciousness D. Assessing the client for signs and symptoms of venous thromboembolism

B Rationale: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the client for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority. PTS: 1 REF: p. 1515 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. The nurse has implemented a bladder retraining program for an older adult client. The nurse places the client on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the client typically has approximately 50 mL of urine remaining in the bladder after voiding. What would be the nurse's best response to this finding? A. Perform a straight catheterization on this client. B. Avoid further interventions at this time, as this is an acceptable finding. C. Place an indwelling urinary catheter. D. Press on the client's bladder in an attempt to encourage complete emptying.

B Rationale: In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted. PTS: 1 REF: p. 1616 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible." B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "Rehabilitation means helping clients do exactly what they did before their stroke."

B Rationale: In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their pre-stroke level of functioning, which may be unrealistic. PTS: 1 REF: p. 2047 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 18. The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A. Place gel pads over the apex and posterior chest for better conduction. B. Ensure no one is touching the client at the time shock is delivered. C. Continue to ventilate the client via endotracheal tube during the procedure. D. Allow at least 3 minutes between shocks.

B Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the client's skin to prevent leaking. Second, ensure that no one is in contact with the client or with anything that is touching the client when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the client. Ventilation should be stopped during defibrillation. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 7. The nurse is caring for a client with mitral stenosis who is scheduled for a balloon valvuloplasty. The client reports being unsure of why the surgeon did not opt to replace the damaged valve rather than repair it. Which statement indicates an advantage of valvuloplasty that the nurse should cite? A. The procedure can be performed on an outpatient basis in a health care provider's office. B. Repaired valves tend to function longer than replaced valves. C. The procedure is not associated with a risk of infection. D. Lower doses of antirejection drugs are required than with valve replacement.

B Rationale: In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and clients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all surgical procedures, and it is not performed in a health care provider's office. Antirejection drugs are unnecessary because foreign tissue is not introduced. PTS: 1 REF: p. 771 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea and restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday

B Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed. PTS: 1 REF: p. 1028 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 23. A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A. A chest tube B. A tracheostomy C. An endotracheal tube D. A feeding tube

B Rationale: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction. PTS: 1 REF: p. 598 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed

B Rationale: In treating the client with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration. PTS: 1 REF: p. 1277 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventive measure should the nurse encourage the client to adopt? A. Increasing intake of protein from plant sources B. Increasing fluid intake C. Adopting a high-calcium diet D. Eating several small meals each day

B Rationale: Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein intake from all sources should be limited. Most clients do not require a low-calcium diet, but increased calcium intake would be contraindicated for all clients. Eating small, frequent meals does not influence the risk for recurrence. PTS: 1 REF: p. 1622 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse is caring for a client who describes changes in voiding patterns. The client states, "I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesn't seem to be much urine flow." What would the nurse expect this client's physical assessment to reveal? A. Hematuria B. Urine retention C. Dehydration D. Kidney injury

B Rationale: Increased urinary urgency and frequency coupled with decreasing urine volume strongly suggest urine retention. Hematuria may be an accompanying symptom, but is likely related to a urinary tract infection secondary to the retention of urine. Dehydration and kidney injury both result in a decrease in urine output, but the client with these conditions does not have normal urine production and decreased or minimal flow of urine to the bladder. The symptoms of urgency and frequency do not accompany kidney injury and dehydration due to decreased urine production. PTS: 1 REF: p. 1542 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 27. A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs and symptoms of wasting syndrome D. Strategies for adjusting antiretroviral dosages

B Rationale: Infection control is of high importance in clients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the client's CD4+ count is below 50. PTS: 1 REF: p. 1033 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 32. A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A. Ensure that the day nurse knows not to give the antiemetic. B. Contact the prescriber to have the subcutaneous option discontinued. C. Reassess the client's need for antiemetics. D. Remove the subcutaneous route from the client's MAR.

B Rationale: Injections must be avoided in clients with hemophilia. Consequently, the nurse should ensure that the prescriber makes the necessary change. The nurse cannot independently make a change to a client's MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse. PTS: 1 REF: p. 936 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 9. A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection

D Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the client exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection against the hepatitis B virus, but plays no role in protection for the client exposed to hepatitis A. Albumin confers no therapeutic benefit. PTS: 1 REF: p. 1386 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A. Haloperidol B. Prostigmine C. Epinephrine D. Glucagon

D Rationale: Glucagon is given prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for clients with myasthenia gravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm. PTS: 1 REF: p. 1256 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A nurse is providing care for a client whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A. Risk for disuse syndrome B. Unilateral neglect C. Risk for trauma D. Ineffective tissue perfusion

D Rationale: Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site. PTS: 1 REF: p. 1236 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? A. Intermittent hearing loss B. Tinnitus C. Tongue enlargement D. Vocal paralysis

D Rationale: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease. PTS: 1 REF: p. 2107 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what client population does this syndrome most often occur? A. Clients who are obese and who have no known history of diabetes B. Clients with type 1 diabetes and poor dietary control C. Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D. Middle-aged or older people with either type 2 diabetes or no known history of diabetes

D Rationale: HHS occurs most often in older clients (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. HHS is a serious metabolic disorder resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. Obesity does play a role in HHS but clients usually have a history of type 2 diabetes. Clients with type 1 diabetes usually present with DKA (diabetic ketoacidosis). Adolescents with type 2 have a low incidence of this condition. PTS: 1 REF: p. 1516 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 2. The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure? A. The client takes furosemide 20 mg/day. B. The client's potassium level is 4.7 mEq/L. C. The client is white. D. The client's age is greater than 65.

D Rationale: Heart failure is the most common reason for hospitalization of people older than 65 years of age and is the second-most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does not indicate an increased risk for heart failure, although this drug is often used in the treatment of heart failure. The client being white indicates a decreased risk for heart failure compared with Black and Hispanic clients. PTS: 1 REF: p. 794 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 33. A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response? A. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." C. "Hypertension is the leading cause of death in people your age." D. "Hypertension greatly increases your risk of stroke and heart disease."

D Rationale: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age. PTS: 1 REF: p. 870 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 4. The staff educator is teaching emergency department nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in which way? A. The blood pressure (BP) is always higher in a hypertensive emergency. B. Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C. Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D. Hypertensive emergencies are associated with evidence of target organ damage.

D Rationale: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that they cause. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the client's BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as intravenous vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies. PTS: 1 REF: p. 880 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 24. A client with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of which of the following? A. IV antibiotics B. Oral antihypertensives C. Parenteral nutrition D. IV corticosteroids

D Rationale: IV administration of corticosteroids (methylprednisolone sodium succinate may begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency. Antibiotics, antihypertensives, and parenteral nutrition do not prevent adrenal insufficiency or other common complications of adrenalectomy. PTS: 1 REF: p. 1476 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. A client is being treated in the emergency department for epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using which treatment to control the bleeding? A. Irrigation with a hypertonic solution B. Nasopharyngeal suction C. Normal saline application D. Silver nitrate application

D Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis. Normal saline application would not alleviate epistaxis. PTS: 1 REF: p. 512 NAT: Client Needs: Safe, Effective Care Environment: Management of Care |Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse educating a client with anemia is describing the process of red blood cell production. When the client's kidneys sense a low level of oxygen in circulating blood, which physiologic response is initiated? A. Increased stem cell synthesis B. Decreased respiratory rate C. Arterial vasoconstriction D. Increased levels of erythropoietin

D Rationale: If the kidney detects low levels of oxygen, as occurs when fewer red blood cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity. PTS: 1 REF: p. 887 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 11. A 42-year-old client is admitted to the ED after an assault. The client received blunt trauma to the face and has a suspected nasal fracture. What intervention should the nurse perform? A. Administer nasal spray and apply an occlusive dressing to the client's face. B. Position the client's head in a dependent position. C. Irrigate the client's nose with warm tap water. D. Apply ice and keep the client's head elevated.

D Rationale: Immediately after the fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used. PTS: 1 REF: p. 513 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 4. The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? A. Smoking decreases the amount of mucus production. B. Smoke particles compete for binding sites on hemoglobin. C. Smoking causes atrophy of the alveoli. D. Smoking damages the ciliary cleansing mechanism.

D Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites. PTS: 1 REF: p. 544 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 20. A nurse is preparing to perform an admission assessment on a client with chronic obstructive pulmonary disease (COPD). It is most important for the nurse to review which of the following? A. Social work assessment B. Finances C. Chloride levels D. Available diagnostic tests

D Rationale: In addition to the client's history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of clients. Chloride levels are relevant to cystic fibrosis, not COPD. Immediate physiological status would be more important than finances. PTS: 1 REF: p. 619 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. The nurse is caring for a client who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A. Spleen and kidneys B. Kidneys and pancreas C. Pancreas and liver D. Liver and spleen

D Rationale: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body. PTS: 1 REF: p. 885 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

D Rationale: In an ischemic stroke, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The cerebral cortex, temporal lobe, and central sulcus are all different areas of the brain. Since the specific area was not identified in the scenario; the area that would most benefit from immediate interventions would be the area surrounding the infarct called the penumbra region. PTS: 1 REF: p. 2033 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 38. A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones? A. Acute pancreatitis B. Atrophy of the gallbladder C. Gallbladder cancer D. Gangrene of the gallbladder

D Rationale: In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Pancreatitis, atrophy, and cancer of the gallbladder are not plausible complications. PTS: 1 REF: p. 1430 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A client in hypertensive urgency is admitted to the hospital. The nurse should be aware of which goal of treatment for a client in hypertensive urgency? A. Normalizing blood pressure (BP) within 2 hours B. Obtaining a BP of less than 110/70 mm Hg within 36 hours C. Obtaining a BP of less than 120/80 mm Hg within 36 hours D. Normalizing BP within 24 to 48 hours

D Rationale: In cases of hypertensive urgency, oral agents can be given with the goal of normalizing BP within 24 to 48 hours. For clients with this health problem, a BP of <120/80 mm Hg may be unrealistic. Normalizing BP within only 2 hours is not realistic. PTS: 1 REF: p. 880 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

D Rationale: In elderly clients, it is important to monitor the client's serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels. PTS: 1 REF: p. 1291 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A client comes into the clinic reporting fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. Which condition should the nurse most suspect the client has? A. A hypoproliferative anemia B. A leukemia C. Thrombocytopenia D. A hemolytic anemia

D Rationale: In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma; the released hemoglobin is converted in large part to bilirubin, and therefore the bilirubin concentration rises. The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production. This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes. Hypoproliferative anemias, leukemia, and thrombocytopenia lack this pathology and presentation. PTS: 1 REF: p. 911 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Select 10. The home care nurse is conducting client teaching with a client on corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when should the home care nurse instruct the client to take the corticosteroids? A. In the evening between 4 PM and 6 PM B. Prior to going to sleep at night C. At noon every day D. In the morning between 7 AM and 8 AM

D Rationale: In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects. PTS: 1 REF: p. 1484 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? A. Decreased cardiac output B. Decreased cardiac contractility C. Infarction of the myocardium D. Coronary arteriosclerosis

D Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease. PTS: 1 REF: p. 726 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 34. A client with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A. Continuous monitoring for portal hypertension B. Administration of immunosuppressive drugs during the first weeks after transplantation C. Real-time monitoring of vascular changes in the hepatic system D. Delivery of a continuous chemotherapeutic dose

D Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system. PTS: 1 REF: p. 1407 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. A nurse working in a long-term care facility is performing the admission assessment of a newly admitted 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of which health problem? A. Chronic venous insufficiency B. Raynaud phenomenon C. Venous thromboembolism (VTE) D. Peripheral artery disease (PAD)

D Rationale: In older adults, symptoms of PAD may be more pronounced than in younger people. In older adult clients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud phenomenon do not cause the ischemia that underlies gangrene. PTS: 1 REF: p. 835 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A client's plan of care specifies postural drainage. Which action should the nurse perform when providing this noninvasive therapy? A. Administer the treatment with the client in a high Fowler or semi-Fowler position. B. Perform the procedure immediately following the client's meals. C. The client is instructed to avoid coughing during the therapy. D. Assist the client into a position that will allow gravity to move secretions.

D Rationale: In postural drainage, the client assumes a position that allows gravity to facilitate the draining of secretions from all areas of the lungs. Postural drainage is usually performed two to four times per day, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Because the client usually sits in an upright position (i.e., high- or semi-Fowler position), secretions are likely to accumulate in the lower parts of the lungs. Several other positions are used in postural drainage so that the force of gravity helps move secretions from the smaller bronchial airways to the main bronchi and trachea. The client is encouraged to cough and remove secretions during postural drainage. PTS: 1 REF: p. 625 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A client is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A. Muscle wasting B. Chronic jaundice in the absence of liver disease C. The presence of fat in the client's stool D. Persistently low hemoglobin and hematocrit

D Rationale: In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results. This would result in a marked reduction in hemoglobin and hematocrit. PTS: 1 REF: p. 1210 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. The nurse is caring for a client on telemetry. The client's ECG shows atrial fibrillation, wide QRS and a fast, irregular ventricular rhythm. What does this ECG show? A. Sinus bradycardia B. Myocardial infarction C. Lupus-like syndrome D. Wolff-Parkinson-White (WPW) syndrome

D Rationale: In the client with atrial fibrillation, if the QRS is wide and the ventricular rhythm is very fast and irregular, an accessory pathway should be suspected. An accessory pathway is typically congenital tissue between the atria, bundle of His, AV node, Purkinje fibers, or ventricular myocardium. This anomaly is known as Wolff-Parkinson-White (WPW) syndrome. These characteristics are not typical of the other listed cardiac anomalies. PTS: 1 REF: p. 703 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 3. The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A. Increased urine output B. Decreased heart rate C. Hyperactive bowel sounds D. Cool, clammy skin

D Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases. PTS: 1 REF: p. 276 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 17. A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? A. Encourage the client to perform deep breathing and coughing exercises hourly. B. Reposition the client into a prone or semi-Fowler position and apply supplementary oxygen by nasal cannula. C. Activate the emergency response system. D. Report this finding promptly to the health care provider and remain with the client.

D Rationale: In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The client's current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the client are inadequate responses. PTS: 1 REF: p. 1240 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. A client with an ICD calls the cardiologist's office and talks to the nurse. The client is concerned about being defibrillated too often. The nurse tells the client to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what issue? A. Infection B. Failure to capture C. Premature battery depletion D. Oversensing of dysrhythmias

D Rationale: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common. PTS: 1 REF: p. 718 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 29. A nurse is teaching basic "survival skills" to a client newly diagnosed with type 1 diabetes. What topic should the nurse address? A. Signs and symptoms of diabetic nephropathy B. Management of diabetic ketoacidosis C. Effects of surgery and pregnancy on blood sugar levels D. Recognition of hypoglycemia and hyperglycemia

D Rationale: It is imperative that newly diagnosed clients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for education, but are not components of the client's immediate "survival skills" following a new diagnosis. PTS: 1 REF: p. 1506 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing physical activity and taking OTC iron supplements C. Limiting psychosocial stress and eating a high-protein diet D. Avoiding cold temperatures and ensuring sufficient hydration

D Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic. PTS: 1 REF: p. 924 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? A. "The test will temporarily limit blood flow through the brain." B. "An allergy to iodine precludes getting the radio-opaque dye." C. "The client will need to endure loud noises during the test." D. "The test may result in dizziness or lightheadedness."

D Rationale: Key nursing interventions for PET scan include explaining the test and teaching the client about inhalation techniques and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI. PTS: 1 REF: p. 1987 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Response 23. The hospital case manager for a group of recently discharged clients with asthma is providing health education. Which aspect of client teaching would have the greatest impact on preventing readmissions? A. Alternative treatment modalities B. Family participation in care C. Pathophysiology of the disease process D. Self-care and the therapeutic regimen

D Rationale: Knowledge about self-care and the therapeutic regimen would have the greatest impact on preventing admissions. For clients, the ability to understand the complex therapies of inhalers, anti-allergy and anti-reflux medications, and avoidance measures are essential for long-term control. Knowledge of alternative treatment modalities, such herbs, vitamins, or yoga, may help but is usually most effective as a complementary measure to an existing plan. Involving the family in care is important and can help the client with compliance, support, and encouragement, but ultimately the client is responsible for their own health. Understanding the pathophysiology of the disease process is important to include in education as it provides a better understanding in regards to causation and how it affects the body. However, how to physically manage asthma takes precedence over understanding in terms of readmission strategies. PTS: 1 REF: p. 629 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 31. A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

D Rationale: Laxatives should not normally be used on an ongoing basis because of the risk of dependence. In most cases they have a minimal effect on electrolyte levels. A client who has increased activity and improved diet likely has an understanding of the usual causes of constipation. Excessive laxative use could lead to diarrhea or fecal incontinence, but for most clients the risk of dependence is more significant. PTS: 1 REF: p. 1289 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 38. A client's recently elevated BP has prompted the primary care provider to prescribe furosemide. The nurse should closely monitor which of the following levels? A. The client's oxygen saturation level B. The client's red blood cells, hematocrit, and hemoglobin C. The client's level of consciousness D. The client's potassium level

D Rationale: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation. PTS: 1 REF: p. 871 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Dry mucous membranes C. Signs of internal bleeding D. Loss of brain stem reflexes

D Rationale: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death. PTS: 1 REF: p. 2009 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? A. "Client exhibits increased muscle tone." B. "Client demonstrates normal muscle structure with no evidence of atrophy." C. "Client demonstrates hyperactive deep tendon reflexes." D. "Client demonstrates an absence of deep tendon reflexes."

D Rationale: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control. PTS: 1 REF: p. 1976 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze

Multiple Choice 8. A client comes to the walk-in clinic with reports of pain in the foot following stepping on a roofing nail 4 days ago. The client has a visible red streak running up his foot and ankle. Which health problem should the nurse suspect? A. Cellulitis B. Local inflammation C. Elephantiasis D. Lymphangitis

D Rationale: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs. PTS: 1 REF: p. 861 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 32. The client has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The health care provider suspects bronchogenic carcinoma. An MRI would most likely assess for which condition in this client? A. Alveolar dysfunction B. Forced vital capacity C. Tidal volume D. Chest wall invasion

D Rationale: MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli (as would be the case in alveolar dysfunction) because the problem is in the bronchi. A static image such as MRI cannot inform pulmonary function tests. PTS: 1 REF: p. 489 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. "Drinking beverages after your meal, rather than with your meal, may bring some relief." B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." D. "Instead of eating three meals a day, try eating smaller amounts more often."

D Rationale: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial. PTS: 1 REF: p. 1255 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 7. A geriatric nurse is performing an assessment of body systems on an older adult client. The nurse should be aware of what age-related change affecting the renal and urinary systems? A. Increased ability to concentrate urine B. Increased bladder capacity C. Urinary incontinence D. Decreased glomerular filtration rate

D Rationale: Many age-related changes in the renal and urinary systems should be taken into consideration when taking a health history of an older adult. One change includes a decreased glomerular surface area resulting in a decreased glomerular filtration rate. Other changes include the decreased ability to concentrate urine and a decreased bladder capacity. It also should be understood that urinary incontinence is not a normal age-related change, but is common in older adults, especially in women because of the loss of pelvic muscle tone. PTS: 1 REF: p. 1539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. The nurse is providing health education to the parents of a 3-year-old who has been diagnosed with food allergies. Which statement should the nurse make when teaching this family about the child's health problem? A. "Food allergies are a lifelong condition, but most families adjust well to the necessary lifestyle changes." B. "Consistent use of over-the-counter antihistamines can often help a child overcome food allergies." C. "Make sure that you carry a steroid inhaler with you at all times, especially when you eat in restaurants." D. "Many children outgrow their food allergies in a few years if they avoid the offending foods."

D Rationale: Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the client carefully avoids the offending food. Antihistamines do not cure allergies, and an EpiPen is carried for clients with food allergies, not a steroid inhaler. PTS: 1 REF: p. 1061 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries? A. Hormonal changes brought on by the stress response cause an acidic oral environment B. Systemic infections frequently migrate to the teeth C. Hydration that is received intravenously lacks fluoride D. Inadequate nutrition and decreased saliva production can cause cavities

D Rationale: Many ill clients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the client is not significant in the development of dental caries in the ill client. PTS: 1 REF: p. 1232 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 26. An older adult has experienced a new onset of urinary incontinence, and family members identify this problem as being unprecedented. When assessing the client for factors that may have contributed to incontinence, the nurse should prioritize what assessment? A. Reviewing the client's 24-hour food recall for changes in diet B. Assessing for recent contact with individuals who have UTIs C. Assessing for changes in the client's level of psychosocial stress D. Reviewing the client's medication administration record for recent changes

D Rationale: Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. Stress and dietary changes could potentially affect the client's continence, but medications are more frequently causative of incontinence. UTIs can cause incontinence, but these infections do not result from contact with infected individuals. PTS: 1 REF: p. 1612 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 22. A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

D Rationale: Measures to help relieve pain include instructing the client to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the client about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing. PTS: 1 REF: p. 1277 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 25. A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? A. Monitoring the client's neutrophil levels B. Assessing the client for signs of impaired liver function C. Monitoring the client's level of consciousness and behavior D. Reviewing the client's creatinine and BUN levels

D Rationale: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the client's kidney function. This drug does not typically affect clients' neutrophils, liver function, or cognition. PTS: 1 REF: p. 1505 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 33: Assessment and Management of Patients with Allergic Disorders 1. A client received a bee sting on the lip approximately 2 hours ago and has arrived at an urgent/walk-in clinic for treatment because the swelling is now accompanied by nasal congestion. On assessment, the client reports pruritus and a sensation of warmth at the site. Which degree of anaphylaxis is the client experiencing? A. No systemic reaction B. Moderate systemic reaction C. Severe systemic reaction D. Mild systemic reaction

D Rationale: Mild systemic reactions begin within the first 2 hours after the exposure, and consist of cluster tingling and a sensation of warmth. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes is expected. While onset timing is the same, moderate systemic reactions include bronchospasm, edema of the airways or larynx with dyspnea, cough, and wheezing. Severe systemic reactions have an abrupt onset with symptoms progressing rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Severe systemic reaction should be considered as an emergent situation. A systemic reaction occurred as a vector (the bee sting) and a reaction (signs/symptoms) resulted. PTS: 1 REF: p. 1046 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? A. Complete bed rest B. Bed rest with bathroom privileges C. Out of bed (OOB) to the chair twice a day D. Ambulation and activity as tolerated

D Rationale: Mobility, through walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Bed rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the client to getting out of bed only a few times a day also increases calcium excretion and the associated risks. PTS: 1 REF: p. 1471 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A critical care nurse is caring for a client with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill clients? A. Pulmonary artery systolic pressure B. Right ventricular afterload C. Pulmonary artery pressure D. Left ventricular preload

D Rationale: Monitoring of the pulmonary artery diastolic and pulmonary artery wedge pressures is particularly important in critically ill clients because it is used to evaluate left ventricular filling pressures (i.e., left ventricular preload). This device does not directly measure the other listed aspects of cardiac function. PTS: 1 REF: p. 686 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 35. The nurse is caring for a client who will have coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse should address which subject? A. Symptoms of hypovolemia B. Symptoms of low blood pressure C. Complications requiring graft removal D. Intubation and mechanical ventilation

D Rationale: Most clients remain intubated and on mechanical ventilation for several hours after surgery. It is important that clients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most clients. Teaching would also generally not include rare complications that would require graft removal. PTS: 1 REF: p. 753 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Select 23. An 18-year-old client who is pregnant has tested positive for human immunodeficiency virus (HIV) and asks the nurse if her baby is going to be born with HIV. Which response by the nurse is the best? A. "Your baby has a one in four chance of being born with HIV." B. "Your health care provider is likely the best one to answer that question." C. "If the baby is HIV-positive, we can't do anything until after the birth, so try not to worry." D. "Your baby could contract HIV before, during, or after delivery."

D Rationale: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breastfeeding. There is no evidence that the infant's risk is 25%. Deferral to the health care provider is not a substitute for responding appropriately to the client's concern. Downplaying the client's concerns is inappropriate. PTS: 1 REF: p. 1009 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 12. The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what issue? A. Genetic dysfunction B. Upper and lower motor neuron lesions C. Decreased conduction of impulses in an upper motor neuron lesion D. A lower motor neuron lesion

D Rationale: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron. PTS: 1 REF: p. 2101 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 31. A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A. Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's pain. B. Opioids partially inhibit the client's synthesis of clotting factors. C. Opioids may cause vasodilation and exacerbate bleeding. D. NSAIDs are contraindicated due to the risk for bleeding.

D Rationale: NSAIDs may be contraindicated in clients with hemophilia due to the associated risk of bleeding. Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic. PTS: 1 REF: p. 935 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 20. A client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of which health problem? A. Bronchitis B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Asthma

D Rationale: Nurses should be aware that atopic dermatitis is often the first step in a process, known as atopic march, that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, or RA. PTS: 1 REF: p. 1057 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. A nurse's colleague has applied an incontinence pad to an older adult client who has experienced occasional episodes of functional incontinence. What principle should guide the nurse's management of urinary incontinence in older adults? A. Diuretics should be promptly discontinued when an older adult experiences incontinence. B. Restricting fluid intake is recommended for older adults experiencing incontinence. C. Urinary catheterization is a first-line treatment for incontinence in older adults with incontinence. D. Urinary incontinence is not considered a normal consequence of aging.

D Rationale: Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. Diuretics cannot always be safely discontinued. Fluid restriction and catheterization are not considered to be safe, first-line interventions for the treatment of incontinence. PTS: 1 REF: p. 1612 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 9. A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes? A. Have blood glucose levels checked annually. B. Stop using tobacco in any form. C. Undergo eye examinations regularly. D. Lose weight, if obese.

D Rationale: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent diabetes. PTS: 1 REF: p. 1493 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 7. A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide

D Rationale: Octreotide—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not given, and heparin would exacerbate, not alleviate, bleeding. PTS: 1 REF: p. 1377 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 19. A nurse is performing an abdominal assessment of an older adult client. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A. Increased gastric motility B. Decreased gastric pH C. Increased gag reflex D. Decreased mucus secretion

D Rationale: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults. PTS: 1 REF: p. 1213 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 5. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently.

D Rationale: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Oils are contraindicated. PTS: 1 REF: p. 1874 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. The nurse is providing care for an older adult client whose current medication regimen includes levothyroxine. As a result, the nurse should be aware of the heightened risk of adverse sedation effects when administering an intravenous (IV) dose of what medication? A. A fluoroquinolone antibiotic B. A loop diuretic C. A proton pump inhibitor (PPI) D. A benzodiazepine

D Rationale: Oral thyroid hormones interact with many other medications. Even in small IV doses, hypnotic and sedative agents may induce profound somnolence, lasting far longer than anticipated and leading to narcosis (stupor-like condition). Furthermore, they are likely to cause respiratory depression, which can easily be fatal because of decreased respiratory reserve and alveolar hypoventilation. Benzodiazepine is a sedative and may be used to treat seizures and alcohol withdrawal. Concurrent usage with levothyroxine can increase benzodiazepine's sedation effects. Concurrent use of fluoroquinolone antibiotics can decrease absorption of the antibiotic. A loop diuretic and proton pump inhibitor IV have no adverse sedation effects. A PPI taken in pill form can inhibit levothyroxine absorption if taken together. PTS: 1 REF: p. 1457 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated? A. Teach the client deep breathing and coughing exercises. B. Administer supplemental oxygen at all times. C. Limit the client's activity level. D. Avoid positioning the client supine.

D Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of heart failure and, consequently, the nurse should avoid positioning the client supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom. PTS: 1 REF: p. 796 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The nurse performing the health interview of a client with a new onset of periorbital edema has completed a genogram, noting the health history of the client's siblings, parents, and grandparents. This assessment addresses the client's risk of what kidney disorder? A. Nephritic syndrome B. Acute glomerulonephritis C. Nephrotic syndrome D. Polycystic kidney disease (PKD)

D Rationale: PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders. PTS: 1 REF: p. 1562 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 12. A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity intolerance B. Anxiety C. Ineffective coping D. Acute pain

D Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn client has been described as one of the most severe types of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the client's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses. PTS: 1 REF: p. 1884 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following situations? A. Inpatient rehabilitation B. Rehabilitation in the home setting C. Intensive physical therapy D. Hospice care

D Rationale: Pancreatic carcinoma has only a low survival rate regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the client will require hospice care than physical therapy and rehabilitation. PTS: 1 REF: p. 1440 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 24. The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A. It slows the proliferation of bacteria and viruses during shock. B. It decreases the energy expended through the functioning of the GI system. C. It assists in expanding the intravascular volume of the body. D. It promotes GI function through direct exposure to nutrients.

D Rationale: Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body. PTS: 1 REF: p. 283 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings. C. Place a mask over the client's nose. D. Wear personal protective equipment.

D Rationale: Personal protective equipment must be worn when placing a nasogastric tube in a client with COVID since it is considered an aerosol-generating procedure as tube placement often generates a cough. The client should be placed in a supine position for the placement of the nasogastric tube to assure proper visualization, assessment, and advancement of the tube. If possible, a mask should be placed over the client's mouth to avoid transmission of the virus if the client coughs. The mask cannot be placed over the client's nose since the tube will be placed through the nares. The feedings should be administered as a continuous feeding, rather than a bolus, to reduce the risk of contact with bodily fluids and aerosolized droplets. PTS: 1 REF: p. 1246 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopies B. Adherence to recommended immunization schedules C. Regular blood pressure monitoring D. Frequent screening for osteoporosis

D Rationale: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring. PTS: 1 REF: p. 1295 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 27. The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of: A. increased stroke volume. B. increased cardiac output. C. decreased heart rate. D. decreased venous return.

D Rationale: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body. PTS: 1 REF: p. 290 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following? A. Immunity to HIV B. An intact immune system C. An AIDS-related complication D. An HIV infection

D Rationale: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications. PTS: 1 REF: p. 1013 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A. Psychosocial stress B. Hypersensitivity to an immunization C. Menarche D. Streptococcal infection

D Rationale: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes. PTS: 1 REF: p. 1558 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on the client's hands. What should the nurse teach the client to do? A. Wear powdered latex gloves when in public. B. Wash her hands with antibacterial soap every few hours. C. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. D. Keep the hands well moisturized at all times.

D Rationale: Powdered latex gloves can cause contact dermatitis. Skin should be kept well hydrated and should be washed with mild soap. Maintaining room temperature at 75 to 80°F (24° to 27°C) is excessively warm. PTS: 1 REF: p. 1064 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 33. A nurse is explaining to a client with asthma with a new prescription for prednisone what it is used for. What would be the most accurate explanation that the nurse could give? A. To ensure long-term prevention of asthma exacerbations B. To cure any systemic infection underlying asthma attacks C. To prevent recurrent pulmonary infections D. To gain prompt control of inadequately controlled, persistent asthma

D Rationale: Prednisone is used for a short-term (3-10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term. PTS: 1 REF: p. 635 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 21. The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The client is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best action? A. Facilitate a referral to a vascular surgeon. B. Assess the client's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C. Encourage the client to increase her activity level. D. Teach the client that circulatory changes during pregnancy frequently cause varicose veins.

D Rationale: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem. PTS: 1 REF: p. 858 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse is caring for a client who is going to have an open renal biopsy. What nursing action should the nurse prioritize when preparing this client for the procedure? A. Discuss the client's diagnosis with the family. B. Bathe the client before the procedure with antiseptic skin wash. C. Administer antivirals before sending the client for the procedure. D. Keep the client NPO prior to the procedure.

D Rationale: Preparation for an open biopsy is similar to that for any major abdominal surgery. When preparing the client for an open biopsy, the nurse would keep the client NPO. The nurse may discuss the diagnosis with the family, but that is not a preparation for the procedure. A preprocedure wash is not normally ordered and antivirals are not given in anticipation of a biopsy. PTS: 1 REF: p. 1552 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is caring for a client with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client? A. Insert a nasogastric tube. B. Administer a micro Fleet enema at least 3 hours before the procedure. C. Have the client lie in a supine position for the procedure. D. Apply local anesthetic to the back of the client's throat.

D Rationale: Preparation includes spraying or gargling with a local anesthetic. A nasogastric tube or a micro Fleet enema is not required for this procedure. The client should be positioned in a side-lying position in case of emesis. PTS: 1 REF: p. 1222 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

D Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers. PTS: 1 REF: p. 1880 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 12. A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? A. Lymphoma B. Leukemia C. Hemophilia D. Hepatic dysfunction

D Rationale: Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. Liver dysfunction can lead to decreased amount of factors needed for coagulation and hemostasis. The majority of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia. PTS: 1 REF: p. 939 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A client is being treated for a pulmonary embolism, and the medical nurse is aware that the client experienced an acute disturbance in pulmonary perfusion. This involved an alteration in which aspect of normal physiology? A. Maintenance of constant osmotic pressure in the alveoli B. Maintenance of muscle tone in the diaphragm C. pH balance in the pulmonary veins and arteries D. Adequate flow of blood through the pulmonary circulation.

D Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure. PTS: 1 REF: p. 466 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? A. Incentive spirometry B. Arterial blood gas (ABG) measurement C. Peak flow measurement D. Pulse oximetry

D Rationale: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air. PTS: 1 REF: p. 487 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 17. During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A. It suggests onset of metabolic problems. B. It indicates paralysis on the right side of the body. C. It indicates paralysis of cranial nerve X (CN X). D. It indicates an injury at the midbrain level.

D Rationale: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X. PTS: 1 REF: p. 1996 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 61: Management of Clients With Neurologic Dysfunction KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed. C. Assess the risk for injury recurrence. D. Assess the client's psychosocial state.

D Rationale: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance. PTS: 1 REF: p. 1887 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A group of nurses is participating in orientation to a telemetry unit. The nurse who is providing the education should tell the class that ST segments: A. are the part of an ECG that reflects systole. B. are the part of an ECG used to calculate ventricular rate and rhythm. C. are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D. represent early ventricular repolarization.

D Rationale: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 35. An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock

D Rationale: Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause. PTS: 1 REF: p. 940 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 9. When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? A. Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. B. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

D Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the health care provider updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions. PTS: 1 REF: p. 274 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. The nurse is caring for a client who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by: A. nitrogen narcosis. B. infection. C. impaired diffusion. D. shunting.

D Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery, and nitrogen narcosis only occurs from breathing compressed air. PTS: 1 REF: p. 467 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms? A. Subluxated right hip B. Right hip contusion C. Hip strain D. Traumatic hip dislocation

D Rationale: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities. PTS: 1 REF: p. 1154 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A. Warm the client's foot and determine whether circulation improves. B. Reposition the client with the affected foot dependent. C. Reassess the client's neurovascular status in 15 minutes. D. Promptly inform the primary care provider.

D Rationale: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the client may be of some benefit, but the care provider should be informed first. PTS: 1 REF: p. 1190 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take? A. Administer pain medication. B. Massage the client's calf. C. Apply antiembolic stockings. D. Notify the health care provider.

D Rationale: Since calf tenderness may be a sign of deep vein thrombosis (DVT), the nurse should notify the health care provider about this finding. The nurse should not administer pain medication since it is prescribed for surgical pain and this tenderness in the calf should not be masked until it is evaluated. The nurse should not massage the client's calf as this may dislodge a thrombus. Antiembolic stockings should be worn prophylactically to prevent DVT but are not applied to treat DVT. PTS: 1 REF: p. 1178 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A The client is experiencing painful oral lesions following radiation for oropharyngeal cancer. Which instruction should the nurse give this client? A. Spicy foods stimulate salivation and are soothing. B. Eat food while it is hot to enhance flavor. C. Avoid brushing teeth while lesions are present. D. Eat soft or liquid foods.

D Rationale: Since oral lesions can be painful, a soft or liquid diet may be preferred and easier to ingest. Other strategies to reduce pain and discomfort include avoiding spicy and hot foods. The client should continue with mouth care and brushing teeth with a soft toothbrush to keep the oral cavity clean. PTS: 1 REF: p. 1237 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 5. A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12

D Rationale: Since vitamin B12 is absorbed in the stomach, the client requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely. PTS: 1 REF: p. 1270 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 22. A cardiac care nurse is caring for a client who is experiencing positive chronotropy. What effect should the nurse prepare for? A. Exacerbation of an existing dysrhythmia B. Initiation of a new dysrhythmia C. Resolution of ventricular tachycardia D. Increased heart rate

D Rationale: Stimulation of the sympathetic system increases heart rate. This phenomenon is known as positive chronotropy. It does not influence dysrhythmias. PTS: 1 REF: p. 691 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 30. An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? A. Nasogastric intubation B. Administration of probiotic supplements C. Bed rest D. Cautious hydration

D Rationale: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client. PTS: 1 REF: p. 540 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Response 25. A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. Which fact about lung cancer treatment should inform the nurse's response? A. The cells in small cell cancer of the lung are not large enough to visualize in surgery. B. Small cell lung cancer is self-limiting in many clients, and surgery should be delayed. C. Clients with small cell lung cancer are not normally stable enough to survive surgery. D. Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

D Rationale: Surgery is primarily used for non-small cell lung cancer, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a client's medical instability are not the limiting factors. Lung cancer is not a self-limiting disease. PTS: 1 REF: p. 578 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The length of time since the burn B. The location of burned skin surfaces C. The source of the burn D. The total body surface area (TBSA) affected by the burn

D Rationale: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects. PTS: 1 REF: p. 1868 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 15. A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

D Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management. PTS: 1 REF: p. 1872 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A. A diastolic blood pressure that is lower during exhalation B. A diastolic blood pressure that is higher during inhalation C. A systolic blood pressure that is higher during exhalation D. A systolic blood pressure that is lower during inhalation

D Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal. PTS: 1 REF: p. 812 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? A. Cerebral angiography B. ABG analysis C. CT D. EEG

D Rationale: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD. PTS: 1 REF: p. 2094 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin. When assessing the therapeutic response to this medication, which action by the nurse is the most appropriate? A. Assess for signs of myelosuppression. B. Review the client's platelet level. C. Assess the client's capillary refill time. D. Review the client's international normalized ratio (INR).

D Rationale: The INR and activated partial thromboplastin time serve as useful tools for evaluating a client's clotting ability and monitoring the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and assessing capillary refill time do not address the effectiveness of anticoagulants. PTS: 1 REF: p. 894 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client is admitted to a surgical unit after a thyroidectomy. The nurse takes and maintains the inflated blood pressure cuff on the client and observes a carpopedal spasm. What does this result indicate? A. Chvostek sign and hypocalcemia B. Thyroid storm and elevated triiodothyronine C. Homans sign and deep vein thrombosis D. Trousseau sign and overt tetany

D Rationale: The Trousseau sign is positive when carpopedal spasm (spasms of the hand or, less commonly, the feet) is induced by occluding the blood flow to the arm for 3 minutes and indicates tetany. Chvostek sign is positive when a sharp tapping over the facial nerve causes spasm, or twitching of the mouth, nose and eye. Chvostek sign also indicates tetany (neuronal excitability), which is usually associated with hypocalcemia. This result is not the product of a thyroid storm, which involves the excessive release of thyroid hormones given the client's surgery. Although blood pressure can be acquired on the leg; this is not the test for the Homans sign. A positive Homans sign is pain in the calf of the leg upon dorsiflexion of the foot and would suggest a deep vein thrombosis (DVT). PTS: 1 REF: p. 1473 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client's most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding? A. The client is likely to have a decreased level of blood urea nitrogen (BUN). B. The client is at risk for hypokalemia. C. The client is likely to have irregular voiding patterns. D. The client is likely to have increased serum creatinine levels.

D Rationale: The adult GFR can vary from a normal of approximately 125 mL/min (1.67 to 2.0 mL/sec) to a high of 200 mL/min. A low GFR is associated with increased levels of BUN, creatinine, and potassium. PTS: 1 REF: p. 1540 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 21. What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

D Rationale: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day. PTS: 1 REF: p. 2042 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. A nurse is reviewing the physiologic factors that affect a client's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A. The average amount of oxygen removed by each organ in the body B. The amount of oxygen removed from the blood by the heart C. The amount of oxygen returning to the lungs via the pulmonary artery D. The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

D Rationale: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply. PTS: 1 REF: p. 819 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 25. Which of the following individuals would be the most appropriate candidate for immunotherapy? A. A client who had an anaphylactic reaction to an insect sting B. A child with allergies to eggs and dairy C. A client who has had a positive tuberculin skin test D. A client with severe allergies to grass and tree pollen

D Rationale: The benefit of immunotherapy has been fairly well established in instances of allergic rhinitis and bronchial asthma that are clearly due to sensitivity to one of the common pollens, molds, or household dust. Immunotherapy is not used to treat type I hypersensitivities. A positive tuberculin skin test is not an indication for immunotherapy. PTS: 1 REF: p. 1053 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 31. Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns? A. "All donated blood is treated with antiretroviral medications before it is used." B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C. "HIV was eradicated from the blood supply in the early 2000s." D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

D Rationale: The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood. PTS: 1 REF: p. 905 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A client is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis? A. Position the client supine to facilitate diaphragm movement. B. Administer corticosteroids by nebulizer as prescribed. C. Perform oral suctioning as needed to remove secretions. D. Administer analgesic per orders.

D Rationale: The client has ineffective breathing patterns due to pain. To increase the likelihood of the client being able to perform interventions for his/her respiratory status, it would be important to treat acute pain first. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated. PTS: 1 REF: p. 1432 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A nurse is caring for a client who has allergic rhinitis. What intervention would be most likely to help the client meet the goal of improved breathing pattern? A. Teach the client to take deep breaths and cough frequently. B. Use antihistamines daily throughout the year. C. Teach the client to seek medical attention at the first sign of an allergic reaction. D. Modify the environment to reduce the severity of allergic symptoms.

D Rationale: The client is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. Deep breathing and coughing are not indicated unless an infection is present. Anaphylaxis requires prompt medical attention, but a minority of allergic reactions is anaphylaxis. Overuse of antihistamines reduces their effectiveness. PTS: 1 REF: p. 1054 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a client how to manage a new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices? A. Empty the collection bag when it is between one-half and two-thirds full. B. Limit fluid intake to prevent production of large volumes of dilute urine. C. Reinforce the appliance with tape if small leaks are detected. D. Avoid using moisturizing soaps and body washes when cleaning the peristomal area.

D Rationale: The client is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full. PTS: 1 REF: p. 1629 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 9. A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

D Rationale: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated. PTS: 1 REF: p. 2051 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response? A. Administer sublingual nitroglycerin to allow the client to finish the test. B. Initiate cardiopulmonary resuscitation. C. Administer analgesia and slow the test. D. Stop the test and monitor the client closely.

D Rationale: The client may be experiencing signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident. The client should not be permitted to continue the test due to risk of MI, therefore the first option, administer nitroglycerin is incorrect. The nurse would not administer pain medication and slow the test as this could mask the symptoms of MI and the client should not be permitted to continue with the test. Further assessment by the nurses must be completed and protocol for MI initiated. PTS: 1 REF: p. 677 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 36. While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. B. The client may be experiencing neurologic or psychiatric complications of the client's injuries. C. The client may be experiencing inconsistencies in the care being provided. D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

D Rationale: The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers. PTS: 1 REF: p. 1885 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze

Multiple Choice Chapter 44: Management of Patients with Biliary Disorders 1. A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jaw D. Right shoulder

D Rationale: The client may have biliary colic with excruciating upper-right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw. PTS: 1 REF: p. 1418 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. A client will be undergoing a urea breath test for the detection of Helicobacter pylori. Which instruction should the nurse give to the client to prepare for this test? A. Ingest a capsule of carbon-labeled urea ingested three days before the test. B. Take prescribed antibiotics one month before the test. C. Fast for 12 hours before the test. D. Avoid taking cimetidine 24 hours before the test.

D Rationale: The client undergoing a urea breath test should avoid taking cimetidine for 24 hours before the test. The capsule with the carbon-labeled urea is ingested at the time of the test and a breath sample is obtained 10 to 20 minutes later. Antibiotics should be avoided for one month before the test. There is no need to fast for this test. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 36. A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

D Rationale: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these. PTS: 1 REF: p. 2033 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT: A. Malnutrition B. Advanced age C. Multiple comorbidities D. Progressive dyspnea

D Rationale: The client with advanced age is at risk for developing MODS due to the lack of physiological reserve. The client with malnutrition metabolic compromise and the client with multiple comorbidities is at risk for developing MODS due to decreased organ function. Progressive dyspnea is the first sign of MODS. PTS: 1 REF: p. 297 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 23. The nurse caring for a client with a leg ulcer has finished assessing the client and is developing a problem list prior to writing a plan of care. What priority risk would the care plan address? A. Disuse syndrome B. Ineffective health maintenance C. Sedentary lifestyle D. Insufficient nutrition

D Rationale: The client with leg ulcers is at risk for insufficient nutrition related to the increased need for nutrients that promote wound healing. The risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or a sedentary lifestyle. PTS: 1 REF: p. 858 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze

Multiple Choice 26. An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified? A. Altered tissue perfusion risk related to arrhythmia B. Excess fluid volume risk related to medication regimen C. Altered breathing pattern risk related to hypoxia D. Falls risk related to hypotension

D Rationale: The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients with heart failure, but this is not in evidence for this client at this time. PTS: 1 REF: p. 801 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 25: Management of Clients With Complications from Heart Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees? A. Apply the condom prior to erection. B. A condom may be reused with the same partner if ejaculation has not occurred. C. Use skin lotion as a lubricant if alternatives are unavailable. D. Hold the condom during withdrawal so it doesn't come off.

D Rationale: The condom should be held during withdrawal so it does not come off the penis. The condom should be unrolled over the hard penis, not prior to erection, before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, and cold cream should not be used with condoms because they cause latex deterioration/condom breakage. Condoms should never be reused. PTS: 1 REF: p. 1010 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 32. The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate? A. Keep the client in a low Fowler position. B. Perform tracheostomy care at least once per day. C. Maintain continuous bed rest. D. Monitor cuff pressure every 8 hours.

D Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours, not once per day, because of the risk of infection. The client should be encouraged to ambulate, if possible, not maintain continuous bed rest, and a low Fowler position is not indicated. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 17. The nurse is providing care for a client with high cholesterol and triglyceride values. In teaching the client about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A. High HDL values and high triglyceride values B. Absence of detectable total cholesterol levels C. Elevated blood lipids, fasting glucose less than 100 D. Low LDL values and high HDL values

D Rationale: The desired goal for cholesterol readings is for a client to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol. PTS: 1 REF: p. 727 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 34. A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? A. Older adults are often vague historians. B. Older adults have fewer peripheral nerves than younger adults. C. Many older adults are hesitant to admit that their body is changing. D. Many symptoms can be the result of normal aging process.

D Rationale: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the client has come to the clinic seeking help for this problem; this does not indicate a desire on the part of the client to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves. PTS: 1 REF: p. 2110 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 19. A nurse is assessing an older adult client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what examples? A. Fever and pain B. Chills and jaundice C. Nausea and vomiting D. Signs and symptoms of septic shock

D Rationale: The elderly client may not exhibit the typical symptoms of fever, pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea. PTS: 1 REF: p. 1426 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 36. A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in the femoral region. What is the nurse's most appropriate action? A. Call for assistance and initiate cardiopulmonary resuscitation. B. Reposition the client's leg in a nondependent position. C. Promptly remove the femoral sheath. D. Call for help and apply pressure to the access site.

D Rationale: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest. PTS: 1 REF: p. 747 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 11. The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. Depress the client's tongue with a sterile tongue depressor. B. Ask the client to swallow a small quantity of any soft food. C. Observe the client swallowing a small mouthful of water. D. Lightly touch the client's pharynx with a cotton swab.

D Rationale: The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. The gag reflex is not assessed by having the client swallow or by depressing the tongue. PTS: 1 REF: p. 1981 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? A. Appropriate use of prophylactic antibiotics B. Safe injection of corticosteroids C. Improved skin integrity D. Improved coping with lifestyle modifications

D Rationale: The goals for the client with allergies may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. Antibiotics are not used to treat allergies and corticosteroids, if needed, are not given parenterally. Allergies do not normally threaten skin integrity. PTS: 1 REF: p. 1054 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 33: Assessment and Management of Clients With Allergic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that what vessel is most commonly used as source for a CABG? A. Brachial artery B. Brachial vein C. Femoral artery D. Greater saphenous vein

D Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested. PTS: 1 REF: p. 748 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 3. The nurse is caring for a client who has been in a motor vehicle accident and is suspected of having developed pleurisy. Which assessment finding would best corroborate this diagnosis? A. The client is experiencing painless hemoptysis. B. The client's arterial blood gases (ABGs) are normal, but the client demonstrates increased work of breathing. C. The client's oxygen saturation level is below 88%, but the client denies shortness of breath. D. The client's pain intensifies when the client coughs or takes a deep breath.

D Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The client's ABGs would most likely be abnormal, and shortness of breath would be expected. Painless hemoptysis is not characteristic of pleurisy. PTS: 1 REF: p. 553 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 19. A client has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the client about what priority topic? A. Typical diet B. Allergy status C. Psychosocial stressors D. Current medication use

D Rationale: The kidneys are susceptible to the adverse effects of medications because they are repeatedly exposed to substances in the blood. Nephrotoxic medications are a more likely cause of AKI than diet, allergies, or stress. PTS: 1 REF: p. 1567 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. The nurse takes the client's blood pressure, and the reading is 161/101 mm Hg. The nurse knows this blood pressure would be classified as which type? A. Elevated B. Normal C. Stage 1 hypertensive D. Stage 2 hypertensive

D Rationale: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg. PTS: 1 REF: p. 866 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Select 8. A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A. Constipation related to immobility B. Risk for injury related to altered thought processes C. Hyperthermia related to the inflammatory process D. Excess fluid volume related to generalized edema

D Rationale: The major clinical manifestation of nephrotic syndrome is edema, so the appropriate nursing diagnosis is "Excess fluid volume related to generalized edema." Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen. PTS: 1 REF: p. 1561 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client presents at the clinic with pain and weakness in the hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what condition? A. Guillain-Barré syndrome B. Myasthenia gravis C. Trigeminal neuralgia D. Peripheral nerve disorder

D Rationale: The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness, diminished reflexes, pain, and paresthesia (numbness, tingling) of the extremities. Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated by any of the three branches, but most commonly the second and third branches of the trigeminal nerve. Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. PTS: 1 REF: p. 2110 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 16. A nurse is performing an admission assessment for an 81-year-old client who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver

D Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges. PTS: 1 REF: p. 1367 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 33. An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A. Ensure that blood components are never infused at a rate greater than 125 mL/h. B. Administer prophylactic antihistamines prior to all blood transfusions. C. Establish baseline vital signs for all clients receiving transfusions. D. Be vigilant in identifying the client and the blood component.

D Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and client identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction. PTS: 1 REF: p. 901 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common? A. Sudden change in level of consciousness (LOC) B. Recurrent infections C. Anaphylaxis D. Severe fatigue

D Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis. PTS: 1 REF: p. 892 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 32. A client who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis? A. Sudden changes in level of consciousness (LOC) B. Peripheral edema and pulmonary edema C. Pleuritic chest pain D. Flulike symptoms

D Rationale: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis. PTS: 1 REF: p. 787 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 14. A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? A. Diabetic coma B. Decubitus ulcer C. Wound evisceration D. Bile duct injury

D Rationale: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach. PTS: 1 REF: p. 1425 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 37. A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A. Maximize the efficiency of care. B. Ensure that the client's health care is holistic. C. Facilitate the client's adjustment to a new body image. D. Promote the client's highest possible level of function.

D Rationale: The multidisciplinary rehabilitation team helps the client achieve the highest possible level of function and participation in life activities. The team is not primarily motivated by efficiency, the need for holistic care, or the need to foster the client's body image, despite the fact that each of these are valid goals. PTS: 1 REF: p. 1196 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 12. A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? A. Proteinuria and hyperkalemia B. Hemorrhage and hypercalcemia C. Weight loss and hypoglycemia D. Malabsorption and hyperglycemia

D Rationale: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the client's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely. PTS: 1 REF: p. 1442 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 37. The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge? A. Walk 1 mile (1.6 km) 3 to 4 times a week. B. Use weights daily to increase arm strength. C. Walk on a treadmill 30 minutes daily. D. Perform shoulder exercises five times daily.

D Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the client on the importance of performing shoulder exercises five times daily. The client should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks. PTS: 1 REF: p. 585 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 15. The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. One day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client? A. Keep the remaining tablets for an infection at a later time. B. Discontinue the medications if the fever is gone. C. Dispose of the remaining medication in a biohazard receptacle. D. Finish all the antibiotics to eliminate the organism completely.

D Rationale: The nurse informs the client about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire prescribed course to eliminate the microorganisms. A client should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 21. A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.

D Rationale: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the health care provider is notified and the client's vital signs are monitored as the client's condition warrants. Putting the client in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting. PTS: 1 REF: p. 1270 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A. Ask the client's primary provider to liaise between the nurse and the client. B. Delegate care of the client to a colleague. C. Limit contact with the client in order to provide privacy. D. Make appropriate referrals to services that provide psychosocial support.

D Rationale: The nurse should enlist the services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists, if needed. This is preferable to delegating care, since the client has become angry with other care providers as well. It is impractical and inappropriate to expect the primary provider to act as a liaison. It would be inappropriate and unsafe to simply limit contact with the client. PTS: 1 REF: p. 1283 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Caring BLM: Cognitive Level: Apply

Multiple Select 37. What nursing action should the nurse perform when caring for a client undergoing diagnostic testing of the renal-urologic system? A. Withhold medications until 12 hours post-testing. B. Ensure that the client knows the importance of temporary fluid restriction after testing. C. Inform the client of the medical diagnosis after reviewing the results. D. Assess the client's understanding of the test results after their completion.

D Rationale: The nurse should ensure that the client understands the results that are presented by the health care provider. Informing the client of a diagnosis is normally the primary provider's responsibility. Withholding fluids or medications is not normally required after testing. PTS: 1 REF: p. 1547 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 38. The nurse is caring for a client who has a diagnosis of AIDS. Inspection of the client's mouth reveals the new presence of white lesions on the client's oral mucosa. What is the nurse's most appropriate response? A. Encourage the client to gargle with salt water twice daily. B. Attempt to remove the lesions with a tongue depressor. C. Make a referral to the unit's dietitian. D. Inform the primary provider of this finding.

D Rationale: The nurse should inform the primary provider of this abnormal finding in the client's oral cavity, since it necessitates medical treatment. It would be inappropriate to try to remove skin lesions from a client's mouth and salt water will not resolve this problem, which is likely due to candidiasis. A dietitian referral is unnecessary. PTS: 1 REF: p. 1215 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 15. An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A. Administration of antihypertensive medications B. Administering sodium bicarbonate intravenously C. Reversing acidosis by administering insulin D. Fluid and electrolyte replacement

D Rationale: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA). PTS: 1 REF: p. 1517 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 46: Assessment and Management of Clients With Diabetes KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 35. A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? A. Urinary retention B. Bladder spasms C. Urge incontinence D. Bladder contract

D Rationale: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder. PTS: 1 REF: p. 1975 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 25. A client is scheduled to have excess pleural fluid aspirated with a needle to relieve dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? A. It allows for full expansion of the lungs within the thoracic cavity. B. It prevents the lungs from collapsing within the thoracic cavity. C. It limits lung expansion within the thoracic cavity. D. It lubricates the movement of the thorax and lungs.

D Rationale: The pleural fluid, located between two membranes known as the visceral pleura (which cover the lungs) and the parietal pleura (which line the thorax), serves to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleural fluid does not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity. PTS: 1 REF: p. 465 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 28. Which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? A. Risk for unstable blood glucose due to changes in digestion and absorption B. Unilateral neglect related to decreased physical mobility C. Risk for excess fluid volume related to dietary changes and changes in absorption D. Ineffective sexuality patterns related to changes in self-concept

D Rationale: The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the physiologic changes that result from colorectal surgery. PTS: 1 REF: p. 1320 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 41: Management of Clients with Intestinal and Rectal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? A. Grab bars B. Nonslip mats C. Baseboard heaters D. A smoke detector

D Rationale: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the client because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this client. PTS: 1 REF: p. 1985 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select 10. A client's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A. Plasminogen B. Thrombin C. Prothrombin D. Plasmin

D Rationale: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form. PTS: 1 REF: p. 891 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 16. A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

D Rationale: The symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 7. What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A. Dura mater B. Arachnoid C. Fascia D. Pia mater

D Rationale: The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers: the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid. This is not known as "fascia." PTS: 1 REF: p. 1970 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 31. The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A. Cognition is decreased. B. Daily arterial blood gases (ABGs) are necessary. C. Slight tracheal bleeding is anticipated. D. The cough reflex is depressed.

D Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required. PTS: 1 REF: p. 557 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Management of Clients with Chest and Lower Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A client has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this client's high risk for urinary retention and should implement what intervention in the client's plan of care? A. Relaxation techniques B. Sodium restriction C. Lower abdominal massage D. Double voiding

D Rationale: To enhance emptying of a flaccid bladder, the client may be taught to "double void." After each voiding, the client is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective. PTS: 1 REF: p. 1617 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The home health nurse is caring for a client who has a diagnosis of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A. "Are you eating less salt in your diet?" B. "How is your energy level these days?" C. "Do you ever get chest pain when you exercise?" D. "Do you ever see spots in front of your eyes?"

D Rationale: To identify complications or worsening hypertension, the client is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a direct sign of worsening symptoms. PTS: 1 REF: p. 879 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 10. A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D Rationale: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand. PTS: 1 REF: p. 2043 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 27. A client has experienced excessive losses of bicarbonate and has subsequently developed an acid-base imbalance. How will this lost bicarbonate be replaced? A. The kidneys will excrete increased quantities of acid. B. Bicarbonate will be released from the adrenal medulla. C. Alveoli in the lungs will synthesize new bicarbonate. D. Renal tubular cells will generate new bicarbonate.

D Rationale: To replace any lost bicarbonate, the renal tubular cells generate new bicarbonate through a variety of chemical reactions. This newly generated bicarbonate is then reabsorbed by the tubules and returned to the body. The lungs and adrenal glands do not synthesize bicarbonate. Excretion of acid compensates for a lack of bicarbonate, but it does not actively replace it. PTS: 1 REF: p. 1539 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 18. A client is brought into the emergency department (ED) by family members, who tell the nurse the client grabbed their chest and reported substernal chest pain. The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed. Which form of monitoring should the nurse anticipate? A. Left-sided heart catheterization B. Cardiac telemetry C. Transesophageal echocardiography D. Hardwire continuous electrocardiogram (ECG) monitoring

D Rationale: Two types of continuous ECG monitoring techniques are used in health care settings: hardwire cardiac monitoring, found in EDs, critical care units, and progressive care units; and telemetry, found in general nursing care units or outpatient cardiac rehabilitation programs. Cardiac catheterization and transesophageal echocardiography would not be used in emergent situations to monitor cardiac function. PTS: 1 REF: p. 674 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. An adult client has been hospitalized with pyelonephritis. The nurse's review of the client's intake and output records reveals that the client has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? A. Supplement the client's fluid intake with a high-calorie diet. B. Emphasize the need to limit intake to 2 L of fluid daily. C. Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. D. Encourage the client to continue this pattern of fluid intake.

D Rationale: Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. Consequently, there is no need to supplement this fluid intake with additional calories or sodium. PTS: 1 REF: p. 1611 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 6. The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse normally anticipate? A. Decrease in blood urea nitrogen (BUN) B. Less antidiuretic hormone (ADH) released C. Decreased urine osmolality D. Increased urine specific gravity

D Rationale: Urine specific gravity depends largely on hydration status. A decrease in fluid intake will lead to an increase in the urine specific gravity. With high fluid intake, specific gravity decreases. Blood urea nitrogen (BUN) levels are usually elevated with volume deficits related to dehydration. With decreased water intake as seen in a client with fluid volume deficit, blood osmolality increases, which stimulates antidiuretic hormone (ADH) release. ADH acts on the kidney, increasing water reabsorption and returning the blood osmolality to a normal level. Normally, urine osmolality increases (urine is concentrated) with fluid volume deficits. PTS: 1 REF: p. 1548 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribed D. Administration of diuretics as prescribed

D Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary. PTS: 1 REF: p. 1373 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 43: Assessment and Management of Clients With Hepatic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A. Absence of infarcts or emboli B. Reduced stroke volume and cardiac output C. Absence of pulmonary and peripheral edema D. Maintenance of adequate mean arterial pressure

D Rationale: Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts. PTS: 1 REF: p. 283 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the client to walk for 10 minutes 3 times a day. The client questions the relationship between walking and heart function. How should the nurse best reply? A. "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B. "Walking increases your heart rate and blood pressure. Therefore, your heart is under less stress." C. "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

D Rationale: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart's pumping ability, which increases heart rate and blood pressure and the heart's ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the client had an MI—there are no "new arteries." PTS: 1 REF: p. 819 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 17. A client has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A. The volume of air inhaled and exhaled with each breath B. The volume of air in the lungs after a maximal inspiration C. The maximal volume of air inhaled after normal expiration D. The maximal volume of air exhaled from the point of maximal inspiration

D Rationale: Vital capacity is measured by having the client take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 4. The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)? A. Production of inadequate quantities of RBCs B. Premature release of immature RBCs C. Injury to the RBCs in circulation D. Abnormalities in the structure and function of RBCs

D Rationale: Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs. PTS: 1 REF: p. 888 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Assessment of Hematologic Function and Treatment Modalities KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 25. The hospital nurse is caring for a client who reports that an angina attack is beginning. Which action is the nurse's most appropriate initial action? A. Have the client sit down and put the head between the knees. B. Have the client perform pursed-lip breathing. C. Have the client stand still and bend over at the waist. D. Place the client on bed rest in a semi-Fowler position.

D Rationale: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put the head between the legs because cerebral perfusion is not lacking PTS: 1 REF: p. 736 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 21. A client with newly diagnosed hypertension has come to the clinic for a follow-up visit. The client asks the nurse why the client has to come in so often. Which response by the nurse would be best? A. "To identify any of the early symptoms of a stroke" B. "To determine how your blood pressure changes throughout the day" C. "To see how often you should change your medication dose" D. "To make sure your health is stable"

D Rationale: When hypertension is initially detected, nursing assessment involves carefully monitoring the blood pressure at frequent intervals to ensure that the client's condition is stable. Once it is determined that the client's condition is stable, then visits may be scheduled at less frequent but routine intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most clients. The client must not change medication doses unilaterally. PTS: 1 REF: p. 875 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 32. A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment? A. Have the primary care provider prescribe a computed tomography (CT) scan. B. Apply a tourniquet for 3 to 5 minutes and then reassess. C. Elevate the extremity and attempt to palpate the pulses. D. Use Doppler ultrasound to identify the pulses.

D Rationale: When pulses cannot be reliably palpated, a hand-held continuous wave Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted, and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult. PTS: 1 REF: p. 824 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Assessment and Management of Clients with Vascular Disorders and Disorders of Peripheral Circulation KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice Chapter 47: Assessment of Kidney and Urinary Function 1. The care team is considering the use of dialysis in a client whose renal function is progressively declining. Renal replacement therapy is indicated in which situation? A. creatinine level drops below 1.2 mg/dl (110mmol/L) B. blood urea nitrogen (BUN) is above 15 mg/dl C. urinalysis (dipstick test) reveals 140 mg/dl of protein D. functioning nephrons are less than 20%

D Rationale: When the total number of functioning nephrons is less than 20%, renal replacement therapy needs to be considered. Dialysis is an example of renal replacement therapy. Prior to the loss of greater than 80% of the nephron's functioning ability, the client may have mild symptoms of compromised renal function, but symptom management is often obtained through dietary modifications and drug therapy. The listed creatinine level is within normal range for men and slightly elevated for women. The BUN levels are within normal ranges. Proteinuria up to 150 mg/dl, as an occasional finding, is considered normal. Persistent proteinuria can indicate several medical problems including glomerular disease. PTS: 1 REF: p. 1536 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 47: Assessment of Kidney and Urinary Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 28. A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.

D Hemorrhagic strokes take place in either the brain or subarachnoid space. The occurrence of vascular occlusion, the identification as thrombotic stroke or lacunar stroke are associated with ischemia strokes. PTS: 1 REF: p. 2048 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem? A. "Toxins have accumulated and inflamed your pancreas." B. "Bacteria likely migrated from your intestines and became lodged in your pancreas." C. "A virus that was likely already present in your body has begun to attack your pancreatic cells." D. "The enzymes that your pancreas produces have damaged the pancreas itself."

D Rationale: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis. PTS: 1 REF: p. 1430 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 44: Assessment and Management of Clients With Biliary Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 9. The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A. Coronary artery bypass graft (CABG) B. Percutaneous transluminal coronary angioplasty (PTCA) C. Atherectomy D. Cardiopulmonary bypass

D Rationale: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed. PTS: 1 REF: p. 749 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 26. A client with a hypertensive emergency is being treated in the intensive care unit. The nurse knows that which client is at risk for developing this type of emergency? A. A client who stops their antihypertensive medication abruptly B. A client with a diagnosis of primary hypertension C. A client with well-controlled hypertension D. A client with hypertension that was diagnosed 2 years ago

D Rationale: Clients who abruptly stop their antihypertensive medications are at risk for developing hypertensive emergencies. Clients with secondary, not primary, hypertension are also at risk. A client who is undiagnosed is at risk, not one who was diagnosed 2 years ago. A client who has good control of their hypertension is less likely to be at risk. PTS: 1 REF: p. 879 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 8. A nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client? A. Administration of IVIG B. Antibiotic administration C. Appropriate use of gloves and goggles D. Thorough and consistent hand hygiene

D Rationale: Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene. PTS: 1 REF: p. 1007 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 38. A client's total laryngectomy has created a need for alaryngeal speech, which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the client when teaching about this process? A. Training how to perform controlled belching B. Use of an electronically enhanced artificial pharynx C. Insertion of a specialized nasogastric tube D. Fitting for a voice prosthesis

D Rationale: In clients receiving tracheoesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used. PTS: 1 REF: p. 517 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 36. The nurse is providing a client with the supplies necessary to perform two hemoccult tests on the client's stool. What instruction should the nurse give this client? A. "If possible, fast for 12 hours before collecting a sample." B. "Take all your medications except the antihypertensive ones." C. "Don't eat highly acidic foods 72 hours before you start the test." D. "Mail the paper slides to the clinic once you've collected the samples."

D Rationale: In the past, clients were advised to avoid ingesting red meat, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish for 72 hours prior to the study because it was thought that these were associated with false-positive results; likewise, clients were advised to avoid ingesting vitamin C from supplements or foods as it was believed that this was associated with false-negative results. However, these restrictions are no longer advised as their actual effects on test results have not been established; plus, they unnecessarily restrict participation in screening. Fasting is unnecessary and samples are mailed in after they have been collected. PTS: 1 REF: p. 1217 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 38: Assessment of Digestive and Gastrointestinal Function KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 2. A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? A. Gastric cancer does not cause signs or symptoms until metastasis has occurred. B. Adherence to screening recommendations for gastric cancer is exceptionally low. C. Early symptoms of gastric cancer are usually attributed to constipation. D. The early symptoms of gastric cancer are usually not alarming or highly unusual.

D Rationale: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation. PTS: 1 REF: p. 1278 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 10. A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? A. "I'll need to keep several pillows between my legs at night." B. "I need to remember not to cross my legs. It's such a habit." C. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D. "I will need my husband to assist me in getting off the low toilet seat at home."

D Rationale: To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees. PTS: 1 REF: p. 1186 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 37: Management of Clients with Musculoskeletal Trauma KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 21. A client with hypertension is ambulating in the hospital hallway and reports chest pain. In which order would the nurse assess and treat this client? A. The first set of vital signs are done. B. The nurse assesses the client's angina. C. A 12-lead electrocardiogram (ECG) is performed. D. The client is instructed to stop all activity. E. The client receives the first dose of nitroglycerin. F. The client is transferred to a higher acuity unit.

D, B, A, C, E, F Rationale: The client is first directed to stop all activity and sit, rest, and/or is placed in a semi-Fowler position to reduce the oxygen workload on the heart. The nurse then assesses the client's chest pain/angina to determine whether it is the same as the client typically experiences. Vital signs are performed next and any respiratory distress is noted at this time. Typically oxygen is applied at this time, but because the sequence was not specifically spelled out, it was not included. VSS provides information on the damage to the heart that may or may not be occurring. A 12-lead ECG is performed, which continues to support or eliminate a cardiac event. Nitroglycerin is given sublingually up to 3 doses. It is a vasodilator that opens up blood vessels to improve blood flow and decrease chest pain. If the chest pain continues after interventions and/or a myocardial infarction is diagnosed, the client may be transferred to a higher acuity unit. PTS: 1 REF: p. 736 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 12. A nurse is performing a focused assessment on a client with bronchiectasis. Which are the most prevalent signs and symptoms of this condition? Select all that apply. A. Radiating chest pain B. Wheezes on auscultation C. Increased anterior-posterior (AP) diameter D. Copious, purulent sputum E. Chronic cough

D, E Rationale: Characteristic symptoms of bronchiectasis include clubbing of the fingers, chronic cough, and production of purulent sputum in copious amounts. Radiating chest pain, along with additional clinical indicators, are more indicative of a cardiovascular condition. Wheezes on auscultation are common in clients with asthma. An increased AP diameter is noted in clients with chronic obstructive pulmonary disease. PTS: 1 REF: p. 631 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. A gerontologic nurse is assessing a client who has numerous comorbid health problems. What assessment finding(s) should prompt the nurse to suspect a UTI? Select all that apply. A. Food cravings B. Upper abdominal pain C. Insatiable thirst D. Fever E. New onset of confusion

D, E Rationale: Early symptoms of UTI in older adults include burning, urgency, and fever. Some clients develop incontinence and delirium with the onset of a UTI. Food cravings, increased thirst, and upper abdominal pain necessitate further assessment and intervention, but none are directly suggestive of a UTI. PTS: 1 REF: p. 1606 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 49: Management of Clients With Urinary Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 40. An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. A. Shortness of breath B. Chest pain C. Anxiety D. Indigestion E. Nausea

D, E Rationale: Many women experiencing coronary events, including unstable angina, MIs, or sudden cardiac death events, are asymptomatic or present with atypical symptoms. These symptoms include indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among clients of all ages and genders. PTS: 1 REF: p. 727 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 21. A client with chronic obstructive pulmonary disease has recently begun a new bronchodilator. Which therapeutic effect(s) should the nurse expect from this medication? Select all that apply. A. Negative sputum culture B. Increased viscosity of lung secretions C. Increased respiratory rate D. Increased expiratory flow rate E. Relief of dyspnea

D, E Rationale: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process. PTS: 1 REF: p. 642 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post-HIV exposure prophylaxis checklist is started for this nurse. In which order would the checklist be implemented? A. Administer post-exposure prophylaxis (PEP) medication. B. Advise exposed health care providers to use precautions. C. Get counseling at the time of exposure. D. Undergo early reevaluation after exposure. E. Determine the HIV status of the client.

E, C, B, A, D Rationale : It is important to determine the client's HIV status through rapid testing (if possible) to help guide the appropriate use of PEP medications (as needed). The nurse should receive counseling at the time of exposure. Part of that counseling is to advise the nurse (health care provider) to use precautions (barrier conception, avoid blood donation, pregnancy and breast-feeding) to prevent secondary transmission. PEP medication (if needed) then is given. And the nurse (in this case) is recommended to undergo early reevaluation within 72 hours after exposure. PTS: 1 REF: p. 1012 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 32: Management of Clients With Immune Deficiency Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 16. A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit

A Rationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, and elevated hematocrit. PT does not typically decrease. PTS: 1 REF: p. 1851 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 40. The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment? A. Asthma B. Obstructive sleep apnea C. Community-acquired pneumonia D. Pulmonary edema

A Rationale: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors. PTS: 1 REF: p. 475 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. A client has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to which complication? A. Sinus infections B. Esophageal strictures C. Pharyngitis D. Laryngitis

A Rationale: Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of clients with these tubes is critical. Use of a nasogastric tube is not associated with the development of esophageal strictures, pharyngitis, or laryngitis. PTS: 1 REF: p. 501 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 14. The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax

A Rationale: Due to increased intracranial pressure, there is a risk for the client developing seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and pneumothorax do not occur as a complication of an aneurysm. PTS: 1 REF: p. 2050 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 14. A nurse is teaching an client about the risk factors for hypertension. Which factors should the nurse explain as risk factors for primary hypertension? A. Obesity and high intake of sodium and saturated fat B. Diabetes and use of oral contraceptives C. Metabolic syndrome and smoking D. Renal disease and coarctation of the aorta

A Rationale: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, smoking, renal disease, and coarctation of the aorta are causes of secondary hypertension. PTS: 1 REF: p. 867 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 27: Assessment and Management of Clients With Hypertension KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember

Multiple Choice 3. The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure is 122/76 mm Hg, what is the client's pulse pressure? A. 46 mm Hg B. 99 mm Hg C. 198 mm Hg D. 76 mm Hg

A 46 mm Hg Rationale: Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg. PTS: 1 REF: p. 665 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 4. A client has been admitted to the intensive care unit (ICU) after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP? A. Hypovolemia B. Myocardial infarction (MI) C. Left-sided heart failure D. Aortic valve regurgitation

A Hypovolemia Rationale: CVP is a measurement of the pressure in the vena cava or right atrium. A low CVP indicates a reduced right ventricular preload, most often from hypovolemia. An MI is an unlikely cause of low CVP. CVP measures the right side of the heart, so left-sided failure is unlikely to affect CVP. Aortic valve regurgitation is a less likely cause of low CVP. PTS: 1 REF: p. 685 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 28. A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply. A. Anaphylactic B. Hypovolemic C. Cardiogenic D. Septic E. Neurogenic

A, D, E Rationale: The varied mechanisms leading to the initial vasodilation in distributive shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of distributive shock. PTS: 1 REF: p. 290 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand

Multiple Choice 11. A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? A. Nervousness or paresthesia B. Throbbing headache or dizziness C. Drowsiness or blurred vision D. Tinnitus or diplopia

B Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy. PTS: 1 REF: p. 734 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 23: Management of Clients with Coronary Vascular Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 10. A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? A. Dermatitis B. Petechiae C. Urticaria D. Alopecia

B Rationale: When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss). PTS: 1 REF: p. 931 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Management of Clients With Nonmalignant Hematologic Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze

Multiple Choice 6. The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experienced a significant increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in which outcome? A. Development of an atrial-septal defect B. Myocardial ischemia C. Formation of a pulmonary embolism D. Release of potassium ions from cardiac cells

B Myocardial ischemia Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital. PTS: 1 REF: p. 661 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 2. During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI? A. Left midclavicular line of the chest at the level of the nipple B. Left midclavicular line of the chest at the fifth intercostal space C. Midline between the xiphoid process and the left nipple D. Two to three centimeters to the left of the sternum

B. Left midclavicular line ofthe cest at the fifth intercostal space Rationale: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space. PTS: 1 REF: p. 653 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 30. The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? A. Avoid watching television or using a computer for more than 1 hour at a time. B. Use over-the-counter antibiotic eye drops for at least 14 days. C. Avoid rubbing the eye on the affected side of the face. D. Rinse the eye on the affected side with normal saline daily for 1 week.

C Rationale: If the surgery results in sensory deficits to the affected side of the face, the client is instructed not to rub the eye because the pain of a resulting injury will not be detected. There is no need to limit TV viewing or to rinse the eye daily. Antibiotics may or may not be prescribed, and these would not reduce the risk of injury. PTS: 1 REF: p. 2109 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 20. The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state? A. Third spacing of fluid B. Dysrhythmias C. Tachycardia D. Gastric hypermotility

C Rationale: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms. PTS: 1 REF: p. 277 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 8. The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? A. Decreased muscle tone B. Flaccid paralysis C. Loss of voluntary control of movement D. Slow reflexes

C Rationale: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control. PTS: 1 REF: p. 1976 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 3. A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated. C. Weight is maintained or gained. D. High calcium diet is consumed.

C Rationale: Weight loss is common in the postoperative period, with early satiety, dysphagia, reflux and regurgitation, and elimination issues contributing to this problem. The client should weigh oneself daily, with a goal of maintaining or gaining weight. The client should not have bowel movements that maintain a loose consistency, because this would indicate diarrhea and would warrant intervention as it is a symptom of dumping syndrome. The client should be able to tolerate six small meals per day, rather than three large meals. The client does not require a diet excessively rich in calcium but should consume a diet high in calories, iron, vitamin A and vitamin C. PTS: 1 REF: p. 1277 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 34. The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition? A. Pleurisy B. Emphysema C. Asthma D. Pneumonia

C Rationale: Wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia. PTS: 1 REF: p. 485 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Assessment of Respiratory Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 31. The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication. B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.

C Rationale: When administering several medications through a feeding tube, each medication should be administered separately with 15 mL of water administered between each medication. Prior to administering medication, the tube feed should be paused (there is no need to wait one hour) and flushed with 15 mL of water. PTS: 1 REF: p. 1247 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 39: Management of Clients with Oral and Esophageal Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember

Multiple Choice 5. The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? A. Using a stethoscope for auscultating the fistula is contraindicated B. The client feels best immediately after the dialysis treatment C. Taking a BP reading on the affected arm can damage the fistula D. The client should not feel pain during initiation of dialysis

C Rationale: When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful. PTS: 1 REF: p. 1588 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Select Chapter 45: Assessment and Management of Patients with Endocrine Disorders 1. A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? A. Side-lying with one pillow under the head B. Head of the bed elevated 30 degrees and no pillows placed under the head C. Semi-Fowler with the head supported on two pillows D. Supine, with a small roll supporting the neck

C Rationale: When moving and turning the client, the nurse carefully supports the client's head and avoids tension on the sutures. The most comfortable position is the semi-Fowler position, with the head elevated and supported by pillows. PTS: 1 REF: p. 1469 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 45: Assessment and Management of Clients With Endocrine Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? A. Rigidity B. Flaccidity C. Clonus D. Ataxia

C Rationale: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities. PTS: 1 REF: p. 1964 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 60: Assessment of Neurologic Function KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply

Multiple Choice 28. A 17-year-old client is being treated in the intensive care unit after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. Which type of cardiomyopathy is particularly common among young people who appear otherwise healthy? A. Dilated cardiomyopathy (DCM) B. Arrhythmogenic right ventricular cardiomyopathy (ARVC) C. Hypertrophic cardiomyopathy (HCM) D. Restrictive or constrictive cardiomyopathy (RCM)

C Rationale: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy. PTS: 1 REF: p. 777 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Management of Clients with Structural, Infectious and Inflammatory Cardiac Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 10. A client with a partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention? A. Reinforce the xenograft dressing with another piece of Biobrane. B. Remove the xenograft dressing and apply a new dressing. C. Trim away the separated xenograft. D. Notify the health care provider for further emergency-related orders.

C Rationale: Xenografts adhere to granulation tissue. As the tissue heals the xenograft will become removed from the scar tissue. Applying more of the xenograft will not continue to heal the wound (as it is already healed). It is not an emergency and reinforcement is not necessary. PTS: 1 REF: p. 1883 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 57: Management of Clients with Burn Injury KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 5. A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? A. Gradually increase levels of physical exertion. B. Change filters on heaters and air conditioners frequently. C. Take prescribed medications as scheduled. D. Avoid goose-down pillows.

C Rationale: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks. PTS: 1 REF: p. 640 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Management of Clients with Chronic Pulmonary Disease KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Select 36. The nurse is caring for a client after kidney surgery. When assessing for bleeding, what assessment parameter should the nurse evaluate? A. Oral intake B. Pain intensity C. Level of consciousness D. Radiation of pain

C Rationale: Bleeding is a major complication of kidney surgery. The nurse's role is to observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Bleeding is not normally evidenced by changes in pain or oral intake. PTS: 1 REF: p. 1594 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 48: Management of Clients With Kidney Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 13. A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

C Rationale: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the client to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure. PTS: 1 REF: p. 1269 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand

Multiple Choice 11. The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the sinoatrial (SA) node and then proceeds in which sequence? A. Bundle of His to atrioventricular (AV) node to Purkinje fibers B. AV node to Purkinje fibers to bundle of His C. Bundle of His to Purkinje fibers to AV node D. AV node to bundle of His to Purkinje fibers

D Rationale: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers. PTS: 1 REF: p. 654 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand

Multiple Choice 14. The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching? A. Finish the bottle of nasal spray to clear the infection effectively. B. Nasal spray can only be shared between immediate family members. C. Nasal spray should be given in a prone position. D. Overuse of nasal spray may cause rebound congestion.

D Rationale: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle. PTS: 1 REF: p. 500 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 18: Management of Clients with Upper Respiratory Tract Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply

Multiple Choice 22. A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

D Rationale: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim. PTS: 1 REF: p. 2044 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 62: Management of Clients With Cerebrovascular Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply

Multiple Choice 26. A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and C C. Reflux of bile into the distal esophagus D. Influx of extracellular fluid into the small intestine

D Rationale: The rapid bolus of hypertonic food from the stomach to the small intestines draws extracellular fluid into the lumen of the intestines to dilute the high concentrations of electrolytes and sugars, which results in intestinal dilation, increased intestinal transit, hyperglycemia, and the rapid onset of GI and vasomotor symptoms, which characterizes dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux. PTS: 1 REF: p. 1279 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 40: Management of Clients With Gastric and Duodenal Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze

Multiple Choice 8. A client is admitted to a cardiac unit with the diagnosis of syncope. Orthostatic blood pressures are ordered every 8 hours. Which blood pressure readings would best indicate that the nurse should notify the health care provider of a positive finding? A. Supine 146/70 mm Hg, sitting 132/68 mm Hg, standing 130/66 mm Hg B. Supine 110/62 mm Hg, sitting 108/58 mm Hg, standing 106/56 mm Hg C. Supine 128/72 mm Hg, sitting 118/70 mm Hg, standing 110/66 mm Hg D. Supine 138/76 mm Hg, sitting 132/66 mm Hg, standing 122/52 mm Hg

D Supine 138/76 mmHg, Sitting 132/66 mmHg, Standing 122/52 mmHG Rationale: Postural (orthostatic) hypotension is a significant drop in blood pressure (20 mm Hg systolic or more or 10 mm Hg diastolic or more) within 3 minutes of moving from a lying or sitting to a standing position to indicate a positive result. PTS: 1 REF: p. 666 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Assessment of Cardiovascular Function KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply