test bank ch 14, 15, 20, 21, 29, 30, 57

1. A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

ANS: C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

14. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT)

ANS: A A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 602 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 45 degrees.

ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort. DIF: Cognitive Level: Apply (application) REF: 386 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

24. Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used. DIF: Cognitive Level: Apply (application) REF: 646 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

39. The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to episodic dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

ANS: A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness. DIF: Cognitive Level: Analyze (analysis) REF: 386 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

40. Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. Oral temperature is 100.8° F (38.1° C). b. The patient complains of ear "fullness." c. Small amount of dried drainage on dressing. d. The patient reports that hearing has gotten worse.

ANS: A An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery. DIF: Cognitive Level: Analyze (analysis) REF: 376 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. During the preoperative assessment of a patient scheduled for a right cataract extraction and intraocular lens implantation, it is important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for presence of a white pupil in the right eye. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics. DIF: Cognitive Level: Apply (application) REF: 375 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

25. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated. DIF: Cognitive Level: Apply (application) REF: 644 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

ANS: A Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. DIF: Cognitive Level: Apply (application) REF: 1361 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast c. Strawberry and banana fruit plate b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia. DIF: Cognitive Level: Apply (application) REF: 610 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender. PTS: 1 DIF: Cognitive Level: Analyze (analysis) REF: 594 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-Pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

ANS: A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-Pen. The other techniques are used in testing for other eye disorders. DIF: Cognitive Level: Apply (application) REF: 351 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.

ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 645 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from inside an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

ANS: A In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure. DIF: Cognitive Level: Understand (comprehension) REF: 1353 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

ANS: B Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations. DIF: Cognitive Level: Understand (comprehension) REF: 365 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct. DIF: Cognitive Level: Apply (application) REF: 609 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

31. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process. DIF: Cognitive Level: Apply (application) REF: 614 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

33. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/μL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/μL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. c. gastric analysis. b. bilirubin level. d. stool occult blood.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 615 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. Clear fluid is visible through the tympanic membrane. d. The patient frequently asks the nurse to repeat information.

ANS: A The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment. DIF: Cognitive Level: Analyze (analysis) REF: 384 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

47. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History, Physical Assessment, & Laboratory Results: • Fatigue, which has increased over last month • Frequent constipation • Conjunctiva pale pink, moist • Multiple bruises • Clear lung sounds • Hct 33% • WBC 1500/μL • Platelets 70,000/μL a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia

ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

13. A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

ANS: A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. DIF: Cognitive Level: Apply (application) REF: 1359 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. c. Check temperature every 4 hours. b. Encourage increased oral fluids. d. Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 600 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

33. When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution.

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient. DIF: Cognitive Level: Apply (application) REF: 261 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

26. After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

ANS: A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical. DIF: Cognitive Level: Analyze (analysis) REF: 1355 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

32. Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

18. A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. tPA. b. aspirin c. warfarin (Coumadin). d. nimodipine

ANS: B After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

ANS: B Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery. DIF: Cognitive Level: Apply (application) REF: 374 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

39. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 56-yr-old with frequent explosive diarrhea b. A 33-yr-old with a fever of 100.8° F (38.2° C) c. A 66-yr-old who has white pharyngeal lesions d. A 23-yr-old who is complaining of severe fatigue

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

36. Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

ANS: B Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN. DIF: Cognitive Level: Apply (application) REF: 370 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

35. The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery. DIF: Cognitive Level: Apply (application) REF: 375 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema. DIF: Cognitive Level: Apply (application) REF: 614 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion. b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

45. When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. applying sunscreen. c. decreasing dietary sodium. b. preventing fall injuries. d. chemotherapy side effects.

ANS: B Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy. DIF: Cognitive Level: Apply (application) REF: 387 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that clopidogrel will dissolve clots in the cerebral arteries. d. that clopidogrel will reduce cerebral artery plaque formation.

ANS: B Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

ANS: B Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact. DIF: Cognitive Level: Apply (application) REF: 368 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

ANS: B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown. DIF: Cognitive Level: Apply (application) REF: 1360 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

27. Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/μL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia. DIF: Cognitive Level: Analyze (analysis) REF: 623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

31. The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take? a. Apply cool compresses. b. Flush the eyes with saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

ANS: B In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes. DIF: Cognitive Level: Apply (application) REF: 371 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Keep the volume low on the hearing aids for the first week. b. Experiment with volume and hearing in a quiet environment. c. Add the second hearing aid after making adjustments to the first hearing aid. d. Begin wearing the hearing aids for an hour a day, gradually increasing the use.

ANS: B Initially the patient should use the hearing aids in a quiet environment such as the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used. DIF: Cognitive Level: Apply (application) REF: 391 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

34. Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises c. Skin abrasions b. Tarry stools d. Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss. DIF: Cognitive Level: Analyze (analysis) REF: 628 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. c. cobalamin (vitamin B12). b. folic acid. d. ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 608 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. discuss the need for insurance to cover post-HSCT care. b. ask whether there are questions or concerns about HSCT. c. emphasize the positive outcomes of a bone marrow transplant. d. explain that a cure is not possible with any treatment except HSCT.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision. DIF: Cognitive Level: Apply (application) REF: 635 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

12. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG. DIF: Cognitive Level: Apply (application) REF: 379 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized. DIF: Cognitive Level: Apply (application) REF: 618 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for a change in dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

ANS: B Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change. DIF: Cognitive Level: Apply (application) REF: 381 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Applying topical corticosteroids to decrease inflammation b. Discussing the need for sexually transmitted infection testing c. Educating about the use of antiviral eyedrops to treat the infection d. Assisting with applying for community visual rehabilitation services

ANS: B Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate. DIF: Cognitive Level: Apply (application) REF: 371 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

27. The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths. DIF: Cognitive Level: Analyze (analysis) REF: 1351 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

43. Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

ANS: B Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe. DIF: Cognitive Level: Understand (comprehension) REF: 384 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI. DIF: Cognitive Level: Apply (application) REF: 651 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. c. thrombin time. b. bleeding time. d. prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease. DIF: Cognitive Level: Understand (comprehension) REF: 626 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed. DIF: Cognitive Level: Apply (application) REF: 632 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 594 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

46. Which patient arriving at the urgent care center will the nurse assess first? a. Patient with purulent left eye discharge and conjunctival inflammation b. Patient with acute right eye pain that began while using home power tools c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

ANS: B The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

16. The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a. apply heat to the knee. b. immobilize the knee joint. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started. DIF: Cognitive Level: Apply (application) REF: 626 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

28. A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

ANS: B The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

38. Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

ANS: B The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered. DIF: Cognitive Level: Analyze (analysis) REF: 380 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

41. A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Ask the patient about what type of vision problems are being experienced. c. Explain that there are many ways to compensate for decreases in visual acuity. d. Suggest ways of improving the patient's safety, such as using brighter lighting.

ANS: B The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment. DIF: Cognitive Level: Analyze (analysis) REF: 369 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

26. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment. DIF: Cognitive Level: Apply (application) REF: 633 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage a. impaired physical mobility related to right-sided hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

ANS: B The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

38. Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently. DIF: Cognitive Level: Analyze (analysis) REF: 641 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

16. Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment: Complete Blood Count: • BP 110/68 • Hgb 10.6 g/dL • Pulse 98 bpm • Hct 30% • Brisk capillary refill • WBC 5100/μL • Multiple • Platelets 19,500/μL ecchymoses on arms Patient History: • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning a. Heart rate c. Abdominal pain b. Platelet count d. White blood cell count

ANS: B The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.

21. A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information. DIF: Cognitive Level: Apply (application) REF: 636 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

4. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.

ANS: B To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 599 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin c. Warfarin b. Heparin d. Erythropoietin

ANS: B aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 601 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

24. Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

ANS: B To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. DIF: Cognitive Level: Analyze (analysis) REF: 1350 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members. DIF: Cognitive Level: Apply (application) REF: 632 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

30. Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient's ability to administer eye drops. b. Check a patient's visual acuity using a Snellen chart. c. Inspect a patient's external ear for signs of irritation caused by a hearing aid. d. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

ANS: B Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 392 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

32. Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP place an emesis basin at the bedside. d. UAP helps the patient turn to the right side.

ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack. DIF: Cognitive Level: Apply (application) REF: 386 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

25. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Fresh strawberries d. Cream cheese bagel

ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein. DIF: Cognitive Level: Apply (application) REF: 261 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use. DIF: Cognitive Level: Apply (application) REF: 1348 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

21. Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I will hold the tip of the dropper above the ear to administer the drops." c. "I will refrigerate the medication until I am ready to administer the drops." d. "I should lie down before and for 5 minutes after administering the drops."

ANS: C Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate. DIF: Cognitive Level: Apply (application) REF: 383 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 649 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

25. The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 1359 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

17. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

ANS: C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.

ANS: C Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

7. A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Administer tissue plasminogen activator (tPA) intravenously per protocol.

ANS: C Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. DIF: Cognitive Level: Apply (application) REF: 1354 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

12. A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

ANS: C Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. DIF: Cognitive Level: Apply (application) REF: 1361 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. The nurse will instruct a patient who has undergone a left tympanoplasty to a. remain on bed rest. c. avoid blowing the nose. b. keep the head elevated. d. irrigate the left ear canal.

ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation. DIF: Cognitive Level: Apply (application) REF: 385 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

ANS: C During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. DIF: Cognitive Level: Apply (application) REF: 1362 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae c. Numbness of the extremities b. Shiny, smooth tongue d. Gum bleeding and tenderness

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 594 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The use of eye patches to reduce movement of the operative eye b. The need to wear dark glasses to protect the eyes from bright light c. The purpose of maintaining the head resting in a prescribed position d. The procedure for dressing changes when the eye dressing is saturated

ANS: C Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. Dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure. DIF: Cognitive Level: Apply (application) REF: 377 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding. PTS: 1 DIF: Cognitive Level: Understand (comprehension) REF: 589 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

20. Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 lb above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

ANS: C Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension. DIF: Cognitive Level: Analyze (analysis) REF: 1347 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

17. A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful. DIF: Cognitive Level: Apply (application) REF: 384 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

29. The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

ANS: C Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment. DIF: Cognitive Level: Analyze (analysis) REF: 369 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

27. The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

ANS: C Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia. DIF: Cognitive Level: Apply (application) REF: 374 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a. Platelet count c. Hemoglobin level b. Neutrophil count d. White blood cell count

ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 597 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Increase the speaking volume. b. Overenunciate while speaking. c. Speak normally but more slowly. d. Use more facial expressions when talking.

ANS: C Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend. DIF: Cognitive Level: Apply (application) REF: 390 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

ANS: C Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?"

ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 598 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

44. Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak with a low-pitched voice so that the patient is able to hear instructions.

ANS: C The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Ménière's disease, but are not necessary for BPPV. There is no hearing loss with BPPV. DIF: Cognitive Level: Apply (application) REF: 387 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% c. Calf swelling and pain b. Presence of plethora d. Platelet count 450,000/μL

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

40. Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11 g/dL.

ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater. DIF: Cognitive Level: Apply (application) REF: 611 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15. A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

ANS: C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition. DIF: Cognitive Level: Apply (application) REF: 1362 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

14. A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

ANS: C The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted. DIF: Cognitive Level: Apply (application) REF: 1360 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. c. avoid use of aspirin products. b. administer iron supplements. d. monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera. DIF: Cognitive Level: Apply (application) REF: 621 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

36. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Give the PRN diphenhydramine . b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching. DIF: Cognitive Level: Apply (application) REF: 650 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.

ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate at this time? a. Grieving related to current loss of functional vision b. Ineffective health management related to inability to see c. Anxiety related to the possibility of permanent vision loss d. Situational low self-esteem related to loss of visual function

ANS: C The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time. DIF: Cognitive Level: Apply (application) REF: 382 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. c. oral low-dose aspirin therapy. b. heparin intravenous infusion. d. tissue plasminogen activator (tPA).

ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. DIF: Cognitive Level: Apply (application) REF: 1353 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

37. A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Assess cranial nerve functions. b. Administer the prescribed analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma.

ANS: C The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take. DIF: Cognitive Level: Analyze (analysis) REF: 371 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

29. The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical and occupational therapy, which problem is the highest priority? • Well controlled type 2 diabetes for 10 years • Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease • Oriented to time, place, person • Speech clear •Minimal left leg weakness • Uses cane with walking • Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Risk for hypoglycemia b. Impaired transfer ability c. Risk for caregiver role strain d. Ineffective health maintenance

ANS: C The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported. DIF: Cognitive Level: Analyze (analysis) REF: 1362 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

12. The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities c. Elevated temperature b. Pallor and weakness d. Low oxygen saturation

ANS: C The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 600 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medication should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 380 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

42. A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery. DIF: Cognitive Level: Apply (application) REF: 373 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. c. visual deficits. b. confusion. d. poor judgment.

ANS: C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

41. Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color c. Liver function b. Hematocrit d. Serum iron level

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

3. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/μL d. White blood cell (WBC) count of 2800/μL

ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 592 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure? a. Check for any iodine allergy. c. Administer prescribed sedatives. b. Insert a large-bore IV catheter. d. Assist the patient to a flat position.

ANS: D During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan. PTS: 1 DIF: Cognitive Level: Apply (application) REF: 603 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants are not useful for patients with congenital deafness. b. Cochlear implants are most helpful as an early intervention for presbycusis. c. Cochlear implants improve hearing in patients with conductive hearing loss. d. Cochlear implants require extensive training in order to reach the full benefit.

ANS: D Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness. DIF: Cognitive Level: Understand (comprehension) REF: 390 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count c. Total lymphocyte count b. Reticulocyte count d. Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

44. A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia c. Oral ulcers b. Vomiting d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 642 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

26. Which information will the nurse include when teaching a patient with herpes simplex type 1 keratitis? a. Use of natamycin (Natacyn) antifungal eyedrops b. Application of corticosteroid ophthalmic ointment c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Completion of the prescribed series of oral acyclovir (Zovirax)

ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex type 1 is viral, not parasitic or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis. DIF: Cognitive Level: Apply (application) REF: 372 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

ANS: D Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment. DIF: Cognitive Level: Apply (application) REF: 1364 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT. DIF: Cognitive Level: Understand (comprehension) REF: 622 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

33. The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient requests a prescription refill for next week. b. The patient feels uncomfortable wearing an eye patch. c. The patient complains that the vision has not improved. d. The patient reports eye pain rated 5 (on a 0 to 10 scale).

ANS: D Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring. DIF: Cognitive Level: Analyze (analysis) REF: 376 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

ANS: D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. DIF: Cognitive Level: Analyze (analysis) REF: 1354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis MSC: NCLEX: Physiological Integrity

3. A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

ANS: D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke. DIF: Cognitive Level: Apply (application) REF: 1350 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

43. Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15. The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/μL d. White blood cell (WBC) count 15,500/μL

ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal. PTS: 1 DIF: Cognitive Level: Analyze (analysis) REF: 599 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? a. Perform tympanometry. b. Schedule otoscopic examinations. c. Administer influenza immunizations. d. Discuss exposure to amplified music.

ANS: D The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients. DIF: Cognitive Level: Apply (application) REF: 388 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. b. a hematocrit (Hct) value of 38%. an RBC count of 4,500,000/μL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal. DIF: Cognitive Level: Understand (comprehension) REF: 607 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin drip administration. d. tissue plasminogen activator (tPA) infusion.

ANS: D The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke. DIF: Cognitive Level: Apply (application) REF: 1355 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. c. color perception. b. pupil reaction. d. peripheral vision.

ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma. DIF: Cognitive Level: Apply (application) REF: 379 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

34. Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

ANS: D The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye. DIF: Cognitive Level: Analyze (analysis) REF: 377 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

30. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 650 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. A 72-yr-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will use drops to keep my pupils dilated until my appointment." b. "I will need to use brighter lights to read for at least the next week." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment. DIF: Cognitive Level: Apply (application) REF: 379 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

21. A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. DIF: Cognitive Level: Analyze (analysis) REF: 1349 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain hand-held magnifiers

ANS: D Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living. Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision. DIF: Cognitive Level: Apply (application) REF: 369 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread. DIF: Cognitive Level: Apply (application) REF: 241 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age b. Lifestyle c. Symptoms d. Sexual orientation

ANS: A The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range. DIF: Cognitive Level: Apply (application) REF: 226 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

1. The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "Since you don't have symptoms and you have had a negative test, you do not have HIV)." d. "We won't know for years if you will develop acquired immunodeficiency syndrome (AIDS)."

ANS: A HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection. It is not known based on this information whether the patient is infected with HIV or can infect others. DIF: Cognitive Level: Apply (application) REF: 221 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the body's immunologic response to tumor cells. b. IL-2 prevents bone marrow depression caused by chemotherapy. c. IL-2 protects normal cells from harmful effects of chemotherapy. d. IL-2 stimulates malignant cells in the resting phase to enter mitosis.

ANS: A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression. DIF: Cognitive Level: Understand (comprehension) REF: 258 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision b. 74-yr-old who has difficulty seeing well enough to drive at night c. 60-yr-old who has difficulty hearing clearly in a noisy environment d. 64-yr-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision. DIF: Cognitive Level: Analyze (analysis) REF: 357 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

9. A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? a. "I take metoprolol (Lopressor) for angina." b. "I take aspirin when I have a sinus headache." c. "I have had frequent episodes of conjunctivitis." d. "I have not had an eye examination for 10 years."

ANS: A It is important to note whether the patient takes any β-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma. DIF: Cognitive Level: Apply (application) REF: 353 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

37. The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C)

ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 258 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART. DIF: Cognitive Level: Apply (application) REF: 220 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test. DIF: Cognitive Level: Apply (application) REF: 358 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

5. The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Wash hands frequently and avoid touching the eyes. b. Apply antibiotic drops to the eye several times daily. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

ANS: A The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications. DIF: Cognitive Level: Apply (application) REF: 372 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

17. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. DIF: Cognitive Level: Apply (application) REF: 222 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

21. An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.

ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease. DIF: Cognitive Level: Apply (application) REF: 228 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? a. Encourage the patient to purchase a wig or hat to wear when hair loss begins. b. Suggest that the patient limit social contacts until regrowth of the hair occurs. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete.

ANS: A The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem. DIF: Cognitive Level: Apply (application) REF: 256 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

5. During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Obtain more information about the family history. b. Schedule a sigmoidoscopy to provide baseline data. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood.

ANS: A The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning. DIF: Cognitive Level: Analyze (analysis) REF: 241 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye, and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity. DIF: Cognitive Level: Understand (comprehension) REF: 358 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

10. The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet away from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements. DIF: Cognitive Level: Apply (application) REF: 356 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

1. The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

ANS: A,B,C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred. DIF: Cognitive Level: Apply (application) REF: 220 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

3. The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

ANS: A,B,E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza. DIF: Cognitive Level: Apply (application) REF: 216 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

1. The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: A,C,D,E The patient's age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy. DIF: Cognitive Level: Analyze (analysis) REF: 235 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

2. A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work.

ANS: A,C,E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics. DIF: Cognitive Level: Apply (application) REF: 253 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

21. The nurse should report which assessment finding immediately to the health care provider? a. Cone of light is visible. b. Tympanum is blue-tinged. c. Skin in the ear canal is dry and scaly. d. Cerumen is present in the auditory canal.

ANS: B A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care. DIF: Cognitive Level: Analyze (analysis) REF: 365 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 218 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

34. The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated. DIF: Cognitive Level: Apply (application) REF: 250 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

30. The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Crackles heard at the lung bases c. Complaints of nausea and anorexia d. Oral temperature of 100.6° F (38.1° C)

ANS: B Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin- 2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2. DIF: Cognitive Level: Analyze (analysis) REF: 257 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

23. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

ANS: B Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours. DIF: Cognitive Level: Apply (application) REF: 258 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines. DIF: Cognitive Level: Apply (application) REF: 359 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

28. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection. DIF: Cognitive Level: Apply (application) REF: 253 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

4. A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses. b. Discard used eye cosmetics. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

ANS: B Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing. DIF: Cognitive Level: Apply (application) REF: 370 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. DIF: Cognitive Level: Understand (comprehension) REF: 219 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

10. The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Explain to the patient that this is an expected finding. c. Request that an antibiotic be prescribed for the patient. d. Advise the patient that this indicates influenza infection.

ANS: B Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy DIF: Cognitive Level: Apply (application) REF: 225 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. The nurse is performing an eye examination on a 76-yr-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patient. DIF: Cognitive Level: Apply (application) REF: 357 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

ANS: B Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing. DIF: Cognitive Level: Apply (application) REF: 361 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad b. Baked chicken c. Creamed broccoli d. Toasted wheat bread

ANS: B Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided. DIF: Cognitive Level: Apply (application) REF: 254 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

38. A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain.

ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or the use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression. DIF: Cognitive Level: Analyze (analysis) REF: 264 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred. DIF: Cognitive Level: Analyze (analysis) REF: 246 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

ANS: B The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 358 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for a. strength of the eye muscles. c. cloudiness in the eye lenses. b. both near and distant vision. d. intraocular pressure changes.

ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective. DIF: Cognitive Level: Understand (comprehension) REF: 368 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective coping related to inability to admit the impact of the eye injury

ANS: B The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial. DIF: Cognitive Level: Apply (application) REF: 359 TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment

12. The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap.

ANS: B The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation. DIF: Cognitive Level: Apply (application) REF: 255 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

24. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Hospitalization is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required. DIF: Cognitive Level: Understand (comprehension) REF: 261 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15. A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing. DIF: Cognitive Level: Apply (application) REF: 366 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. Which information will the nurse provide to the patient scheduled for refractometry? a. "You should not take any of your eye medicines before the examination." b. "You will need to wear sunglasses for a few hours after the examination." c. "The doctor will shine a bright light into your eye during the examination." d. "The surface of your eye will be numb while the doctor does the examination."

ANS: B The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry. DIF: Cognitive Level: Apply (application) REF: 359 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. The nurse is observing a student who is preparing to perform an ear examination for a 30-yr- old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination. DIF: Cognitive Level: Apply (application) REF: 364 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

20. A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate? a. "Don't you have any friends that will raise the children for you?" b. "Would you like to talk about options for the care of your children?" c. "For now you need to concentrate on getting well and not worrying about your children." d. "Many patients with cancer live for a long time, so there is time to plan for your children."

ANS: B This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's friends will raise the children, more assessment information is needed before making plans. DIF: Cognitive Level: Apply (application) REF: 265 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

11. A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility. DIF: Cognitive Level: Apply (application) REF: 253 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

ANS: B,C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines. DIF: Cognitive Level: Apply (application) REF: 218 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

7. The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life. DIF: Cognitive Level: Apply (application) REF: 238 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs. DIF: Cognitive Level: Understand (comprehension) REF: 245 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem. DIF: Cognitive Level: Apply (application) REF: 230 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient how to reduce risky behaviors. b. Inform the patient about the available treatments. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to identify individuals who had intimate contact with the patient.

ANS: C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals. DIF: Cognitive Level: Analyze (analysis) REF: 222 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can use ice packs to relieve itching." b. "I will scrub the area with warm water." c. "I can buy aloe vera gel to use on my skin." d. "I will expose my skin to a sun lamp each day."

ANS: C Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury. DIF: Cognitive Level: Apply (application) REF: 255 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. schedule an appointment for eye surgery. c. use a gentle baby shampoo to clean the eyelids. d. apply cool compresses to the eyes three times daily.

ANS: C Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder. DIF: Cognitive Level: Apply (application) REF: 371 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient complains of feeling "constantly tired." b. The patient can't explain the effects of indinavir (Crixivan). c. The patient reports missing some doses of zidovudine (AZT). d. The patient reports having no side effects from the medications.

ANS: C Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT. DIF: Cognitive Level: Analyze (analysis) REF: 228 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

35. The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 263 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

4. Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

ANS: C Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma. DIF: Cognitive Level: Apply (application) REF: 357 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

21. A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred. DIF: Cognitive Level: Apply (application) REF: 264 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

29. The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

ANS: C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time. DIF: Cognitive Level: Apply (application) REF: 265 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

16. The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Oral saquinavir (Invirase) d. Aerosolized pentamidine (NebuPent)

ANS: C It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day. DIF: Cognitive Level: Analyze (analysis) REF: 228 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."

ANS: C More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. DIF: Cognitive Level: Apply (application) REF: 227 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

18. The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol taken to prevent angina b. Acetaminophen taken frequently for headaches c. Ibuprofen taken for 20 years to treat osteoarthritis d. Albuterol taken since early childhood to treat asthma

ANS: C Nonsteroidal antiinflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss. DIF: Cognitive Level: Apply (application) REF: 362 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

23. Which action should the nurse take when providing patient teaching to a 76-yr-old patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching. d. Wait until family members have left before initiating teaching.

ANS: C Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high- pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching. DIF: Cognitive Level: Apply (application) REF: 361 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

12. A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."

ANS: C Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs. DIF: Cognitive Level: Analyze (analysis) REF: 226 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

16. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears. DIF: Cognitive Level: Apply (application) REF: 361 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick injury with a suture needle during a surgery b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions

ANS: C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus. DIF: Cognitive Level: Analyze (analysis) REF: 219 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

10. External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation. DIF: Cognitive Level: Apply (application) REF: 251 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower. DIF: Cognitive Level: Analyze (analysis) REF: 218 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

41. After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/μL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain. DIF: Cognitive Level: Analyze (analysis) REF: 253 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

2. The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia

ANS: C The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy. DIF: Cognitive Level: Apply (application) REF: 252 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

6. When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes.

ANS: C The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye and then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements. DIF: Cognitive Level: Apply (application) REF: 358 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur. DIF: Cognitive Level: Understand (comprehension) REF: 240 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive b. Patient whose latest CD4+ count has dropped to 250/μL c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock. DIF: Cognitive Level: Analyze (analysis) REF: 229 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

26. A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem? a. Add protein powder to foods such as casseroles. b. Tell the patient to eat foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add spices to enhance the flavor of foods that are served.

ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding protein powder does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition. DIF: Cognitive Level: Apply (application) REF: 262 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "I will need follow-up examinations for many years after treatment before I can be considered cured." d. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."

ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up. DIF: Cognitive Level: Apply (application) REF: 243 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

39. The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit of 32% b. Pain with deep inspiration c. Serum sodium of 126 mEq/L d. Decreased breath sounds on left side

ANS: C The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and requires rapid treatment to prevent complications such as seizures and coma. The other findings also require intervention but are common in patients with lung cancer and not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 263 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach. DIF: Cognitive Level: Apply (application) REF: 251 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved toward the patient's eyes.

ANS: D Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation. DIF: Cognitive Level: Apply (application) REF: 351 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

20. The nurse in the eye clinic is examining a 67-yr-old patient who says, "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-yr-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient. DIF: Cognitive Level: Analyze (analysis) REF: 353 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

31. The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a. Frequent loose stools b. Nausea and vomiting c. Elevated white blood count (WBC) d. Increased carcinoembryonic antigen (CEA)

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. An elevated WBC may indicate infection but does not reflect the effectiveness of the colorectal cancer therapy. DIF: Cognitive Level: Apply (application) REF: 236 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply prescribed anesthetic gel to oral lesions before meals.

ANS: D Because the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient. DIF: Cognitive Level: Analyze (analysis) REF: 254 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/μL c. HIV-positive patient with a CD4+ count of 160/μL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

ANS: D CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count. DIF: Cognitive Level: Analyze (analysis) REF: 221 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/μL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient will develop symptomatic HIV infection within 1 year." b. "The patient meets the criteria for a diagnosis of acute HIV infection." c. "The patient will be diagnosed with asymptomatic chronic HIV infection." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

ANS: D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection. DIF: Cognitive Level: Understand (comprehension) REF: 221 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen

ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART. DIF: Cognitive Level: Analyze (analysis) REF: 223 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

40. An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient voids every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has crackles up to the midline posterior chest.

ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy. DIF: Cognitive Level: Analyze (analysis) REF: 266 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening. d. Discuss risks associated with cigarette smoking during each patient encounter.

ANS: D Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk. DIF: Cognitive Level: Apply (application) REF: 237 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

13. Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.

ANS: D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule. DIF: Cognitive Level: Apply (application) REF: 228 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

17. A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care? a. Compromised family coping related to disruption in lifestyle b. Impaired home maintenance related to perceived role changes c. Risk for caregiver role strain related to burdens of caregiving responsibilities d. Dysfunctional family processes related to effect of illness on family members

ANS: D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities. DIF: Cognitive Level: Apply (application) REF: 265 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

8. When obtaining a health history from a 49-yr-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging. DIF: Cognitive Level: Apply (application) REF: 357 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

32. The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/μL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/μL

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy. DIF: Cognitive Level: Apply (application) REF: 235 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection. DIF: Cognitive Level: Apply (application) REF: 222 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended. DIF: Cognitive Level: Apply (application) REF: 251 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment d. Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

ANS: D The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors. DIF: Cognitive Level: Apply (application) REF: 265 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

7. A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication.

ANS: D To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams. DIF: Cognitive Level: Analyze (analysis) REF: 224 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

36. Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that "chemo-brain" is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider. DIF: Cognitive Level: Apply (application) REF: 252 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. facing the patient directly when speaking. b. speaking slowly and distinctly to the patient. c. administering both the Rinne and Weber tests. d. encouraging the patient to ambulate independently.

ANS: D Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders. DIF: Cognitive Level: Apply (application) REF: 366 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. The safest technique for the nurse to use when assisting a blind patient in ambulating to the bathroom is to a. have the patient place a hand on the nurse's shoulder and guide the patient. b. lead the patient slowly to the bathroom, holding on to the patient by the arm. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient. DIF: Cognitive Level: Apply (application) REF: 369 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment