Week 2 NCLEX Questions

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client? 1. Glyburide via the oral route 2. Glucagon via the subcutaneous route 3. Insulin aspart via the subcutaneous route 4. Regular insulin via the intravenous (IV) route

4

A client complains of chronic pruritus. Which diagnosis would the nurse expect to note documented in the client's medical record that would support this client's complaint? 1. Anemia 2. Hypothyroidism 3. Diabetes mellitus 4. Chronic kidney disease

4

A client has a tumor that is interfering with the function of the hypothalamus. The nurse would monitor for signs and symptoms related to which imbalance? 1. Melatonin excess or deficit 2. Glucocorticoid excess or deficit 3. Mineralocorticoid excess or deficit 4. Antidiuretic hormone (ADH) excess or deficit

4

A client has begun medication therapy with propylthiouracil. The nurse would assess the client for which condition as an adverse effect of this medication? 1. Joint pain 2. Renal toxicity 3. Hyperglycemia 4. Hypothyroidism

4

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension

4

A client is scheduled for a cardiac catheterization using an iodine agent. Which assessment is most critical before the procedure? 1. Intake and output 2. Height and weight 3.Baseline peripheral pulse rates 4. Previous allergy to contrast agents

4

A client receiving a cleansing enema complains of pain and cramping. The nurse would take which corrective action? 1. Discontinue the enema. 2. Reassure the client, and continue the flow. 3. Raise the enema bag so that the solution can be completed quickly. 4. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

4

A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse would assess for which complication to determine whether the client has other signs of aspirin toxicity? 1. Diarrhea 2. Constipation 3. Double vision 4. Ringing in the ears

4

A client with type 2 diabetes mellitus is complaining of polydipsia, polyuria, weight loss, and weakness. Laboratory results indicate a blood glucose level of 800 mg/dL (45.7 mmol/L) and nonketosis. The nurse reviews the primary health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

4

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring? 1. A P wave preceding every QRS complex 2. QRS complexes that are short and narrow 3. Inverted P waves before the QRS complexes 4. Premature beats followed by a compensatory pause

4

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? 1. Fatigue 2. Constipation 3. Impaired safety 4. Altered body image

4

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse would put the bed in what position? 1. Flat with the knees raised 2. In high-Fowler's position, with the foot of the bed flat 3. In semi-Fowler's position, with the foot of the bed flat 4. In semi-Fowler's position, with the knees slightly flexed

4

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? 1. "I need to slide objects rather than lifting them." 2. "I would try not to remain in the same position for a long period of time." 3. "I need to use large joints instead of small joints when performing activities." 4. "Pain or fatigue is expected, and I would try to continue with the activity if this occurs."

4

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? 1. Serum chloride level of 98 mEq/L (98 mmol/L) 2. Serum sodium level of 145 mEq/L (145 mmol/L) 3. Serum calcium level of 10.5 mg/dL (2.75 mmol/L) 4. Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

4

The nurse is admitting a client diagnosed with pheochromocytoma. The client is complaining of a pounding headache and palpitations and the blood pressure is 170/90 mm Hg. The nurse is aware that which substance is responsible for these clinical manifestations? 1. Cortisol 2. Androgens 3. Aldosterone 4. Epinephrine

4

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse would assess which item based on priority? 1. Anxiety level of the client and family 2. Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on postdischarge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

4

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of Addisonian crisis. The nurse would assess the client for which manifestation that would be associated with this crisis? 1. Agitation 2. Diaphoresis 3. Restlessness 4. Severe abdominal pain

4

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse would make which interpretation? 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May have difficulty with language abilities only 4. Is likely to have perceptual and spatial disabilities

4

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all four quadrants

4

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? 1. 14+ edema noted in lower extremities 2. Crackles auscultated from lung bases to apices 3. Blood pressure rises from 116/68 to 118/74 mm Hg 4. Pulse rate increases from 100 beats/min to 136 beats/min

4

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How would the nurse assess for this disease? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses

4

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1. "I have epigastric pain radiating to my neck." 2. "I have severe abdominal pain that is relieved after vomiting." 3. "My temperature has been running between 96° F (35.5° C) and 97° F (36.1° C)." 4. "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

4

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet." 2. "I am fortunate that I can eat all of the salty foods I enjoy." 3. "I am fortunate that I do not need to follow any special diet." 4. "I need to eat foods that have a lot of potassium in them."

4

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How would the nurse interpret this finding? 1. Normal 2. Indicating severe inflammation 3. Indicating moderate inflammation 4. Indicating mild inflammation

4

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition? 1. Glycosuria 2. Diaphoresis 3. Weight loss 4. Hypertension

4

The nurse provides dietary instructions to a client with Ménière's disease. The nurse would tell the client that which food or fluid item is acceptable to consume? 1. Tea 2. Coffee 3. Cold-cut meats 4. Sugar-free Jell-O

4

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

4,5,6

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1. "I eat at least 3 large meals each day." 2. "I eat while lying in a semirecumbent position." 3. "I have eliminated taking liquids with my meals." 4. "I eat a high-protein, low- to moderate-carbohydrate diet."

1

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding would the nurse expect? 1. Asymptomatic 2. Shortness of breath 3. Visual disturbances 4. Frequent nosebleeds

1

The nurse is caring for a client with a low thrombin level as a result of cirrhosis. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1. Bleeding 2. Infection 3. Dehydration 4. Malnutrition

1

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1. "Does the pain in your stomach radiate to your back?" 2. "Does the pain in your lower abdomen radiate to your hip?" 3. "Does the pain in your lower abdomen radiate to your groin?" 4. "Does the pain in your stomach radiate to your lower middle abdomen?"

1

The nurse is providing postoperative care for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would be most concerned about monitoring for which potential complications? 1. Bleeding and infection 2. Thrombosis and infection 3. Bleeding and wound dehiscence 4. Wound dehiscence and evisceration

1

The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction? 1. Bends over to tie shoes 2. Sits in a recliner with feet elevated 3. Squats to pick up an item from the floor 4. Sleeps in a side-lying position with knees and hips bent

1

The nurse monitors the client for which condition as a complication of polycythemia vera? 1. Thrombosis 2. Hypotension 3. Cardiomyopathy 4. Pulmonary edema

1

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding? 1. Waves of loud gurgles auscultated in all four quadrants 2. Low-pitched swishing auscultated in one or two quadrants 3. Relatively high-pitched clicks or gurgles auscultated in all four quadrants 4. Very high-pitched, loud rushes auscultated especially in one or two quadrants

1 Although frequency and intensity of bowel sounds vary, depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply. 1. Irritability 2. Complaints of nausea 3. Sodium level of 128 mEq/L (128 mmol/L) 4. Potassium level of 3.2 mEq/L (3.2 mmol/L) 5. Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg

1,2,3,5

The nurse caring for a client newly admitted to the hospital who is at risk for diabetes mellitus suspects that the client has metabolic syndrome if which characteristics have been identified in this client? Select all that apply. 1. Hemoglobin A1C of 6.5% 2. Waist circumference of 30 inches 3. Triglycerides 160 mg/dL (1.81 mmol/L) 4. Consistent systolic blood pressures <130 mm Hg 5. Serial fasting glucose levels of 120 mg/dL (6.85 mmol/L), 132 mg/dL (7.54 mmol/L), and 128 mg/dL (7.31 mmol/L)

1,3,5

A 56-year-old client with heart failure is taking digoxin for treatment of the health problem. The nurse auscultates the client's apical heart rate before administering digoxin and notes that the heart rate is 52 beats/min. The nurse would make which interpretation of this information? 1. Normal, because of the client's age 2. Abnormal, requiring further assessment 3. Normal, as a result of the effects of digoxin 4. Normal, because this is the reason the client is receiving digoxin

2

A client has overactivity of the thyroid gland. The nurse would expect which finding? 1. Weight gain 2. Nutritional deficiencies 3. Low blood glucose levels 4. Increased body fat stores

2

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1. Eating helps to decrease the pain. 2. The pain usually increases after vomiting. 3. The pain is mostly around the umbilicus and comes and goes. 4. The pain increases when the client sits up and bends forward.

2

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse would assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration

2

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1. Fresh fruit 2. Brown gravy 3. Fresh vegetables 4. Poultry without skin

2

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding would the nurse expect to note in this client? 1. Dry skin 2. Bulging eyeballs 3. Periorbital edema 4. Coarse facial features

2

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1. Nerve damage 2. Hypertrophy of collagen fibers 3. Compromised circulation at the burn site 4. Increase in subcutaneous tissue at the burn site

2

client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse would expect an excess of which substance? 1. Calcium 2. Cortisol 3. Epinephrine 4. Norepinephrine

2

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion? 1. The cardiac output is above the normal range. 2. The cardiac output is below the normal range. 3. The cardiac output is in the low-normal range. 4. The cardiac output is in the high-normal range.

2; normal is 4-8

A client has been diagnosed with pheochromocytoma. Which clinical manifestation is most indicative of this condition? 1. Water loss 2. Bradycardia 3. Hypertension 4. Decreased cardiac output

3

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse would report the cardiac rhythm to be which rhythm? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block

3

The nurse is assessing an older client who sustained a fall and exhibits a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition would the nurse anticipate? 1. Fractured knee 2. Dislocated knee 3. Fracture of the femoral neck 4. Fracture of the midshaft of the femur

3

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2. A pulse rate of 60 beats/minute 3. Muffled or distant heart sounds 4. Wheezing on auscultation of the lungs

3

The nurse is preparing to care for a client with immunodeficiency. The nurse would plan to address which problem as the priority? 1. Anxiety 2. Fatigue 3. Risk for infection 4. Need for social isolation

3

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse would make which suggestion to the client? 1. Eat foods low in complex carbohydrates. 2. Increase fluid intake, particularly at mealtime. 3. Maintain a low-Fowler's position after eating. 4. Ambulate for at least 30 minutes following each meal.

3

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

3

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How would the nurse interpret this rhythm? 1. Bradycardia 2. Tachycardia 3. Atrial fibrillation 4. Normal sinus rhythm (NSR)

3

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101° F (38.3° C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement."

3

A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. 1. Hypernatremia 2. Signs of water deficit 3. High urine osmolality 4. Low serum osmolality 5. Hypotonicity of body fluids 6. Continued release of antidiuretic hormone (ADH)

3,4,5,6

A client had a colectomy 2 days earlier to remove a bowel tumor and had a new colostomy created. The client is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client would not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.

1

A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? 1. Iodine 2. Calcium 3. Phosphorus 4. Magnesium

1

A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1. Remove fluids from the meal tray. 2. Give the client 2 large meals per day. 3. Ask the client to sit up for 1 hour after eating. 4. Provide a diet high in simple carbohydrate foods.

1

A client is admitted with a serum glucose level of 650 mg/dL (37.14 mmol/L), and diabetic ketoacidosis (DKA) is suspected. Which additional laboratory result does the nurse identify as being supportive of DKA? 1. Ketones in urine 2. Lactic dehydrogenase (LDH) of 200 U/L 3. pH of 7.52 on arterial blood gas (ABG) analysis 4. Blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L)

1

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections

1

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1. Chest pain 2. Urge to cough 3. Warm, flushed feeling 4. Pressure at the insertion site

1

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse would suspect myocardial injury or infarction if which laboratory value comes back elevated? 1. Troponin 2. Myoglobin 3. C-reactive protein 4. Creatine kinase (CK)

1

A client is seen in the primary health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? 1. Median 2. Peroneal 3. Trigeminal 4. Spinal accessory

1

A client presents to the emergency department with upper gastrointestinal (GI) bleeding from a gastric ulcer and is in moderate distress. In planning care, which nursing action would be the priority for this client? 1. Assessment of vital signs 2. Complete abdominal examination 3. Thorough investigation of precipitating events 4. Insertion of a nasogastric tube and Hematest of emesis

1

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse interprets that the client is using which coping mechanism? 1. Distancing 2. Self-control 3. Problem solving 4. Accepting responsibility

1

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)

1

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1. Altered breathing pattern 2. Increased likelihood of injury 3. Ineffective oxygen consumption 4. Increased susceptibility to aspiration

1

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse would suspect dysfunction of which endocrine gland? 1. Thyroid 2. Pituitary 3. Parathyroid 4. Adrenal cortex

1

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call my doctor the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? 1. The client needs immediate education before discharge. 2. The client requires follow-up teaching regarding the administration of oral antidiabetics. 3. The client's statement is inaccurate, and the client needs to be scheduled for outpatient diabetic counseling. 4. The client's statement is inaccurate, and the client needs to be scheduled for educational home health visits.

1

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question? 1. "Are you rotating the injection site?" 2. "Are you aspirating before you inject the insulin?" 3. "Are you using a 1-inch needle to give the injection?" 4. "Are you placing an air bubble in the syringe before injection?"

1

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding would the nurse identify as an indicator that the client is experiencing complications of this therapy? 1. Tarry stools 2. Nausea and vomiting 3. Orange-colored urine 4. Decreased urine output

1

A client with rheumatoid arthritis who had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse would perform which action? 1. Administer an analgesic. 2. Immobilize the knee temporarily. 3. Notify the primary health care provider. 4. Put the client's knee through full passive range of motion.

1

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse correctly interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm

1

A nurse is assessing the status of a client who returned to the surgical nursing unit after a parathyroidectomy procedure. The nurse would place highest priority on which assessment finding? 1. Laryngeal stridor 2. Difficulty voiding 3. Mild incisional pain 4. Absence of bowel sounds

1

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for follow-up care

1

The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1. Restricting fluids 2. Maintaining bed rest 3. Eating a low-purine diet 4. Taking nonsteroidal anti-inflammatory drugs

1

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How would the nurse interpret these findings? 1. Incision is slightly edematous but shows no active signs of infection. 2. Incision shows early signs of infection, although the temperature is nearly normal. 3. Incision shows no sign of infection, although the white blood cell count is elevated. 4. Incision shows early signs of infection, supported by an elevated white blood cell count.

1

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? 1. "Baked foods such as chicken or fish are all right to eat." 2."Citrus fruits and raw vegetables need to be included in my daily diet." 3. "I can drink beer as long as I consume only a moderate amount each day." 4. "I can drink coffee or tea as long as I limit the amount to 2 cups daily."

1

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1. Dark red drainage 2. Dark brown drainage 3. Green-tinged drainage 4. Light yellowish-brown drainage

1

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How would the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema

1

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding? 1. Pink color to the skin flap 2. Hot feeling on palpation of the skin flap 3. Serous fluid leaking from the skin flap incision 4. Absent pulse at the proximal pulse point site closest to the skin flap

1

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? 1. Hypotension and fever 2. Mental status changes and hypertension 3. Subnormal temperature and hypotension 4. Complaints of weakness and hypertension

1

The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse would tell the client that the vesicles are consistent with which condition? 1. Acne 2. Freckles 3. Psoriasis 4. Sebaceous cysts

1

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse would next assess the client for which finding? 1. Hypotension 2. Flat neck veins 3. Complaints of nausea 4. Complaints of headache

1

The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what would the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

1

The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective? 1. "Stable angina is chronic." 2. "Variant angina is caused by emotional stress." 3. "Unstable angina is not a life-threatening condition." 4. "Intractable angina rarely limits the client's lifestyle."

1

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

1

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate

1

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1. Fever and tachycardia 2. Pallor and tachycardia 3. Agitation and bradycardia 4. Restlessness and bradycardia

1

The nurse is performing a cardiovascular assessment on a client with heart failure. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? 1. Breath sounds 2. Peripheral edema 3. Hepatojugular reflux 4. Jugular vein distention

1

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse would immediately ask the client which question? 1. "Where is the pain located?" 2. "Are you having any nausea?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?"

1

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1. Listening to lung sounds 2. Palpating for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema

1

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client? 1. Dry skin 2. Thin, silky hair 3. Bulging eyeballs 4. Fine muscle tremors

1

A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. 1. Infection 2. Recent injury 3. Inflammation 4. Degenerative disease 5. Delayed growth

1,2,3

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are the characteristics of this disorder? Select all that apply. 1. Nocturia 2. Incontinence 3. Enlarged prostate 4. Nocturnal emissions 5. Decreased desire for sexual intercourse

1,2,3

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1. Emotional stress 2. Atrial fibrillation 3. Nutritional anemia 4. Peptic ulcer disease 5. Recent upper respiratory infection

1,2,3,5

The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. 1. The client reports that they don't exercise much at all. 2. The client reports that they smoke a few cigarettes a day. 3. The client reports that they are taking phenytoin to treat a seizure disorder. 4. The client reports that they consume calcium and vitamin foods and supplements daily. 5. The client reports that they take a daily low dose of prednisone to treat a chronic respiratory condition.

1,2,3,5

A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. 1. Polyuria 2. Polydipsia 3. Concentrated urine 4. Complaints of excessive thirst 5. Specific gravity lower than 1.005

1,2,4,5

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

1,2,5

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

1,3

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort

1,3,5

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk

1,3,6

The nurse is caring for a client with a serum phosphorus level of 5.0 mg/dL (1.61 mmol/L). What other laboratory value might the nurse expect to note in the medical record? 1. Calcium level of 8 mg/dL (2.0 mmol/L) 2. Calcium level of 11.2 mg/dL (2.8 mmol/L) 3. Potassium level of 2.9 mEq/L (2.9 mmol/L) 4. Potassium level of 5.6 mEq/L (5.6 mmol/L)

1; When calcium levels are elevated (normal is 9 to 10.5 mg/dL [2.25 to 2.75 mmol/L]) and phosphorous levels are decreased (normal is 3.0 to 4.5 mg/dL [0.97 to 1.45 mmol/L]), this suggests hyperparathyroidism. If the phosphorus level is elevated, the nurse would expect the calcium level to be low. Therefore, option 1 is the correct answer.

A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse would next assess the results of which serum laboratory study? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

2

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn would be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial

2

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How would the nurse interpret this client statement? 1. A normal response that indicates the presence of phantom limb pain 2. A normal response that indicates the presence of phantom limb sensation 3. An abnormal response that indicates that the client is in denial about the limb loss 4. An abnormal response that indicates that the client needs more psychological support

2

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1. Pruritus 2.Tinnitus 3. Hearing loss 4. Burning in the ear

2

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage would the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

2

A client is treated in a primary health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? 1. Resting the foot 2. Applying a heating pad 3. Applying an elastic compression bandage 4. Elevating the ankle on a pillow while sitting or lying down

2

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Drawing the legs to the chest

2

A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse would anticipate that which substance will be elevated? 1. Glucose 2. Ketones 3. Glucagon 4. Lactate dehydrogenase

2

A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse would expect which electrolyte abnormality? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

2

A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

2

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1. Encourage foods that are high in protein. 2. Monitor for fluid and electrolyte imbalance. 3. Explain that high-fat diets usually are better tolerated. 4. Explain that most daily calories need to be consumed in the evening hours.

2

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition? 1. Atrial flutter 2. Atrial fibrillation 3.First-degree AV block 4. Third-degree atrioventricular (AV) block

2

A client's laboratory results indicate the serum calcium is 12 mg/dL (3 mmol/L) and the serum phosphorous is 2.1 mg/dL (0.697 mmol/L). Based on these findings, the nurse suspects imbalance of which hormone? 1. Thyroid hormone 2. Parathyroid hormone 3. Follicle-stimulating hormone 4. Adrenocorticotropic hormone

2

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1. Stroke 2. Pernicious anemia 3. Bacterial meningitis 4. Peripheral arterial disease

2

The family of a bedridden client with type 2 diabetes mellitus and chronic kidney disease calls the nurse to report symptoms of headache, polydipsia, and increased lethargy. Which most important question would the nurse ask the family to determine a possible problem? 1. "What is the client's urine output?" 2. "What is the client's capillary blood glucose level?" 3. "Has there been any change in the dietary intake?" 4. "Have you increased the amount of fluids provided?"

2

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition would the nurse document? 1. Occipital lobe impairment 2. Damage to the auditory association areas 3. Frontal lobe and optic nerve tracts damage 4. Difficulty with concept formation and abstraction areas

2

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment would the nurse formulate for the client? 1. Impaired nutritional intake 2. Increased risk for aspiration 3. Increased likelihood for injury 4. Susceptibility to fluid volume deficit

2

The nurse has applied a hypothermia blanket to a client with an infection who has a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Venous insufficiency 4. Arterial insufficiency

2

The nurse in a health care clinic is reviewing the record of a client with diabetes mellitus who was just seen by the primary health care provider (PHCP). The nurse notes that the PHCP has prescribed acarbose. Which preexisting disorder, if noted in the client's record, would indicate a contraindication to the use of this medication? 1. Hypothyroidism 2. Renal insufficiency 3. Arterial insufficiency 4. Coronary artery disease

2

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

2

The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? 1. Muscle metabolism and growth 2. Bone resorption and regeneration 3. Nervous system impulse transmission 4. Joint integrity and synovial fluid production

2

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states the ankle was twisted. Based on these findings, which condition does the nurse determine the client has most likely experienced? 1. Strain 2. Sprain 3. Fracture 4. Contusion

2

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for a diagnostic test 4. A client with diabetes mellitus scheduled for debridement of a foot ulcer

2

A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which items would be the most appropriate choice for this client to meet nutritional needs? 1. Crackers with cheese and tea 2. Graham crackers and warm milk 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar

2 (can't have chocolate, vanilla, tea, coffee, etc.)

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1. Ice 2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction

2,3,4,5

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. 1. Irritability 2. Periorbital edema 3. Coarse, brittle hair 4. Slow or slurred speech 5. Abdominal distention 6. Soft, silky, thinning hair

2,3,4,5

A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest feeding? Select all that apply. 1. 1% milk 2. Egg yolk 3. Dried beans 4. Hard cheeses 5. Green leafy vegetables

2,3,5

The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? Select all that apply. 1. Multiparity 2. Early menarche 3. Early menopause 4. Family history of breast cancer 5. High-dose radiation exposure to chest 6. Previous cancer of the breast, uterus, or ovaries

2,4,5,6

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation would the nurse observe for when performing the client's focused assessment? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Clubbed fingertips and headache

3

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? 1. Lack of control 2. Lack of physical mobility 3. Inability to entertain self 4. Inability to maintain health

3

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat

3

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? 1. Strain 2. Sprain 3. Fracture 4. Contusion

3

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse would assess the client for a history of chronic use of which medication? 1. Ibuprofen 2. Ranitidine 3. Acetaminophen 4. Acetylsalicylic acid

3

A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? 1. Fever, bradycardia 2. Fever, hypertension 3. Tachycardia, hypotension 4. Bradycardia, hypertension

3

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias

3

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How would the nurse report this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm

3

A client's total cholesterol level is 344 mg/dL (8.6 mmol/L), low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL (4.25 mmol/L), and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL (0.77 mmol/L). Based on analysis of the data, how would the nurse direct client teaching? 1. The client needs to maintain the current dietary regimen but increase activity level. 2. Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. 3. The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors need to be taught. 4. The client is at low risk for cardiovascular disease, so the client needs to be encouraged to continue to follow the current regimen.

3

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2. A vascular ulcer 3. An arterial ulcer 4. A venous stasis ulcer

3

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands the instructions? 1. "I will decrease my carbohydrate intake." 2. "High fat intake is essential with this disease." 3. "I will maintain a normal sodium intake in my diet." 4. "I will need to restrict the amount of protein in my diet."

3

A nurse is assessing a client who has had cranial surgery and is at risk for development of diabetes insipidus. The nurse would assess for which signs or symptoms that could indicate development of this complication? 1. Diarrhea 2. Infection 3. Polydipsia 4. Weight gain

3

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. Client's Chart History and PhysicalLaboratory and Diagnostic ResultsMedicationsGravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0Venereal Disease Research Laboratory (VDRL) nonreactivePrenatal vitaminsWeight 135 lb (61 kg)Rubella immunePositive Goodell and ChadwickRh positive, type O 1. "You need to avoid all school-age children during pregnancy." 2. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4. "Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."

3

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1. Air in the stomach 2. Too slow an infusion rate 3. Delayed gastric emptying 4. Early signs of peptic ulcer

3

The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse would instruct the client that it is acceptable to include which item in the diet? 1. Fish 2. Cereals 3. Vegetables 4. Meat and poultry

3

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1. Anxiety related to the need to make lifestyle changes 2. Boredom resulting from having already learned the material 3. An attempt to ignore or deny the need to make lifestyle changes 4. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2. Atrial fibrillation 3. Myocardial infarction 4. Ventricular tachycardia

3

The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain that is relieved by food intake 4. Pain that radiates down the right arm

3

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse? 1. Heart rate 2. Skin color 3. Status of airway 4. Peripheral pulse strength

3

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical spinal cord injury 4. Altered level of consciousness

3

The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 1. Pressure on the spinal cord 2. Pressure on the spinal nerve root 3. Muscle spasm in the area of the herniated disk 4. Excess cerebrospinal fluid production in the area

3

The nurse is caring for a client postoperatively after creation of a colostomy to treat a bowel tumor. What is an appropriate potential client problem? 1. Fear 2. Sexual dysfunction 3. Altered body image 4. Excessive nutritional intake

3

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1. Provide pin care. 2. Medicate the client. 3. Call the primary health care provider. 4. Remove 2 lb (0.9 kg) of weight from the traction system.

3

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? 1. The client reports some pain before meals. 2. The client frequently is awakened at 2 a.m. with heartburn. 3. The client has eliminated any irritating foods from the diet. 4. The client's pain is minimal with histamine H2-receptor antagonists.

3

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? 1. Bradycardia 2. Flaccid paralysis 3. Tingling around the mouth 4. Absence of Chvostek's sign

3

The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication? 1. Slow pulse; lethargy; warm, dry skin 2. Elevated pulse; lethargy; warm, dry skin 3. Elevated pulse; shakiness; cool, clammy skin 4. Slow pulse, confusion, increased urine output

3

The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? 1. Tinnitus 2. Fatigue 3. Bone pain 4. Difficulty with ambulating

3

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2. Broccoli 3. Antacids 4. Cantaloupe

3

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? 1. A platelet count of 200,000 mm3 (200 × 109/L) 2. A blood glucose level of 99 mg/dL (5.5 mmol/L) 3. A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) 4. A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

3

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1. "I need to start exercising more to improve my health." 2. "I will be sure to keep my appointment with the cardiologist." 3. "I don't have anyone to help me with doing heavy housework at home." 4. "I think I have a good understanding of what all my medications are for."

3

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse would interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1. The client is not experiencing dyspnea. 2. The client is not experiencing nausea or vomiting. 3. The pain has not been relieved by rest and nitroglycerin tablets. 4. The client says the pain began while trying to open a stuck dresser drawer.

3

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? 1. Chloride level of 98 mEq/L (98 mmol/L) 2. Sodium level of 135 mEq/L (135 mmol/L) 3. Potassium level of 6.8 mEq/L (6.8 mmol/L) 4. Magnesium level of 1.8-2.6 mEq/L (0.74 mmol/L)

3

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question would best help the nurse discriminate pain caused by a noncardiac problem? 1. "Can you describe the pain to me?" 2. "Have you ever had this pain before?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3--> would have determine if pulmonary problem

A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestations best support a diagnosis of DKA? 1. Blood glucose 500 mg/dL (27.8 mmol/L); arterial blood gases: pH 7.30, Paco2 50, Hco3- 26. 2. Blood glucose 400 mg/dL (22.2 mmol/L); arterial blood gases: pH 7.38, Paco2 40, Hco3- 22. 3. Blood glucose 450 mg/dL (25.0 mmol/L); arterial blood gases: pH 7.48, Paco2 39, Hco3- 29. 4. Blood glucose 350 mg/dL (19.4 mmol/L); arterial blood gases: pH 7.28, Paco2 30, Hco3- 14.

4

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1. Oxygen saturation decreased from 96% to 91%. 2. Pulse rate increased from 80 to 104 beats per minute. 3. Blood pressure decreased from 140/86 to 112/72 mm Hg. 4. Respiratory rate increased from 16 to 19 breaths per minute.

4

A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102° F (38.9° C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse would interpret that this fever is most associated with which condition? 1. Inadequate thermoregulation 2. Insufficient medication dosing 3. Toxic nervous system effects from the medication 4. Infection caused by leukopenic effects of the medication

4

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1. Heparin overdose 2. Vitamin K deficiency 3. Factor VIII deficiency 4. Disseminated intravascular coagulopathy (DIC)

4

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? 1. "I know I can massage my abdomen." 2. "I will continue using antispasmodic medication." 3. "One of the best things I can do is use relaxation techniques." 4. "The best position for me is to lie supine with my legs straight."

4

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1. Before each P wave 2. Just after each P wave 3. Just after each T wave 4. Before each QRS complex

4

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1. Carrots and ranch dip 2. Whole-grain cereal and milk 3. A cup of popcorn and a cola drink 4. Gelatin and a graham cracker

4

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and the abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1. Difficulty with sleeping 2. Risk for skin breakdown 3. Difficulty with breathing 4. Excessive body fluid volume

4

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result would the nurse review as the priority? 1. Sodium level 2. Digoxin level 3. Creatinine level 4. Potassium level

4

A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the primary health care provider's documentation and expects to note which diagnosis? 1. Hypoglycemia 2. Pheochromocytoma 3. Diabetic ketoacidosis (DKA) 4. Hyperosmolar hyperglycemic syndrome (HHS)

4

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure

4

After client education about the importance of sunscreen use and active vitamin production via the skin, the nurse determines that the client understands the teaching when which statement is made? 1. "Vitamin B is activated in the outer layer of the skin by the sun." 2. "Vitamin E deficiency occurs from lack of exposure to sunlight." 3. "Vitamin K can be depleted if exposed to excess ultraviolet light." 4. "Vitamin D is activated in the epidermis from ultraviolet light, such as sunlight."

4

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1. "I will drink 8 oz of water with each meal." 2. "I will eat three servings of cracked wheat bread each day." 3. "I will eat two saltine crackers before I get up each morning." 4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."

4

The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note in this disorder? 1. Serum pH of 9.02 2. Absent ketones in the urine 3. Serum bicarbonate of 22 mEq/L (22 mmol/L) 4. Blood glucose level of 500 mg/dL (28.5 mmol/L)

4

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1. "I need to eat foods high in potassium." 2. "I need to drink at least 2 to 3 L of fluid daily." 3. "I need to eat small, frequent meals and snacks if nauseated." 4. "I need to increase my intake of dietary items that are high in calcium."

4

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse would expect to note which finding on assessment of the client? 1. Unresponsive pupils 2. Negative Chvostek's sign 3. Hyperactive bowel sounds 4. Positive Trousseau's sign

4

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator

4

The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The cardiologist tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area? 1. Circumflex coronary artery 2. Right coronary artery (RCA) 3. Posterior descending coronary artery (PDA) 4. Left anterior descending coronary artery (LAD)

4

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1. Age 2. Hypertension 3. Hyperlipidemia 4. Glucose intolerance

4

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half hour or so later."

4

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which would the nurse expect to note on assessment of the client? 1. Skin atrophy 2. The presence of sunken eyes 3. Drooping on one side of the face 4. A rounded "moonlike" appearance to the face

4

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? 1. Recently retired from a job 2. Significant other has a gastric ulcer 3. Occasionally drinks 1 cup of coffee in the morning 4. Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis

4

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diet. Which statement, if made by the client, indicates a need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I'll snack on fruit instead of cake." 4. "I need to purchase special diabetic foods."

4

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1. "It's due to insufficient production of vitamin B12 in the colon." 2. "Increased production of intrinsic factor in the stomach leads to this type of anemia." 3. "Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

4

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? 1. Monitor oxygen saturation with pulse oximetry. 2. Assess activity tolerance before and after exercise. 3. Observe the client's cardiac rhythm with telemetry. 4. Assess peripheral pulses with an ultrasonic Doppler device.

4

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective?

happens at same time each day