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Complete 140 Q&A) Med-Surg II HESI Test Bank_ 2022/2023 Package Deal
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2022-23 Med-Surg HESI Practice Questions
What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. sexual activities may be resu... [Show More] med upon return home b. light housekeeping is permitted but avoid heavy lifting c. use a metal eye shield on operative eye during the day d. administer eye ointment before applying eye drops b. light housekeeping is permitted but avoid heavy lifting A male adult comes to the urgent care clinic 5 days after being diagnosed with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound a. obtain a sputum sample for culture An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake c. palpate the bladder above the symphysis pubis An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l d. potassium of 2.5 meq/l A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f a. explain specific reason for urgent notification An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalized he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. IV pentamine may offer protection to others aids related conditions such as kaposis sarcoma c. it will be necessary to continue prophylactic doses of IV or aerosol pentamine every month A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity a. collect a clean catch specimen A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client if the healthcare provider has given her any information about the classification of her cancer d. help the client make plans to begin immediate treatment since her cancer is likely to spread quickly c. ask the client if the healthcare provider has given her any information about the classification of her cancer A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5% albumin IV c. stop dialysis treatment A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr? 9 mL/hour The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion a. upper mid abdominal gnawing and burning pain The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. the xenograft is taken from nonhuman sources b. grafting increases the risk for bacterial infection c. as the burn heals the graft permanently attaches d. grafts are later removed by debriding procedure a. the xenograft is taken from nonhuman sources A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss a. jaundice sclera During a home visit the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited d. a grandson and his new dog recently visited When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate b. restrict sodium intake A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants d. auscultate bowel sounds in all four quadrants A client diagnosed with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 if pain is unrelieved and chew a tablet of aspirin 325mg d. call 911 if pain is unrelieved and chew a tablet of aspirin 325 mg After taking orlistat (Xenical) for one week a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider c. ask the client to describe her dietary intake history for the last several days Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures b. assess airway patency and oxygen saturation A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain a. low back pain and hypotension A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client's central venous catheter. When the client's respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload d. decrease infusion rate to address fluid overload When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch d. apply a new patch in a different location after removing the original patch A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36. What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute c. reduce the rate of the nitroglycerin infusion An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST d. LDH or LD, SGOT or ALT, SGPT or AST acetaminophen is processed by the liver [Show Less]
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Med-Surg II HESI Test Bank_ 2022/2023
What Information should the nurse include in the teaching plan of a client diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three... [Show More] full meals per day with no snacks C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid Participation in any aerobic exercise program C. Minimize symptoms by wearing loose, comfortable clothing After a hospitalization for SIADH, a client develops pontine myelinolysis. Which Intervention should the nurse implement first? A. Reorient client to room B. Place a patch on one eye C. Evaluate clients ability to swallow D. Perform range of motion exercises A. Reorient client to room A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his medication? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night? B. Has his weight changed over the last several days? An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high flow venturi mask D. Assist her to an upright position D. Assist her to an upright position A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucous and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self care? A. Increase the daily intake of oral fluids to liquify secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects or medications occur D. Teach anxiety reduction methods for feelings of suffocation A. Increase the daily intake of oral fluids to liquify secretions A cardiac catheterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and 95% proximal right coronary artery( RCA). The client later asks the nurse "What does all of that mean for me?" What information should the nurse provide? A. Blood supply to the heart is diminished by atherosclerotic lesions which necessitate life style changes. B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack. C. Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscle D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention C. Three main arteries have major blockages with only 1-5% of the blood flow getting through to the heart muscle A client who weighs 175 lbs is receiving an IV bolus dose of Heparin 80 units/kg. The Heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is permitted, round to the nearest tenth) 0.6ml The nurse is caring for a client with a lower left lobe pulmonary abscess. What position should the nurse instruct the client to maintain? A. Left lateral B. Supine, knees flexed. C. Dorsal recumbent D. Knee-chest A. Left Lateral A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseous and vomiting. Which finding should the nurse report to the healthcare provider? A. Belching B. Amber urine C. Yellow sclera D. Flatulence C. Yellow Sclera While caring for a client with Amyotrophic Lateral Sclerosis (ALS), a nurse performs a neurological assessment every 4 hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness D. Asymmetrical weakness The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? A. Grafting icreases the risk for bacterial infections B. The xenograft is taken from a non-human source. C. Grafts are later removed by a debriding procedure. D. As the burn heals, the graft permanently attaches. B. The xenograft is taken from a non-human source. A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and ulcerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room. B. Prepare the client to return to the OR C. Obtain a sample of the drainage to send to the lab. D. Auscultate the abdomen for bowel sound activity. A. Bring additional sterile dressing supplies to the room. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this clients plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output C. Fluid volume excess A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? A. Begin preparing the client for thyroidectomy procedure. B. Space the clients care to provide periods of rest. C. Assess the client for hyperactive bowel sounds. D. Provide warm blankets to prevent heat loss. C. Assess the client for hyperactive bowel sounds. The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods. C. Limit oral fluid intake of 500ml per day D. Increase intake of potassium rich foods such as bananas and cantaloupe. B. Restrict protein intake by limiting meats and other high-protein foods. An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply) A. Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP D. Document anxiety on the surgical checklist. E. Administer a PRN dose of regular insulin. A,B,C A. Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on skin of the abdomen. C. Quarter sized blood spot on the dressing D. Pitting ankle edema. A. Irregular apical pulse. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the clients oxygen saturation C. Report the finding to the HCP as soon as possible. D. Continue to monitor the fingers until color returns to normal. D. continue to monitor the fingers until color returns to normal. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level. B. Encourage incentive spirometry. C. Assess lower extremity circulation D. Administer PRN oral antipyretic. D. Administer PRN oral antipyretic The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomyunder general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure? A. Light yellow coloring of the clients skin and eyes. B. The clients blood pressure reading 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid. D. The IV insertion site is red, swollen, and leaking IV fluid. B. The clients blood pressure reading 184/88 mm Hg A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema. B. Hematocrit of 30% C. Cold and dry skin D. Further decline in LOC D. Further decline in LOC Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep it free of kinks. B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder. D. Drink 1,000 ml of fluids daily to irrigate catheter. C. Keep the drainage back lower than the level of the bladder. Which client has the highest risk for developing skin cancer? A. A 16 year old dark skinned female who tans in tanning beds once a week. B. A 65 year old fair skinned male who is a construction worker C. A 25 year old dark skinned male whose mother had skin cancer. D. A 70 year old fair skinned female who works as a a secretary. B. A 65 year old fair skinned male who is a construction worker. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds. A. Daily weight [Show Less]
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Complete 140 Q&A) Med-Surg II HESI Test Bank_ 2022/2023
Why and what should a pt with diverticulosis eat? High fiber foods(grains, beans, broccoli) and increased fluids Why? will help prevent constipation and... [Show More] to increase fluids which will promote hydration and maintain normal stool consistency and prevent straining What is the priority teaching for a patient recieving radiation? 1. avoid sunlight exposure of the portal site to reduce any further damage to the irradiated skin. 2. The radiation area should be washed daily while taking care not to wash off ink marking with mild soap and water A patient with PAD is having lower extremity and foot pain Checking the feet is essential to detect early signs of skin breakdown to prevent ulcer formation. >>>avoid cool temps, and rest with pain The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons 1. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. 2. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Which patient is has the highest risk fo renal calculi formation? pt who frequently eats cheese products is at a greater risk for formation of renal calculi What should a patient with DM do to reduce risk of diabetic retinopathy? The patient should do annual routine ophthalmic exams for early detection A patient is presenting with syptoms of menigitis with an unknown source of origin. What is most important for the RN to do? it is most important to initiate isolation precautions. What priority action should the nurse take for a patient who is experiencing hypotension during hemodialysis? the nurse should do is lower the client's head and elevate their feet What should be the outcome in the plan of care for a patient with cardiovascular diease who reports blurred vision? The client's daily blood pressure will be less than 140/80 this month is an outcome in the plan of care What position is best for a patient with COPD? upright and leaning forward if possible to promote adequete ventilation What is most important for the RN to tell the surgeon regarding an MVC patient? It is most important for the nurse to notify the surgeon of the MVC victims current medication history. A patient on steriod therapy has experienced rapid weight gain? What does this indicate? that indicates a significant fluid load that can compromise cardiac function and should be reported to the HCP A patient with osteomalacia is ask the RN what is the best foods to inculde in their diet and why? fortified milk and cereals because Osteomalacia is caused by a vitamin d deficiency. What should be recommended for a patient with ineffective airway clearence, a risk of bronchcitis and thickened sputum ? an increase in the client daily oral fluids should be recommended What should the nurse do for the patient with DM knowing they are prone to poor healing, infection, etc? Look at skin changes that are consistent with long term changes A patient is concerned about having a thoracentisis due to their orthopnea. What should the RN do? Educate the patient about the procedure, about the position for a thoracentesis as sitting up What education should the nurse provide to the patient with DM and their family? the family members regularly inspect the client's feet for lesions, skin breakdown, injury or infection A patient with bladder irrigation is experiencing a blood clot. What is the nurse's first priority? The nurse should first increase the flow of the bladder irrigation What are the priority discharge teachings for a patient who is a known smoker being sent home with O2? Maintaining safe and effective use of oxygen has highest priority for a client to be discharged with oxygen therapy, What are some clinical manifestations that a patient may have with gallbladder obstruction? distended, hard, and rigid abdomen. This should be immediately reported to the HCP [Show Less]
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Med-Surg II HESI Exam - set two
1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who ex- ercises regularly, reports havi... [Show More] ng pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. 2. A client with peripheral vascular disease has undergone a right femoralpopliteal bypass graft. The blood pressure has de- creased from 124/80 to 94/62. What should the nurse assess first? 1. IV fluid solution. 2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill. 3. An overweight client taking warfarin (Coumadin) has dry skin due to de- creased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to in- tact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 4. Instruct the client to limit activities of 4 2 1, 2, 3, 5 daily living (ADLs). 5. Use an electric razor to shave. 4. The nurse is caring for a client with pe- 3 ripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking Plavix if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming." 5. A client is receiving Cilostazol (Pletal) for 3 peripheral arterial disease causing intermittent claudication. The nurse de- termines this medication is effective when the client reports which of the following? 1. "I am having fewer aches and pains." 2. "I do not have headaches anymore." 3. "I am able to walk further without leg pain." 4. "My toes are turning grayish black in color." 6. The client admitted with peripheral vas- 1 cular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation. 7. The nurse is planning care for a client who is diagnosed with peripheral vascu- lar disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exer- cise related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity. 8. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure. 9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) 1 4 4 The presence of a strong dor- Which assessment provides the most ac- curate information about the client's postopera- tive status? 10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences. 11. The nurse is assessing the lower extrem- ities of the client with peripheral vascular disease (PVD). During the as- sessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. salis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; an- swer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse. CN: Reduction of risk potential; CL: Analyze 2 2 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin. 12. The nurse is unable to palpate the client's 3 left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stetho- scope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity. 13. Which of the following lipid abnormalities 3 is a risk factor for the development of atherosclerosis and peripheral vascu- lar disease? 1. Low concentration of triglycerides. 2. High levels of high-density lipid (HDL) cholesterol. 3. High levels of low-density lipid (LDL) cholesterol. 4. Low levels of LDL cholesterol. 14. When assessing an individual with pe- 4 ripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. Aching pain in the left calf. 2. Burning pain in the left calf. 3. Numbness and tingling in the left leg. 4. Coldness of the left foot and ankle. 15. A client with peripheral vascular disease 2, 4, 3, 1 returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Postoperative pain. 2. Peripheral pulses. 3. Urine output. 4. Incision site. 16. . A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent posi- tion. Which of the following goals is the prior- ity? 1 1. Decrease venous congestion. 2. Maintain normal respirations. 3. Maintain body temperature. 4. Prevent injury to lower extremities. 17. . The nurse is assessing an older Cau- casian male who has a history of periph- eral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 3 1. Atrophy. 2. Contraction. 3. Gangrene. 4. Rubor. [Show Less]
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Med-Surg II HESI Exam - set one
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' Disease. The nurse should assess this client for: 1. anorexia... [Show More] 2. tachycardia 3. weight gain 4. cold skin 2. tachycardia Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism. CN: Physiological adaptation; CL: Analyze When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle? 1. dysmenorrhea 2. metrorrhagia 3. oligomenorrhea 4. menorrhagia 3. oligomenorrhea A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a symptom of hypothyroidism. CN: Physiological adaptation; CL: Analyze A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? (Select all that apply.) 1. rapid pulse 2. decreased energy and fatigue 3. weight gain of 10 lbs (4.5 kg) 4. fine, thin hair with hair loss 5. constipation 6. menorrhagia. 2. decreased energy and fatigue, 3. weight gain of 10 lbs (4.5 kg), 5. constipation, 6. menorrhagia Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? 1. sore throat 2. painful, excessive menstruation 3. constipation 4. increased urine output 1. sore throat The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. CN: Pharmacological and parenteral therapies; CL: Synthesize A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? 1. "Your behavior is caused by temporary confusion brought on by your illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." 3. "Your behavior is caused by your worrying about the seriousness of your illness." 4. "Your behavior is caused by the stress of trying to manage a career and cope with illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. CN: Psychosocial integrity; CL: Synthesize The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which of the following statements from the client indicates the desired outcome of the drug? 1. "I have excess energy throughout the day." 2. "I am able to sleep and rest at night." 3. "I have lost weight since taking this medication." 4. "I do perspire throughout the entire day." 2. "I am able to sleep and rest at night." PTU is a prototype of thioamide antithyroid drugs. It inhibits production of thyroid hormones and peripheral conversion of T4 to the more active T3. A client taking this antithyroid drug should be able to sleep and rest well at night since the level of thyroid hormones is reduced in the blood. Excess energy throughout the day, loss of weight and perspiring through the day are symptoms of hyperthyroidism indicating the drug has not produced its outcome. CN: Pharmacological and parenteral therapies; CL: Evaluate. The nurse should teach the client with Graves' disease to prevent corneal irritation from mild exophthalmos by: 1. Massaging the eyes at regular intervals. 2. Instilling an ophthalmic anesthetic as prescribed. 3. Wearing dark-colored glasses. 4. Covering both eyes with moistened gauze pads. 3. Wearing dark-colored glasses. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased. CN: Reduction of risk potential; CL: Synthesize A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? 1. "The RAI stabilizes the thyroid hormone levels before a thyroidectomy." 2. "The RAI reduces uptake of thyroxine and thereby improves your condition." 3. "The RAI lowers the levels of thyroid hormones by slowing your body's production of them." 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced." 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced." Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI. CN: Pharmacological and parenteral therapies; CL: Synthesize After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to: 1. Monitor for signs and symptoms of hyperthyroidism. 2. Rest for 1 week to prevent complications of the medication. 3. Take thyroxine replacement for the remainder of the client's life. 4. Assess for hypertension and tachycardia resulting from altered thyroid activity. 3. Take thyroxine replacement for the remainder of the client's life. The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. CN: Pharmacological and parenteral therapies; CL: Synthesize A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The expected outcome of using this drug is that it helps: 1. Slow progression of exophthalmos. 2. Reduce the vascularity of the thyroid gland. 3. Decrease the body's ability to store thyroxine. 4. Increase the body's ability to excrete thyroxine. 2. Reduce the vascularity of the thyroid gland. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine. CN: Pharmacological and parenteral therapies; CL: Apply The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should: 1. Pour the solution over ice chips. 2. Mix the solution with an antacid. 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. 4. Disguise the solution in a pureed fruit or vegetable. 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth. CN: Pharmacological and parenteral therapies; CL: Apply Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of which of the following? 1. Internal hemorrhage. 2. Decreasing level of consciousness. 3. Laryngeal nerve damage. 4. Upper airway obstruction. 3. Laryngeal nerve damage. Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern. CN: Reduction of risk potential; CL: Analyze A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: 1. Begin total parenteral nutrition. 2. Start a cutdown infusion. 3. Administer tube feedings. 4. Perform a tracheotomy. 4. Perform a tracheotomy One day following a subtotal thyroidectomy, a client begins to have tingling in the fingers and toes. The nurse should first: 1. Encourage the client to flex and extend the fingers and toes. 2. Notify the physician. 3. Assess the client for thrombophlebitis. 4. Ask the client to speak. 2. Notify the physician Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? 1. Sodium phosphate. 2. Calcium gluconate. 3. Echothiophate iodide. 4. Sodium bicarbonate. 2. Calcium gluconate A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? 1. Tachycardia. 2. Weight gain. 3. Diarrhea. 4. Nausea. Weight gain The nurse should assess a client with hypothyroidism for which of the following? 1. Corneal abrasion due to inability to close the eyelids. 2. Weight loss due to hypermetabolism. 3. Fluid loss due to diarrhea. 4. Decreased activity due to fatigue. 4. Decreased activity due to fatigue When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: 1. The effects of thyroid hormone replacement therapy and will diminish over time. 2. Related to thyroid hormone replacement therapy and will not diminish over time. 3. A normal part of having a chronic illness. 4. Most likely related to low thyroid hormone levels and will improve with treatment. 4. Most likely related to low thyroid hormone levels and will improve with treatment. The nurse is instructing the client with hypothyroidism who takes levothyroxine (Synthroid) 100 mcg, digoxin (Lanoxin) and simvastatin (Zocor). Teaching regarding medications is effective if the client will take: 1. The Synthroid with breakfast and the other medications after breakfast. 2. The Synthroid before breakfast and the other medications 4 hours later. 3. All medications together 1 hour after eating breakfast. 4. All medications before going to bed. 2. The Synthroid before breakfast and the other medications 4 hours later. The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following? 1. "How much does your family need to be involved in learning about your condition?" 2. "What is required for your family to manage your symptoms?" 3. "What activities are most important for you to be able to maintain control of your diabetes?" 4. "What do you know about your medications and condition?" 3. "What activities are most important for you to be able to maintain control of your diabetes?" The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the client should eat which of the following? 1. Bland foods. 2. High-protein foods. 3. Any foods that are tolerated. 4. A glass of milk with each meal. 3. Any foods that are tolerated. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from a briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: 1. Involvement with the job will keep the client from becoming bored. 2. A relaxed environment will promote ulcer healing. 3. Not keeping up with the job will increase the client's stress level. 4. Setting limits on the client's behavior is an important nursing responsibility. 2. A relaxed environment will promote ulcer healing. A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? 1. Conduct physical activity in the morning in order to be able to rest in the afternoon. 2. Have the family agree to perform the necessary yard work at home. 3. Give up jogging and substitute a less demanding hobby. 4. Incorporate periods of physical and mental rest in the daily schedule. 4. Incorporate periods of physical and mental rest in the daily schedule. A client is to take one daily dose of ranitidine (Zantac) at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug at which of the following times? 1. Before meals. 2. With meals. 3. At bedtime. 4. When pain occurs. 3. At bedtime. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? 1. The client has not been including enough fiber in the diet. 2. The client needs to increase the daily exercise. 3. The client is experiencing an adverse effect of the aluminum hydroxide. 4. The client has developed a gastrointestinal obstruction. 3. The client is experiencing an adverse effect of the aluminum hydroxide. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? 1. "I should take my antacid before I take my other medications." 2. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." 3. "My antacid will be most effective if I take it whenever I experience stomach pains." 4. "It is best for me to take my antacid 1 to 3 hours after meals." 4. "It is best for me to take my antacid 1 to 3 hours after meals." Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate engaging in contact sports. 2. Explain the rationale for eliminating alcohol from the diet. Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate engaging in contact sports. 2. Explain the rationale for eliminating alcohol from the diet. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? 1. The client has a sore throat. 2. The client displays signs of sedation. 3. The client experiences a sudden increase in temperature. 4. The client demonstrates a lack of appetite. 3. The client experiences a sudden increase in temperature. [Show Less]
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MED SURG II HESI (Elsevier) Med-Surg II HESI Test Bank_ 2022/2023
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the... [Show More] client begins screaming, "I can't breathe!" The nursing priority action is: 1. Discontinue the IV site and contact the primary health care provider 2. Elevate the head of the bed and obtain vital signs 3. Contact the primary health care provider to obtain a prescription for a sedative 4. Assess for allergies and change the IV to an intermittent infusion device Elevate the head of the bed and obtain vital signs A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state: 1. "My ankles are swollen." 2. "I am tired at the end of the day." 3. "When I eat a large meal, I feel bloated." 4. "I have trouble breathing when I walk rapidly 4. "I have trouble breathing when I walk rapidly A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response? 1. Focus on the client's feelings by exploring the reason why the question was asked. 2. Explain that it is all right to be frightened and refer the client to the psychiatric nurse. 3. Provide information that the client is correct in being especially careful in these areas. 4. Suggest that the client discuss follow-up care with the health care provider and the dietitian. 1. Focus on the client's feelings by exploring the reason why the question was asked. The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this occurs? 1. Slowed pulse rate 2. Pleural friction rub 3. Neck vein distention 4. Increasing hypotension 3. Neck vein distention A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1. Inadequate arterial blood supply." 2. Delayed healing of tissues after an injury." 3. Increased production of melanin in the area." 4. Leakage of red blood cells through the vascular wall." 4. Leakage of red blood cells through the vascular wall." A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to: 1. Maintain elevation of both legs 2. Massage the legs when painful 3. Apply a hot water bottle to the legs 4. Check pulses in the legs regularly 4. Check pulses in the legs regularly A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis? 1. Perform leg exercises 2. Sit with the knees flexed 3. Apply warm soaks to the legs daily 4. Put on elastic stockings before arising 4. Put on elastic stockings before arising During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1. Interrupt the therapy. 2. Encourage deep breathing. 3. Place the client in the low-Fowler position. 4. Have the client complete the therapy before resting. 1. Interrupt the therapy. The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on the list? (Select all that apply.) 1. Spinach 2. Oranges 3. Broccoli 4. Chicken breast 5 Sweet potatoes 1. Spinach 3. Broccoli The nurse is planning nutritional education for a client with lower extremity arterial disease (LEAD). What diet modifications should the nurse include? 1. Decreasing both fluid and sodium intake 2. Increasing both calcium and potassium intake 3. Increasing both vitamin E and refined grain intake 4. Decreasing both cholesterol and saturated fat intake 4. Decreasing both cholesterol and saturated fat intake A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? 1. Continue to monitor the client. 2. Notify the health care provider. 3. Ensure that a defibrillator is close by. 4. Administer lidocaine intravenously as per protocol. 1. Continue to monitor the client. After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? 1. Elevate the legs and tell the client to drink more fluids. 2. Instruct the client to remain in bed and notify the health care provider. 3. Rub the client's legs to stimulate circulation and cover the client with a blanket. 4. Tell the client about the dangers of prolonged bed rest and encourage ambulation. 2. Instruct the client to remain in bed and notify the health care provider. Add or Remove Terms [Show Less]
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Med-Surg II HESI Test Bank_ Complete Updated fall 2022-2023.
1. A. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse inclu... [Show More] de in the teaching? A. Take temperature once a day. B. Wash the armpits and genitals with a gentle cleanser daily. C. Change the litter boxes while wearing gloves. D. Wash dishes in warm water. 2. A. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secre- tions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? A. Provide humidified oxygen. B. Perform chest physiotherapy prior to suctioning. C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. D. Hyperventilate the client with 100% oxygen before suctioning the airway.. 3. B. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the fol- lowing nursing actions should the nurse take to promote the client's comfort? A. Rub the client's feet briskly for several minutes. B. Obtain a pair of slipper socks for the client. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet. 4. C. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? A. Emesis of 100 mL B. Oral temperature of 37.5° C (99.5° F) C. Thick, red-colored urine D. Pain level of 4 on a 0 to 10 rating scale 5. A. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hy- pothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? A. Shivering B. Infection C. Burns D. Hypervolemia 6. D. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will carry a complex carbohydrate snack with me when I exercise." B. "I should exercise first thing in the morning before eating breakfast." C. "I should avoid injecting insulin into my thigh if I am going to go running." D. "I will not exercise if my urine is positive for ketones." 7. A. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? A. Cover the client's wound with a moist, sterile dressing. B. Have the client lie supine with knees flexed. C. Check the client's vital signs. D. Inform the client about the need to return to surgery. 8. B. A nurse is collecting data from a client who has alco- hol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? A. Cool, clammy skin. B. Hyperventilation C. Increased blood pressure D. Bradycardia 9. A. A nurse is reinforcing discharge teaching with a client fol- lowing a cataract extraction. Which of the following should the nurse include in the teaching? A. Avoid bending at the waist. B. Remove the eye shield at bedtime. C. Limit the use of laxatives if constipated. D. Seeing flashes of light is an expected finding following extraction. 10. C A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following ac- tions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic. 11. D. A nurse is caring for a client who is 3 days postoper- ative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent 12. A. A nurse is reinforcing discharge teaching to a client follow- ing arthroscopic surgery. To prevent postoperative compli- cations which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed. 13. A, B, C, D A nurse is collecting data from a client who has emphy- sema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia 14. D. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. 15. C. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. 16. D. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding 17. A. A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache 18. A. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale 19. A. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch. 20. B. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. 21. C. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever 22. A. A nurse is collecting data from a client who has open-an- gle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes 23. C. A nurse is collecting data from a client who has acute gas- troenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 24. D. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower." 25. B. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experienc- ing pain. 2) Ensure the client's weights are hanging freely from the bed. 3) Check the client's bony prominences every 12 hr. 4) Cleanse the client's pin sites with povidone-iodine. 26. A. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following in- structions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medica- tion. 27. C. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. 4) Keep draining lesions uncovered to air dry. 28. D. A nurse is reinforcing teaching with a client who is post- operative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric form. 29. D. A nurse is caring for a client with severe burns to both low- er extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." 3) "A piece of skin will be removed and grafted over the burned area." 4) "Large incisions will be made in the burned tissue to improve circulation." 30. A A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception 2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain 31. C. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler's position. 4) Moisten the client's lips with lemon-glycerin swabs. 32. A, B, C A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face 4) Tremors 5) Obese extremities 33. C. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily. 34. C. A nurse is reinforcing teaching about an esophagogastro- duodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." 35. C. A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures 36. C. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystec- tomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." 37. B. A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an ex- pected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. 38. A, B A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following ac- tions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client's head of bed. 5) Apply a cervical collar to the client. 39. D. A nurse is assisting with the care of a client who is post- operative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the follow- ing is the priority action? 1) Relieve the client's pain. 2) Check the client's pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration. 40. D. A nurse is collecting data from a client who has sclero- derma. Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin 41. C. A nurse is caring for an older adult client who has dyspha- gia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swal- lows. 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. 4) Serve food at room temperature. 42. A. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures 43. A. A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihista- mine. 44. A, D A nurse is caring for a client who is 12 hours postoper- ative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing. 45. D. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 46. C. A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function. 47. A. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia 48. B. A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis 49. D. A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should rec- ognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." 50. D. A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temper- ature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music. 51. C. A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response 52. D. A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the fol- lowing food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket 53. D. A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client's fluid intake. 3) Monitor the Homan's sign. 4) Maintain abduction of the right hip. 54. B. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. 55. B. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." 56. B. A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. 57. A. A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pres- sure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. 58. B. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." 59. C. A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with em- physema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. 60. B. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia 61. A, B, E A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the med- ication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief 62. C. A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supple- ments with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin 63. D. A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tra- cheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions 64. D. A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-con- trol device. 4) Propel a wheelchair equipped with knobs on the wheels. 65. B. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk fac- tors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn 66. A. Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?" 67. B. A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk 68. D. A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy 69. D. A nurse is reinforcing teaching about a tonometry exami- nation with a client who has manifestations of glaucoma. Which of the following statements should the nurse in- clude in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye." 70. B. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse iden- tify as the most important to report to the provider? 1) Increase in serum glucose 2) Increase in serum creatinine 3) Decrease in white blood cell count 4) Decrease in platelets 71. D. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position 4) Drop in systolic BP more than 10 mm Hg on inspiration 72. A. A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of an- other client, who becomes upset and frightened. Which of the following actions should the nurse take? 1) Attempt to determine what the client was looking for. 2) Explain the client's Alzheimer's diagnosis to the fright- ened client. 3) Reprimand the client for invading the other client's privacy. 4) Ask the client to apologize for his behavior. 73. A. A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? 1) Check pedal pulses every 15 min. 2) Perform passive range-of-motion for the affected ex- tremity. 3) Remind the client not to turn from side to side. 4) Keep the client in high-Fowler's position for 6 hr. 74. C. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? 1) Individuals at high risk should receive the live influenza vaccine. 2) Immunization for influenza should be repeated every 10 years. 3) The composition of the influenza vaccine changes yearly. 4) The influenza vaccine is necessary only for clients who have never had influenza. 75. C. A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? 1) Tell the client to have a family member call the provider to ask what options he plans to recommend. 2) Assure the client that the provider will tell him what is planned. 3) Help the client write down questions to ask his provider. 4) Provide the client with a pamphlet of information about cancer. 76. C. A nurse is caring for a client who has hemiplegia fol- lowing a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? 1) "If you just sit quietly with your mother, I'm sure she will calm down." 2) "I'll talk with your mother and see if I can comfort her." 3) "It must be hard to see your mother so ill and upset." 4) "Your mother's crying seems to bother you more than it does her." 77. B. A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following man- ifestations of dementia should the nurse include in the teaching? 1) Temporary, reversible loss of brain function 2) Forgetfulness gradually progressing to disorientation 3) Sleeping more during the day than nighttime 4) Hyper vigilant behaviors 78. B. A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? 1) Limit fluid intake.. 2) Monitor client's cardinal fields of vision. 3) Encourage ambulation. 4) Ensure the room is brightly lit. 79. B. A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? 1) Apply ice to the extremity 2) Monitor platelet levels 3) Restrict oral fluids 4) Administer vasodilating medications 80. D. A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? 1) Tuberculin skin test 2) Sputum culture for acid fast bacillus (AFB) 3) Bacille Calmette-Guérin (bCG) vaccine 4) Chest x-ray 81. C. A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL 82. B. A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? 1) "I took a laxative yesterday." 2) "I took my metformin before breakfast." 3) "I haven't had anything to eat or drink since last night." 4) "The last time I voided it was painful." 83. A. A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? 1) Expiratory wheeze 2) Pleural friction rub 3) Fine rales 4) Rhonchi 84. C. A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? 1) Remove the entire dressing at once. 2) Loosen the dressing by pulling the tape away from the wound. 3) Don clean gloves to remove the dressing. 4) Open sterile supplies before removing the dressing. 85. B. A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? 1) Prone with arms raised over the head. 2) Sitting, leaning forward over the bedside table. 3) High Fowler's position 4) Side-lying with knees drawn up to the chest. 86. A. A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? 1) Denial 2) Bargaining 3) Acceptance 4) Anger 87. D. A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritoni- tis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler's position. 88. C. A nurse is caring for a client who is receiving hemodial- ysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 1) Neck vein distention 2) Blood pressure 3) Body weight 4) Abdominal girth 89. C. A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1) Urticaria 2) Muscle pain 3) Hypotension 4) Distended neck veins 90. B. A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should rec- ognize the client is experiencing which of the following conditions? 1) A continuous seizure state in which seizures occur in rapid succession 2) A sensory warning that a seizure is imminent 3) A period of sleepiness following the seizure during which arousal is difficult 4) A brief loss of consciousness accompanied by staring 91. D. A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 1) "The bright light in this room is really bothering me." 2) "My eye really itches, but I'm trying not to rub it." 3) "It's really hard to see with a patch on one eye." 4) "I need something for the horrible pain in my eye." 92. C. A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? 1) "You shouldn't feel any pain since the local area is anesthetized." 2) "Most clients report more discomfort from the prepara- tion than from the procedure itself." 3) "You may feel some cramping during the procedure." 4) "Don't worry; you won't remember anything about the procedure due to the effects of the medication." 93. B. A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activ- ities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity 94. A. A nurse is caring for a client during the immediate post- operative period following thoracic surgery. When admin- istering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 1) Reducing anxiety 2) Increasing blood pressure 3) Increasing coughing 4) Increasing the client's respiratory rate 95. A. A nurse is collecting data on a client who has hyperthy- roidism. Which of the following manifestations should the nurse expect the client to report? 1) Frequent mood changes 2) Constipation 3) Sensitivity to cold 4) Weight gain 96. D. A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 1) Serosanguineous drainage 2) Mild erythema 3) Warmth 4) Fever 97. B, C, E A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) 1) Polyuria 2) Blurry vision 3) Tachycardia 4) Polydipsia 5) Sweating 98. A, B, C, D A nurse is collecting data from a client who has an exac- erbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin 5) Symmetrical joint pain 99. A. A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 1) Respiratory difficulty 2) Confusion 3) Increased intracranial pressure 4) Joint pain 100. B. A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recog- nize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacer- bation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility. 101. A. A nurse is reinforcing teaching about rifampin with a fe- male client who has active tuberculosis. Which of the fol- lowing statements should the nurse include in the teach- ing? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary." 102. C. A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make ade- quate urine." 3) "I will need to take this medication for the rest of my life." 4) "This medication will boost my immune system." 103. C. A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling 104. B. A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client de- velops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine. 105. A. A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phe- nomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I start- ed." 4) "I will wear gloves when removing food from the freez- er." 106. A. A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medica- tion." 4) "I should take the medication with milk." 107. A. A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron 4) Folate 108. B. A nurse is caring for a client who is scheduled for surgi- cal repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following state- ments by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb." 109. C. A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal mem- branes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis 110. A. A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client's hip so that it is internally rotated. 4) Encourage foot exercises every 4 hr. 111. B. A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 1) Aphagia 2) Hoarseness 3) Tinnitus 4) Epistaxis 112. D. A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following labo- ratory values should the nurse review to determine the client's renal function? 1) Antinuclear antibody 2) C-reactive protein 3) Erythrocyte sedimentation rate 4) Serum creatinine 113. A. A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision 114. C. A nurse is caring for a client who is postoperative and re- questing something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client's head of bed. 3) Auscultate the client's abdomen. 4) Order a lunch tray for the client. 115. D. A nurse is collecting data on a client who has a surgi- cal wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular ap- pearance. 3) The wound has serosanguineous drainage. 4) The wound has a halo of erythema on the surrounding skin. 116. C. A nurse is assisting with the care of a client who has mul- tiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles 117. D. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema 118. D. A nurse is caring for a client who is receiving chemother- apy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals. 2) Instruct the client to restrict food intake prior to treat- ment. 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy. 4) Encourage the client to drink a carbonated beverage 1 hr before meals. 119. B. A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour. 120. A. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week." 4) "I will bend at the waist to tie my shoes." 121. B. A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea 122. A. A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? 1) Encourage the client to drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating. 123. D. A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction 124. A. A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite 125. A. A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastecto- my with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes 126. C. A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associat- ed with perimenopause. Which of the following findings should the nurse expect? 1) Report of urinary retention 2) Elevated blood pressure above 140/90 3) Report of dryness with vaginal intercourse 4) Elevated body temperature above 37.8° C (100° F) 127. C. A nurse is reinforcing teaching about breast self-exami- nation (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation 128. B. A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) ½ cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) ½ cup black beans with a brownie 4) Roast beef with romaine lettuce salad [Show Less]
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