Med Surge Final Exam 1…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation
... [Show More] of which of following values? Amylase Rational Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days. 2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? Dysmenorrhea that is unresponsive to NSAIDs. Rational Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period but can cause pain at other times in the cycle. The discomfort is often unrelieved by the use of NSAIDs. 3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Establish a plan of care with the client that sets attainable goals. Rational The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable contact: [email protected] 4….A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? Large incisions will be made in the eschar to improve circulation. Rational An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. 5….A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Dark and foamy Rational The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood. 6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? Erythrocyte sedimentation rate (ESR) Rational Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases. 7….A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day. Rational The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation. 8….A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? Excessive thrombosis and bleeding Rational The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways. 9….A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? Postmenopausal bleeding Rational Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. 10…A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Hypercholesterolemia Hypertension Obesity Smoking 11…A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environment Rational A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. 12…A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.) Assess blood glucose level Assess for neck vein distention Incorrect. Monitor for an irregular heart rate Incorrect. Monitor for postural hypotension Weigh the client daily 13…A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Sedentary lifestyle Incorrect. Obesity Aging Caffeine intake Secondhand smoke Sedentary lifestyle is correct. Immobility depletes bone. Obesity is incorrect. Women who are obese have a greater capacity for storing estrogen to help maintain acceptable levels of calcium. Aging is correct. Women lose bone due to estrogen depletion after menopause. Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine. Secondhand smoke is correct. Smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking. 14…A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? Sputum culture for acid-fast bacillus Rational Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis. 15…A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) Dyspnea Incorrect. Bradycardia Barrel chest Clubbing of the fingers Incorrect. Deep respirations Rational Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterialoxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 16…A nurse in an emergency room is caring a the client who sustained partialthickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? Inspect the mouth for signs of inhalation injuries. Rational Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time 17…A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? Fresh flowers and potted plants in the room 18…A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? Avoid foods high in fat. Rational The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods 19…A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? Instruct the client about the use of a sequential compression device. Rational The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication. 20…A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? Dryness with intercourse Rational Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse 21…During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? Basal cell carcinoma Rational A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration. 22…A nurse is teaching a group of newly license nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? Ask about the client's exposure to any past or present STIs. Rational The nurse should assess the client exposure to any past or present STIs and any treatment taken. 23…A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? Practice effective hand hygiene. Rational Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A. 24…A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) Increased heart rate Increased blood pressure Increased respiratory rate Incorrect. Increase hematocrit Incorrect. Increased temperature Rational Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 25…A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? It is caused by the lack of production of aldosterone by the adrenal gland. Rational Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland 26…FLAG A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? Do not apply heat to the area of irradiation. Rational This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation. 27…A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching? A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. Rational CA 125 tests are useful in monitoring progress during and after treatment of ovarian cancer 28…A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A non-healing sore Incorrect. Bloating Change in bowel pattern Change in moles Nagging cough 29…A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? Heart rate Rational When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement 30…A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects? Bleeding from the gums Rational Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets. 31…A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? Cold and numb numbness distal to the fistula site Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider. 32…A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? Basal cell carcinoma has a low incidence of metastasis. Rational Basal cell carcinoma is a localized lesion that seldom metastasizes. 33…A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? As soon as the nurse can prepare the client and the administration set Rational The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr. 34…A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? Rest frequently throughout the day. Rational Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands. 35…A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? CD4-T-cell count 180 cells/mm3 Rational A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider 36…A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? I will eat foods that are served at room temperature. Rational The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea. 37…A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Rational The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. 38…A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider? Musculoskeletal pain Rational The client who is experiencing musculoskeletal pain should notify the provider. Musculoskeletal pain is a common adverse effect that affects 50% of clients that is possibly caused from estrogen deprivation 39…A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? Decreased serum calcium level Rational A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. 40…A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? Poor Rational At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages. 41…A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? Artificial lubrication can be used to treat vaginal itching and dryness. Rational The nurse should instruct the client that atrophic vaginal changes occur due to the loss of estrogen postoperatively and can also cause pain and dryness during sexual intercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production. 42…A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Rational A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. 43…A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Thyroid hormones Rational Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss. 44…A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching? The urethral orifice is assessed by separating the labia minora. Rational The urethral orifice, clitoris, and vaginal orifice are examined for lesions, inflammation, and discharge by separating the labia minora. 45…FLAG A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Rational Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. 46…A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? Hold the wrist at a 90-degree flexion. Rational Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the hand and wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90-degree flexion will usually result in numbness, tingling, or weakness 47…A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? Avoid foods prepared with tap water. Rational To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water. 48…A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? Feces can be present in the vagina. Rational The presence of feces in the vagina is a manifestation of a genital fistula. This statement indicates a need for further teaching. 49…A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? Cover the wound with a moist, sterile gauze dressing. Rational The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing 50…A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serosanguineous Rational Watery red drainage should be documented as serosanguineous. 51…A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? Before the examination, your provider will give you a sedative that will make you sleepy. Rational This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. 52…A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? I will reduce my intake of vitamin K-rich foods. Rational Vitamin K is necessary for bone health. The nurse should instruct the client to increase her intake of vitamin K-rich foods—such as green, leafy vegetables—to promote bone health 53…A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? Oncology nurse Rational The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion. 54…A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner. Rational The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort 55…A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? Reduce the client's intake of protein. Rational Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended. 56…A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Cheyne-Stokes respirations Rational Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death). 57…A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be Dysphagia. Rational Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness 58…A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's threechamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Verify that the suction regulator is on and check the tubing for leaks. Rational A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing. 59…A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures? Your pain will gradually become less severe. Rational Phantom leg pain usually diminishes over time, and often is intermittent in response to a trigger. 60…A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations? Developing breast cancer Rational The BRCA1 gene is used to determine the probability of a client developing breast cancer. BRCA1 genetic testing is used for women who have a strong family history of breast cancer 61…A nurse is planning a teaching session about hysterosalpingography for a client who has a diagnosis of infertility. The nurse should include which of the following information in the teaching plan? The client might experience shoulder pain following the procedure. Rational Shoulder pain can occur due to phrenic nerve irritation cause by the contrast media. 62…A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? History of breast cancer Rational Women with a history of breast cancer should be counseled against using HT. 63…A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care? Limit the number of health care workers entering the room. Rational The nurse should limit the number of health care workers entering the client's room to prevent possible overexposure to microorganisms that can lead to an infection. 64…A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions? Prevent the spread of infection with good household cleaning practices. Rational The client should follow standard precautions and use a 1:10 solution of bleach to disinfect areas that come into contact with blood and body fluids. 65…A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has gastroenteritis and is febrile. Rational This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit. 66…A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? Performing the procedure independently Rational The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home 67…A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? Check the results of the client's most recent CBC Rational The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher. 68…A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? DIC is caused by abnormal coagulation involving fibrinogen. Rational DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage. 69…A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? Completing a dressing change Rational Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids 70…A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching? Postcoital bleeding may occur. Rational The client may experience postcoital bleeding, because the polyps are soft, fragile, and bleed when touched. 71…A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include? It is primarily transmitted through direct contact with infected body fluids. Rational The nurse should include in the teaching that HIV is transmitted through direct contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk and other body fluids 72…A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment? Fatigue Rational The nurse should inform the client to expect fatigue with her radiation treatment. Fatigue occurs regardless of the radiation target site. 73…A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paraplegia Rational Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1. 74…A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? MRI of the chest Rational A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction. 75… A nurse is reviewing laboratory values for a client who has systemic lupus erythematous (SLE). Which of the following values should give the nurse the best indication of the client's renal function? Serum creatinine Rational A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function. 76…A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Incorrect. Bacteria Incorrect. Diuretics Aging Obesity Smoking Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which does not cause irreversible damage to joints. Infection is not a risk factor for osteoarthritis. Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for osteoarthritis. Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time. Smoking is correct. Smoking is a risk factor for osteoarthritis, as smoking predisposes people to the loss of cartilage in the knees. 77… A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Pantoprazole 80 mg IV bolus twice daily Rational The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions 78… A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? Output of burgundy colored urine Rational Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter. 79…A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg Rational The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg. 80…A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a SengstakenBlakemore tube to control the bleeding. Which of the following actions should the nurse take? Provide frequent oral and nares care. Rational A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions. 81…A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? It facilitates the client's deep breathing 82… A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms? Flu-like symptoms and night sweats Rational The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection. 83… A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? Obtain a sputum culture Rational The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia 84…A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? Perform a 12-lead ECG Rational The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction. 85… A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? I should expect the hospice team to help me manage my dyspnea. Rational Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness. 86…A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? The client will walk for 30 min 5 days a week. Rational CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week. 87…A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? Defibrillation Rational The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm. 88…A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? Elevated central venous pressure (CVP). Rational CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure 89…A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 Rational With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis. 90…A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication? Bradycardia Rational Atenolol is a beta-blocker, which slows the heart rate. The nurse should instruct the client to monitor his pulse rate and report bradycardia. 91…While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? Discontinue the existing IV line Rational The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line. 92…A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.) Troponin I Troponin T Incorrect. Plasma low-density lipoproteins CPK Myoglobin 93…A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Keep the drainage system below the level of the client's chest at all times. Rational During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity 94…A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Continue to monitor the client. Rational The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube. 95…A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serosanguineous 96…A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-colesterol diet. Which of the following food choices by the client indicates the need for further teaching? A slice of cheese Rational The client should limit the intake of cheese due to high levels of fat and sodium. 97…A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? Lethargy Rational A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion. 98…A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? Check the client's vital signs every hour during the transfusion. Rational The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction. 99…A nurse is planning to teach a client about a lowpotassium diet. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) Incorrect. Butter Incorrect. Poultry Correct. Yogurt Incorrect. Frozen vegetables Correct. Orange juice 100..A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? WBC count Rational An elevation in the WBC count (leukocytosis) indicates that the client’s immune system is defending him against the pathogens causing an infection. 101..A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Atropine Rational The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable. Epinephrine The team administers epinephrine during cardiopulmonary resuscitation (CPR) to clients who have asystole or pulseless electrical activity. Magnesium The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of ventricular tachycardia. Sodium bicarbonate The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR. 102..A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Encourage the use of an incentive spirometer Rational Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications. 103..A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? Fresh flowers and potted plants in the room Rational Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed fruits and vegetables. Immunocompromised clients are more susceptible to infection and illness from food-borne bacteria than other clients. 104..A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor? Hypokalemia Rational Hypokalemia is an adverse effect of furosemide 105..A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client fo [Show Less]