Adult Health

Question 1

The nurse is performing a neuro assessment on a client and elicits a positive Romberg’s sign. The nurse makes this determination based on which observation?

1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the ankle and great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

Answer 1

3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

Question 2

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

1. A defect in the cochlea
2. A defect in cranial nerve VIII
3. physical obstruction to the transmission of sound waves
4. A defect in the sensory fibres that lead to the cerebral cortex

Answer 2

3. physical obstruction to the transmission of sound waves

Question 3

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

1. Test the corneal reflexes
2. Test the 6 cardinal positions of gaze
3. Test visual acuity, using a Snellen eye chart
4. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

Answer 3

2. Test the 6 cardinal positions of gaze

Question 4

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?

1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet.
2. The client flexes a leg at the hip and knee and reports paining the vertebral column when the leg is extended
3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column
4. The client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated

Answer 4

3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

Question 5

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

1. “It connects the pulmonary artery to the aorta”
2. “It is an opening between the right and left atria”
3. “It connects the umbilical vein to the inferior vena cava”
4. “It connects the umbilical artery to the inferior vena cava”

Answer 5

3. “It connects the umbilical vein to the inferior vena cava”

Question 6

The nurse is conducting a prenatal class on the female reproductive system. When a client in the fetal class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurses best response?

1. “It promotes the fertilized ovum’s chances of survival.”
2. “It promotes the fertilized ovum’s exposure to estrogen and progesterone”
3. “It promotes the fertilized ovum’s normal implantation in the top portion of the uterus”
4. “It promotes the fertilized ovum’s exposure to luteinizing hormone and follicle-stimulating hormone.”

Answer 6

3. “It promotes the fertilized ovum’s normal implantation in the top portion of the uterus”

Question 7

A couple comes tot elf family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether the method of family planning would be more appropriate?

1. “Did you ever had surgery?”
2. “Do you plan to have any other children?”
3. “Do either of you have DM?”
4. “Do either of you have problems with high-blood pressure?”

Answer 7

2. “Do you plan to have any other children?”

Question 8

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply?

1. Present of striae
2. Palpable radial pulses
3. Absence of any ecchymosis on the extremities
4. Thinner and decrease in number of reddish papule
5. Scarce amount of salivary-white scaly patches on the arms

Answer 8

4. Thinner and decrease in number of reddish papule

5. Scarce amount of salivary-white scaly patches on the arms

Question 9

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.

1. Lesion is painful to touch
2. Lesion is highly metastatic
3. Lesion is a nevus that has changes in color.
4. Skin under the lesion is reddened and warm to touch.
5. Lesion occurs in body area exposed to outdoor sunlight.

Answer 9

2. Lesion is highly metastatic

3. Lesion is a nevus that has changes in color.

Question 10

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.

1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald spot atop the head that is exposed to outdoor sunlight.

Answer 10

4. A pearly papule with a central crater and a waxy border

5. Location in the bald spot atop the head that is exposed to outdoor sunlight.

Question 11

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client’s hand?

1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch

Answer 11

4. A white color to the skin, which is insensitive to touch

Question 12

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is anticipated therapeutic outcome of the escharotomy?

1. Return of distal pulses
2. Brisk bleeding from the site
3. Decreasing edema formation
4. Formation of granulation tissue

Answer 12

1. Return of distal pulses

Question 13

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

1. Restrict fluids
2. Assess for airway potency
3. Administer oxygen as prescribed
4. Place a cooling blanker on the client
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.

Answer 13

2. Assess for airway potency
3. Administer oxygen as prescribed
4. Elevate extremities if no fractures are present.

Question 14

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which findings does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

1. Decreased heart rate
2. Increased urinary output
3. Increased blood pressure
4. Elevated hematocrit levels

Answer 14

4. Elevated hematocrit levels

Question 15

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

1. Coma
2. Flushing
3. Dizziness
4. Tachycardia

Answer 15

2. Flushing

Question 16

The nurse is reviewing the lab results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

1. Increased calcium levels
2. Increased white blood cells
3. Decreased blood urea nitrogen level
4. Decreased number of plasma cells in the bone marrow

Answer 16

1. Increased calcium levels

Question 17

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client’s pain should include which assessment?

1. The client’s pain rating
2. Nonverbal cues from the client
3. The nurse’s impression of the client’s pain
4. Pain relief after appropriate nursing intervention

Answer 17

1. The client’s pain rating

Question 18

The nurse is caring for a client who is post-op following a pelvic exenteration and the HCP changes the client’s diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?

1. Bowel sounds
2. Ability to ambulate
3. Incision appearance
4. Urine specific gravity

Answer 18

1. Bowel sounds

Question 19

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

1. Diarrhea
2. Hypermenorrhea
3. Abnormal bleeding
4. Abdominal distention

Answer 19

4. Abdominal distention

Question 20

The nurse is conducting a history and monitoring lab values on a client with multiple myeloma What assessment findings should the nurse expect to note? Select all that apply.

1. Pathological fracture
2. Urinalysis positive for nitrates
3. Hemoglobin level of 15.5 g/dL (155mmol/L)
4. Calcium level of 8.6 mg/dL (2.15 mmol/L)
5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

Answer 20

1. Pathological fracture
2. Urinalysis positive for nitrates
3. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

Question 21

A gastrectomy is performed on a client with gastric cancer. In the immediate postop period, the nurse notes bloody discharge from the NG tube. The nurse should take which most appropriate action?

1. Measure abdominal girth
2. Irrigate the NG tube
3. Continue to monitor the drainage
4. Notify the HCP

Answer 21

3. Continue to monitor the drainage

Question 22

A client with carcinoma of the lungs develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of cancer. The nurse anticipates that the hCP will request which prescriptions? Select all that apply.

1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Decreased oral sodium intake
5. Serum sodium level determination
6. Medication that is antagonistic to antidiuretic hormone

Answer 22

1. Radiation
2. Chemotherapy
3. Serum sodium level determination
4. Medication that is antagonistic to antidiuretic hormone

Question 23

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this ontological emergency?

1. Cyanosis
2. Arm edema
3. Periorbital edema
4. Mental status changes

Answer 23

3. Periorbital edema

Question 24

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency?

1. headache
2. dysphagia
3. constipation
4. ECG changes

Answer 24

4. ECG changes

Question 25

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency depart- ment. Which findings support this diagnosis? Select all that apply.

1. IncreaseinpH
2. Comatose state
3. Deep, rapid breathing
4. Decreased urine output
5. Elevated blood glucose level

Answer 25

2. Comatose state
3. Deep, rapid breathing
4. Elevated blood glucose level

Question 26

A client with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client’s anxiety?

1. Administer a sedative.
2. Convey empathy, trust, and respect toward the client.
3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.

Answer 26

2. Convey empathy, trust, and respect toward the client.

Question 27

Aclient is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glu- cose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now de- creased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? 1.Anampuleof50%dextrose

2. NPH insulin subcutaneously
3. IV fluids containing dextrose
4. Phenytoin for the prevention of seizures

Answer 27

3. IV fluids containing dextrose

Question 28

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic com- plications of diabetes if the blood glucose is not adequately managed?

1. Polyuria
2. Diaphoresis
3. Pedal edema
4. Decreased respiratory rate

Answer 28

1. Polyuria

Question 29

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. Thenurseplacespriorityonwhichclientproblem? 1. Lack of knowledge

2. Inadequate fluid volume
3. Compromised family coping
4. Inadequate consumption of nutrients

Answer 29

2. Inadequate fluid volume

Question 30

The nurse is caring for a client after hypophysec- tomy and notes clear nasal drainage from the cli- ent’s nostril. The nurse should take which initial action?

1. Lower the head of the bed.
2. Test the drainage for glucose.
3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

Answer 30

2. Test the drainage for glucose.

Question 31

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?

1. Correct the acidosis.
2. Administer 5% dextrose intravenously.
3. Apply a monitor for an electrocardiogram.
4. Administer short-duration insulin intravenously.

Answer 31

4. Administer short-duration insulin intravenously.

Question 32

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client com- plaint would be characteristic of this disorder? Select all that apply.

1. Polyuria
2. Headache
3. Bonepain
4. Nervousness 5. Weight gain

Answer 32

1. Polyuria

3. Bonepain

Question 33

The nurse is teaching a client with hyperparathy- roidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?
1. “I should limit my fluids to 1 liter per day.”
2. “I should use my treadmill or go for
walks daily.”
3. “I should follow a moderate-calcium, high-
fiber diet.”
4. “My alendronate helps to keep calcium from
coming out of my bones.”

Answer 33

1. “I should limit my fluids to 1 liter per day.”

Question 34

A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.

1. Hypotension
2. Leukocytosis
3. Hyperkalemia
4. Hypercalcemia
5. Hypernatremia

Answer 34

1. Hypotension 3. Hyperkalemia

Question 35

The nurse is monitoring a client who was diag- nosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the pres- ence of a possible hypoglycemic reaction? Select all that apply.

1. Tremors
2. Anorexia
3. Irritability
4. Nervousness
5. Hot, dry skin
6. Muscle cramps

Answer 35

1. Tremors
2. Irritability
3. Nervousness

Question 36

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

1. A urinary output of 50 mL/hour 2.Acoagulationtimeof5minutes
2. Aheart rate that is 90 beats/minute and irregular
3. A blood urea nitrogen level of 20 mg/dL
   (7. 1 mmol/L)

Answer 36

3. Aheart rate that is 90 beats/minute and irregular

Question 37

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complica- tion? Select all that apply.

1. Anxiety
2. Leukocytosis
3. Chvostek’s sign
4. Urinary output of 800 mL/hour
5. Clear drainage on nasal dripper pad

Answer 37

2. Leukocytosis
3. Urinary output of 800 mL/hour
4. Clear drainage on nasal dripper pad

Question 38

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

1. Pulse
2. Respiration
3. Temperature
4. Blood pressure

Answer 38

3. Temperature

Question 39

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse deter- mines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.

1. Tremors
2. Weight loss
3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

Answer 39

3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

Question 40

Aclient has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply.

1. Fever
2. Nausea
3. Lethargy
4. Tremors
5. Confusion
6. Bradycardia

Answer 40

1. Fever
2. Nausea
3. Tremors
4. Confusion

Question 41

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

Answer 41

1. Fever
2. Complaints of indigestion
3. Pain in the upper right quadrant after a
   fatty meal

Question 42

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

1. Nuts
2. Corn
3. Liver
4. Apples 5. Lentils 6. Bananas

Answer 42

1. Nuts
2. Liver
3. Lentils

Question 43

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, boardlike abdomen

Answer 43

4. A rigid, boardlike abdomen

Question 44

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

Answer 44

1. Maintain NPO (nothing by mouth) status.
2. Encourage coughing and deep breathing.
3. Give hydromorphone intravenously as prescribed for pain.

Question 45

A client with hiatal hernia chronically experi- ences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
1. Lying recumbent following meals
2. Consuming small, frequent, bland meals
3. Taking H2-receptor antagonist medication
4. Raising the head of the bed on 6-inch (15 cm)
blocks

Answer 45

1. Lying recumbent following meals

Question 46

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which find- ings indicate this occurrence?

1. Sweating and pallor
2. Bradycardia and indigestion
3. Double vision and chest pain 4. Abdominal cramping and pain

Answer 46

1. Sweating and pallor

Question 47

Thenurseispreparingalistofhomecareinstructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except
family members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary because family members already have been exposed.
5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
6. When 1 sputum culture is negative, the cli- ent is no longer considered infectious and
usually can return to former employment.

Answer 47

1. Activities should be resumed gradually.
2. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
3. Respiratory isolation is not necessary because family members already have been exposed.
4. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

Question 48

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate

Answer 48

4. Increased respiratory rate

Question 49

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration prob- lems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drain- age the nurse will perform which action to help loosen secretions?
1. Palpation and clubbing
2. Percussion and vibration
3. Hyperoxygenation and suctioning
4. Administer a bronchodilator and monitor peak
flow

Answer 49

2. Percussion and vibration

Question 50

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse deter- mines that the client has understood the informa- tion if the client makes which statement?
1. “I need to continue medication therapy for 1 month.”
2. “I can’t shop at the mall for the next 6 months.”
3. “I can return to work if a sputum culture comes
back negative.”
4. “I should not be contagious after 2 to 3 weeks of
medication therapy.”

Answer 50

4. “I should not be contagious after 2 to 3 weeks of

medication therapy.”

Question 51

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxy- gen delivery system would the nurse prepare for the client?

1. Facetent
2. Venturi mask
3. Aerosol mask
4. Tracheostomy collar

Answer 51

2. Venturi mask

Question 52

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.
1. Dyspnea
2. Headache
3. Night sweats
4. A bloody, productive cough
5. A cough with the expectoration of mucoid
sputum

Answer 52

1. Dyspnea
2. Night sweats
3. A bloody, productive cough
4. A cough with the expectoration of mucoid
   sputum

Question 53

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

1. Chestx-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test

Answer 53

3. Sputum culture

Question 54

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to deter- mine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

1. Administer oxygen
2. Check the client’s vital signs
3. Ventilate the client manually
4. Start cardiopulmonary resuscitation

Answer 54

3. Ventilate the client manually

Question 55

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to imple- ment which priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intrave-
nously
5. Transporting the client to the coronary
care unit
6. Placing the client in a low Fowler’s side-lying
position

Answer 55

1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously

Question 56

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?

1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds

Answer 56

2. Crackles

Question 57

The nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRScomplex. How should the nurse correctly interpret the client’s heart rhythm?

1. Atrial fibrillation
2. Sinus tachycardia
3. Ventricular fibrillation
4. Ventricular tachycardia

Answer 57

1. Atrial fibrillation

Question 58

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morn- ing. Which nursing action is the priority?

1. Check the urine specific gravity
2. Call the HCP
3. Put the IV line on a pump so that the infusion rate is sure to stay stable.
4. Check to see if the client had a blood sample for a serum albumin level drawn.

Answer 58

2. Call the HCP

Question 59

The nurse discusses plans for future treatment options with a client with symptomatic polycys- tic kidney disease. Which treatment should be included in this discussion? Select all that apply.

1. Hemodialysis
2. Peritoneal dialysis
3. Kidney transplant
4. Bilateral nephrectomy
5. Intense immunosuppression therapy

Answer 59

1. Hemodialysis
2. Kidney transplant
3. Bilateral nephrectomy

Question 60

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
1. Fever, diarrhea, groin pain, and ecchymosis
2. Nausea, painful scrotal edema, and ecchymosis
3. Fever, nausea, vomiting, and painful scrotal edema
4. Diarrhea, groin pain, testicular torsion, and
scrotal edema

Answer 60

3. Fever, nausea, vomiting, and painful scrotal edema

Question 61

A client complains of fever, perineal pain, and uri- nary urgency, frequency, and dysuria. To assess whether the client’s problem is related to bacterial prostatitis, the nurse reviews the results of the pros- tate examination for which characteristic of this disorder?

1. Soft and swollen prostate gland
2. Swollen, and boggy prostate gland
3. Tender and edematous prostate gland
4. Tender, indurated prostate gland that is warm to the touch

Answer 61

4. Tender, indurated prostate gland that is warm to the touch

Question 62

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions should the nurse take? Select all that apply.
1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Contact the health care provider (HCP).
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for
kinks.
6. Increase the flow rate of the peritoneal dialysis solution.

Answer 62

1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Place the client in good body alignment.
4. Check the peritoneal dialysis system for
   kinks.

Question 63

A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply.

1. Peritoneal dialysis
2. Analysis of the urinary stone
3. Intravenous opioid analgesics
4. Insertion of a nephrostomy tube
5. Placement of a ureteral stent with ureteroscopy

Answer 63

4. Insertion of a nephrostomy tube

5. Placement of a ureteral stent with ureteroscopy

Question 64

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

1. Hypertension, tachycardia, and fever
2. Hypotension, bradycardia, and hypothermia
3. Restlessness, irritability, and generalized weakness
4. Headache, deteriorating level of consciousness, and twitching

Answer 64

4. Headache, deteriorating level of consciousness, and twitching

Question 65

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?
1. Avoid overuse of the eyes.
2. Decrease the amount of salt in the diet.
3. Eye medications will need to be administered
for life.
4. Decrease fluid intake to control the intraocular
p ressu re.

Answer 65

3. Eye medications will need to be administered

for life.

Question 66

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

1. Diplopia
2. Eye pain
3. Floating spots
4. Blurred vision

Answer 66

4. Blurred vision

Question 67

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?
1. Apply ice to the affected eye.
2. Irrigate the eye with cool water.
3. Notify the health care provider (HCP).
4. Accompany the client to the emergency
department.

Answer 67

1. Apply ice to the affected eye.

Question 68

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at th is time?
1. Document the finding.
2. Continue to monitor the drainage.
3. Notify the health care provider (HCP).
4. Mark the drainage on the dressing and monitor
for any increase in bleeding.

Answer 68

3. Notify the health care provider (HCP).

Question 69

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.
1. Avoid activities that require bending over.
2. Contact the surgeon if eye scratchiness occurs.
3. Take acetaminophen for minor eye discomfort.
4. Expect episodes of sudden severe pain in
the eye.
5. Place an eye shield on the surgical eye at
bedtime.
6. Contact the surgeon if a decrease in visual
acuity occurs.

Answer 69

1. Avoid activities that require bending over.
2. Take acetaminophen for minor eye discomfort.
3. Place an eye shield on the surgical eye at
   bedtime.
4. Contact the surgeon if a decrease in visual
   acuity occurs.

Question 70

Thenurseiscaringforaclientfollowingcraniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

1. Cranial nerve I, olfactory
2. Cranial nerve IV, trochlear
3. Cranial nerve III, oculomotor
4. Cranial nerve VII, facial nerve

Answer 70

4. Cranial nerve VII, facial nerve

Question 71

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client’s chart. Based on this information, what action should the nurse take?
1. Speak loudly, but mumble or slur the words.
2. Speak loudly and clearly while facing the client.
3. Speak at normal tone and pitch, slowly and
clearly.
4. Speak loudly and directly into the client’s
affected ear.

Answer 71

3. Speak at normal tone and pitch, slowly and

clearly.

Question 72

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

1. The right eye is tested, followed by the left eye, and then both eyes are tested.
2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye.
3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the larg- est line on the chart.
4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

Answer 72

1. The right eye is tested, followed by the left eye, and then both eyes are tested.

Question 73

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

1. Speak loudly.
2. Speak frequently.
3. Speak at a normal volume.
4. Speak directly into the impaired ear.

Answer 73

3. Speak at a normal volume.