CLO 1-4

Question 1

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

-Subdural hematoma
-Intracranial hematoma
-Epidural hematoma
-Extradural hematoma

Answer 1

Epidural Hematoma

Question 2

Which client symptom change would most likely indicate, to the nurse, a progression
of mitral stenosis?

-Increased systolic pressure
-Decreased systolic pressure
-Normal diastolic pressure
-Widening pulse pressure

Answer 2

Decreased systolic pressure

Question 3

The nurse is caring for a client with a resting heart rate of 150 beats/minute. Which nursing intervention would be the highest priority in plan of care?

-Place a pillow under the feet and ankles.
-Instruct to sit on the edge of the bed before rising.
-Arrange periods of activity with periods of rest.
-Maintain strict intake and output.

Answer 3

Instruct to sit on the edge of the bed before rising

Question 4

What type of cytokine will attract neutrophils and monocytes to remove debris?

-Lymphokines
-Cytotoxic T cells
-Regulator T cells
-Suppressor T cells

Answer 4

Lymphokines

Question 5

The client has returned to the floor with a transthoracic pacemaker ready to be connected. The nurse knows that a transthoracic pacemaker is a temporary pacemaker used in what situation?

-Transthoracic pacemakers are used after a coronary bypass graft surgery.
-Transthoracic pacemakers are used when a client has an MI.
-Transthoracic pacemakers are used for tachyarrhythmias.
-Transthoracic pacemakers are used in a client who has had open heart surgery.

Answer 5

Transthoracic pacemakers are used in a client who has had open heart surgery.

Question 6

Which symptom is most important in determining the diagnosis and nursing care for a client experiencing pulmonary hypertension?

-Increased stroke volume
-Frothy sputum
-High systolic pressure
-Bradycardia

Answer 6

Frothy sputum

Question 7

A teenaged client with a diagnosis of HIV presents at the public health clinic complaining of pharyngitis, rash on the palms and soles of his feet, and diarrhea.
What would the nurse suspect the client is suffering from?

-Distal sensory polyneuropathy (DSP)
-AIDS dementia complex (ADC)
-Acute retroviral syndrome (ARS)
-AIDS-related complex (ARC)

Answer 7

Acute retro viral syndrome (ARS)

Question 8

A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder?

-Eosinophils 6%
-WBC of 7000/mm3
-Neutrophils 60%
-Radioallergosorbent blood test (RAST) of 3

Answer 8

Radioallergosorbent blood test (RAST) of 3

Question 9

Which type of skin graft is more comparable in appearance to normal skin?

-Slit graft
-Full-thickness graft
-Split-thickness graft
-Lace graft

Answer 9

Full-thickness graft

Question 10

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

-Hypernatremia
-Myoglobin in the urine
-Elevation of blood glucose levels
-Increase in antidiuretic hormone (ADH)

Answer 10

Myoglobin in the urine

Question 11

The nurse is caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?

-Advise the client to avoid being in crowds.
-Advise the client to avoid moderate exertion.
-Instruct the client to reduce the intake of potassium-rich foods.
-Educate the client about the disease process.

Answer 11

Educate the client about the disease process.

Question 12

The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?

-Affects only older adults and infants less than 3 months
-Absence of a triggering event
-Progressive tissue damage without any verifiable etiology
-Profound fatigue with no identifiable cause

Answer 12

Progressive tissue damage without any verifiable etiology

Question 13

A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly assessments on which of the following?

-Arterial blood gases
-Mentation
-Blood sugar level
-Fluid intake and urine output

Answer 13

Fluid intake and urine output

Question 14

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply.

-Neurogenic shock; diabetes
-Hypovolemic shock; blood loss
-Septic shock; infection
-Cardiogenic shock; myocardial infarction
-Anaphylactic shock; nut allergy
-Obstructive shock; kidney stone

Answer 14

-Hypovolemic shock; blood loss
-Septic shock; infection
-Cardiogenic shock; myocardial infarction
-Anaphylactic shock; nut allergy

Question 15

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint.
What does the nurse recognize this deformity as?

-Ulnar deviation
-Boutonnière deformity
-Rheumatoid nodules
-Swan neck deformity

Answer 15

Swan neck deformity

Question 16

A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse’s response be?

-“A concussion is a blow to the head that bruises the brain.”
-“A concussion is a blow to the head that is minor and has no real consequences.”
-“A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.”
-“A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.”

Answer 16

A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain

Question 17

The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?

-4:1
-2:1
-3:1
-1:1

Answer 17

3:1

Question 18

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

-Atrial fibrillation
-Supraventricular tachycardia
-Ventricular fibrillation
-Sustained asystole

Answer 18

Ventricular fibrillation

Question 19

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

-Irreversible
-Decompensation
-Compensation
-Early

Answer 19

Decompensation

Question 20

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

-Neurologic examination
-Radiography
-Computed tomography (CT) scan
-Myelography

Answer 20

Neurologic examination

Question 21

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?

-Activation of renin-angiotensin-aldosterone system
-Production of antidiuretic hormone and corticosteroid hormones
-Release of catecholamines
-Secretion of epinephrine and norepinephrine

Answer 21

Production of antidiuretic hormone and corticosteroid hormones

Question 22

One of the nursing students asks the nursing instructor why someone would need cardiac surgery. What would be an appropriate response by the nursing instructor?

-Mitral valve sufficiency
-Endocarditis
-An atrial aneurysm
-A ventricular aneurysm

Answer 22

A ventricular aneurysm

Question 23

A client with cytomegalovirus (CMV) infection reports difficulty seeing. The physician determines that the client is developing CMV retinitis. What medication
does the nurse anticipate the client will receive for this?

-foscarnet
-zidovudine
-fluconazole
-azithromycin

Answer 23

foscarnet

Question 24

The nurse is caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

-Protein electrophoresis
-T-cell and B-cell assays
-Enzyme-linked immunosorbent assay
-Plasmapheresis

Answer 24

Protein electrophoresis

Question 25

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?

-Change in the level of consciousness (LOC)
-Halo sign
-Signs of increased intracranial pressure (IICP)
-Swelling

Answer 25

Halo sign

Question 26

The nurse is caring for a client who does not accept blood or blood products. Which nursing actions conserve blood? Select all that apply.

-Administer blood product only in an emergency.
-Administer plasma to expand intravascular volume.
-Administer factor Vill to stimulate coagulation process.
-Administer medication to stimulate bone marrow
-Reinfuse the client’s own blood via closed circuit container.
Draw minimum volume of blood for diagnostic tests.

Answer 26

-Administer factor Vill to stimulate coagulation process.
-Administer medication to stimulate bone marrow
-Reinfuse the client’s own blood via closed circuit container.
-Draw minimum volume of blood for diagnostic tests.

Question 27

A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client’s lungs after positioning. What finding does the nurse hear when listening to lung sounds?

-Pericardial friction rub
-Crackles in the bases
-Rhonchi
-Lung sounds are diminished in the apical area.

Answer 27

Lung sounds are diminished in the apical area.

Question 28

Which zone consists of the area where the injury is most severe and deepest?

-Stasis
-Coagulation
-Hyperemia
-Necrosis

Answer 28

Coagulation

Question 29

A client comes to the clinic to see the physician with the complaint of “I think I ate something that I am allergic to.” What symptoms would be appropriate for the nurse to ask the questions about?

-Diarrhea and abdominal cramping
-Hives and itching
-Sneezing and runny nose
-Nasal congestion and coughing

Answer 29

Diarrhea and abdominal cramping

Question 30

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

Circumoral paresthesia
Pancreatitis
Alterations in the renal function
Peripheral neuropathy

Answer 30

Pancreatitis

Question 31

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?

-Couplets
-Bigeminy
-R-on-T phenomenon
-Multifocal PVCs

Answer 31

Bigeminy

Question 32

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply.

-p24 antigen test
-polymerase chain reaction
-ELISA test
-T4/T8 ratio
-Western blot

Answer 32

-p24 antigen test
-polymerase chain reaction

Question 33

The nurse is caring for a client with a valvular disorder. The client is at risk for decreased cardiac output. What nursing intervention should a nurse perform for this client?

-Measure urine output.
-Keep legs horizontal.
-Perform exercises consistently.
-Auscultate lung and heart sounds.

Answer 33

Measure urine output.

Question 34

Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion?

-Atropine
-Diazepam
-Enalapril
-Digoxin

Answer 34

Diazepam

Question 35

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?

-Disrupting the heart during the critical period of ventricular depolarization
-Disrupting the heart during the critical period of atrial repolarization
-Disrupting the heart during the critical period of atrial depolarization
-Disrupting the heart during critical period of ventricular repolarization

Answer 35

Disrupting the heart during critical period of ventricular repolarization

Question 36

Which of the following is a disadvantage of surgical debridement?

-Scarring
-Bleeding
-Loss of function
-Contractures

Answer 36

Bleeding

Question 37

A nurse is required to care for a client with facial burns who is prescribed the open method treatment. Which of the following nursing interventions should a nurse perform?

-Place a bed cradle or sheets over the client.
-Keep the client’s room cool and airy.
-Place the client on a moist linen sheet.
-Administer a cold sponge bath to the client.

Answer 37

Place a bed cradle or sheets over the client.

Question 38

An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

-The older client because of lifestyle
-The younger client because of age
-The older client because of age
-The younger client because of lifestyle

Answer 38

The older client because of age

Question 39

When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?

-S1 heart sound
-S3 heart sound
-Heart murmur
-Crackles

Answer 39

S3 heart sound

Question 40

The client is scheduled for a percutaneous balloon valvuloplasty. The client asks the nurse how long it takes for the opening to close after the procedure. What would be the nurse’s best response?

-Within 1 year
-Within 6 months
-Within 1 month
-Within 1 week

Answer 40

Within 6 months

Question 41

A mechanical prosthetic heart valve client is admitted with leukopenia and abdominal pain. Which diagnostic lab data would the nurse access first?

-Blood urea nitrogen (BUN)
-Complete blood count (CBC)
-Sodium (Na++) and potassium (K+) level
-Prothrombin time and international normalized ratio (PT/INR)

Answer 41

Prothrombin time and international normalized ratio (PT/INR)

Question 42

A client has a pulmonary artery catheter for monitoring and to ensure fluid balance. When measuring pulmonary capillary wedge pressure, the nurse forgets to deflate the balloon and leaves it inflated. What outcome can be the result of this action by the nurse?

-A myocardial infarction
-Pulmonary embolism
-Pulmonary infarction
-Pulmonary edema

Answer 42

Pulmonary infarction

Question 43

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

-Position the client.
-Help the client perform exercises.
-Keep the client hydrated.
-Provide a well-halanced diet

Answer 43

Keep the client hydrated.

Question 44

A client has experienced a myocardial infarction (MI). After the acute stage of the MI, what is the most lethal complication the nurse should be aware can occur?

-Ventricular aneurysm
-Septic shock
-Thrombophlebitis
-Mitral valve prolapse

Answer 44

Ventricular aneurysm

Question 45

A client is receiving treatment for rheumatoid arthritis but states that he is allergic to eggs. What medication would the client not be able to receive?

-Synvisc
-Methotrexate (Rheumatrex)
-Prednisone
-Anakinra (Kineret)

Answer 45

Synvisc

Question 46

A client is cutting vegetable for dinner and accidently cuts his finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger?

-The release of antibodies
-Passive immunity
-A cell-mediated response
-The release of memory cells

Answer 46

The release of antibodies

Question 47

What must the nurse be assessing for in order to determine adequate care for a client with aortic stenosis?

-Angina
-Calcification of aortic valve
-Systolic murmur
-Increased systolic pressure

Answer 47

Angina

Question 48

Which diagnostic study best evaluates different medications ability to restore normal heart rhythm?

-Electrophysiology study
-Echocardiogram
-Elective electrical cardioversion
-Electrocardiogram (ECG)

Answer 48

Electrophysiology study

Question 49

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client’ s stage of disease?

-Inspect the client’s mouth.
-Observe the client’s gait.
-Review the client’s medical record.
-Auscultate the client’s lung sounds.

Answer 49

Review the client’s medical record.

Question 50

The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia?

-Supraventricular tachycardia
-Complete heart block
-Atrial flutter
-Ventricular fibrillation

Answer 50

Complete heart block

Question 51

A nurse caring for a client who has had cardiac surgery must understand how pulmonary artery pressure is monitored. What is important about pulmonary artery pressure?

-Assesses left atrial heart pressures
-Assesses right-sided heart pressures
-Aids in early treatment of right-sided congestive heart failure
-Aids in the early treatment of fluid imbalances

Answer 51

Aids in the early treatment of fluid imbalances

Question 52

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is
promptly reported to the physician?

-The client prefers to rest in the semi-Fowler’s position.
-The client has periorbital edema and ecchymosis.
-The client’s level of consciousness has improved.
-The client’s vital signs are temperature, 100.9° F; heart rate, 88 beats/minute respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

Answer 52

The client’s vital signs are temperature, 100.9° F; heart rate, 88 beats/minute respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

Question 53

The client presents to the Emergency Department with blunt trauma causing bruising and bleeding of the heart. The nurse knows that which of the following may help stop the bleeding?

-Embolectomy
-Thoracentesis
-Pericardiocentesis
-Inactivity and pressure from blood in the pericardium

Answer 53

Inactivity and pressure from blood in the pericardium

Question 54

A client is suspected to have Lyme disease and has a red macule at the site or the tick bite with a bull’s-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness. What stage of Lyme disease is the client experiencing?

-Latent stage
-Later stage
-Early stage 1
-Mid-stage

Answer 54

Early stage 1

Question 55

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

-Rule of nines
-Parkland formula
-Lund and Browder burns assessment
-Use client’s palm size

Answer 55

Use client’s palm size

Question 56

The nurse listens to the lung sounds ot a postoperative client and determines that the client is not able to clear the secretions from the lungs. What intervention should the nurse provide prior to suctioning?

-Plan to suction for at least 20 seconds to remove secretions.
-Administer a sedative prior to suctioning.
-Place the client in the supine position.
-Hyperoxygenate the client with 100% oxygen.

Answer 56

Hyperoxygenate the client with 100% oxygen.

Question 57

A client comes to the clinic and informs the nurse that he had a mild case of the flu a couple of months ago and “hasn’t felt well since.” The client tells the nurse that he is fatigued and it gets worse after any physical activity and a recurrent sore throat and joint pain. What does the nurse recognize these symptoms may indicate?

-Chronic fatigue syndrome
-Ulcerative colitis
-Rheumatoid arthritis
-Recurrent flu

Answer 57

Chronic fatigue syndrome

Question 58

The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?

-Blanch the nailbeds.
-Inspect the conjunctiva
-Note dullness in skin color.
-Assess the earlobe.

Answer 58

Inspect the conjunctiva

Question 59

A client with aortic valve regurgitation is asking about his disease process. What would the nurse tell the client is the first sign of aortic valve regurgitation?

-Left-sided heart failure
-Dysrhythmias
-Tachycardia
-Pain

Answer 59

Tachycardia