EXAM B Flashcards
1. A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? A: Weight gain B: Enlarged liver C: Distended abdomen D: Cool extremities
D: Cool extremities
MY ANSWER
Rational: The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion.
2. A Nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following Manifestations Should the nurse expect? A: Protruding tongue B: Facial flushing C: Nasal flaring D: Tympany with chest percussion
C: Nasal flaring
Rational: Infants who have bacterial pneumonia can exhibit manifestations such as nasal flaring and retractions of the intercostal and substernal spaces due to attempts to breathe in more oxygen to compensate for hypoxia.
- A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first?
A: Encourage the child to take frequent sips of cool fluids.
B: Apply humidified oxygen with a simple mask.
C: Start a peripheral access IV.
D: Administer an albuterol nebulizer treatment
B: Apply humidified oxygen with a simple mask.
Rational: The first action the nurse should take when using the airway, breathing, and circulation approach to client care for a school-age child who is experiencing acute asthma exacerbation is to apply humidified oxygen with a simple mask. Humidified oxygen should be administered at a level to maintain oxygen saturation above 90%.
- A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?
A: “I’ll wash my feet every day with soap and lukewarm water.”
B: “I’ll apply lotion to my feet daily, especially in between my toes.”
C: “It’s okay for me to go barefoot in the house, but not outside.”
D: “I’ll soak my feet every evening before bedtime.”
A: “I’ll wash my feet every day with soap and lukewarm water.”
Rational: The client should keep her feet clean to prevent abrasions and infection. A client who has diabetic neuropathy has reduced sensation in the feet. Therefore, the client should use an elbow or a thermometer to test the temperature of the water and ensure that it is lukewarm. Hot water can irritate the skin and lead to breakdown.
- A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis?
A: Diabetes mellitus
B: Radical prostatectomy 2 years ago
C: Cholelithiasis
D: Taking permethrin to treat pediculosis capitis
A: Diabetes mellitus
Rational: The nurse should identify that clients who have diabetes mellitus are at increased risk for the development of pyelonephritis due to a loss of bladder tone as a result of neuropathy, or from an ascending lower urinary tract infection caused by glycosuria.
6. A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? (Select all that apply.) A: Fever B: Dyspepsia C: Pain radiating to the left shoulder D: Blood-tinged stools E: Eructation -
A: Fever is correct.
Rational: The nurse should expect to find a fever in the client who has acute cholecystitis due to the inflammatory process.
B: Dyspepsia is correct.
Rational: The nurse should expect to find dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.
E: Eructation is correct.
Rational: The nurse should expect the client who has acute cholecystitis to exhibit eructation, or belching, due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.
- A nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?
A: Restrict oral intake to clear fluids.
B: Place a heating pad on the client’s abdomen.
C: Place the client in semi-Fowler’s position.
D: Administer an enema.
C: Place the client in semi-Fowler’s position.
Rational: The nurse should place the client in semi-Fowler’s position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum.
- A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need?
A: The client requests to see a priest for spiritual guidance.
B: The client reports coughing and a change of voice whenever he eats.
C: The client reports pain immediately following physical therapy.
D: The client is worried about financially supporting his family because of his illness.
B: The client reports coughing and a change of voice whenever he eats.
Rational: When using Maslow’s hierarchy of needs, the nurse should determine that the priority finding is the client’s physiological needs, such as coughing and a change of voice whenever he eats. This finding indicates a risk for aspiration, which can impair the client’s breathing and oxygenation status. Difficulty eating also creates an impairment of nutrition. Breathing, oxygenation, and nutrition are all physiological needs. Therefore, the nurse should identify this finding as the priority client need.
- A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first?
A: Place the client on mechanical ventilation.
B: Apply oxygen using a rebreather oxygen mask.
C: Ensure a patent airway using a chin-lift maneuver.
D: Administer a reversal agent to the client.
C: Ensure a patent airway using a chin-lift maneuver.
Rational: The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to open the client’s airway by performing a chin-lift maneuver.
- A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis?
A: A client who has a fever
B: A client who has abdominal ascites
C: A client who is anxious
D: A client who is receiving nasogastric suctioning
B: A client who has abdominal ascites
Rational: The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis.
- A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make?
A: “Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby.”
B: “Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light.”
C: “Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet.”
D: “Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night’s sleep.”
C: “Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet.”
Rational: The nurse should instruct the parents to dress the newborn in a one-piece sleeper or a “sleep-sack” at bedtime, which keeps the newborn’s body covered. Blankets and quilts significantly increase the newborn’s risk of suffocation and should be avoided.
12. A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? A: LDL 168 mg/dL B: HDL 50 mg/dL C: Total cholesterol 268 mg/dL D: Triglycerides 250 mg/dL
B: HDL 50 mg/dL
Rational: This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client.
- A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?
A: “Administer the medication into your child’s abdomen.”
B: “Expect your child to sleep for several hours after receiving the medication.”
C: “Place your child’s unused extra syringes in the refrigerator for storage.”
D: “Give a second injection if the first fails to reverse your child’s symptoms.”
D: “Give a second injection if the first fails to reverse your child’s symptoms.”
Rational: The nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose doesn’t completely reverse the child’s allergic reaction. The effects of the medication will begin to fade in 20 min. However, the child should be transported to the nearest hospital immediately because hospitalization for a few hours following administration of the injection is recommended. The nurse should instruct the parent to bring the auto-injector with the child to the hospital.
- A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A: Distract the client by having him complete a puzzle.
B: Encourage the client to take a deep breath every 2 seconds.
C: Administer methylphenidate to the client.
D: Stay with the client until manifestations subside.
D: Stay with the client until manifestations subside.
Rational: The nurse should stay with the client during a panic attack until manifestations subside and the client is reoriented to reality. This ensures the client’s safety and conveys concern to the client.
- A nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all Steps.)
A: Withdraw the prescribed volume of insulin aspart into the syringe.
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
A: Withdraw the prescribed volume of insulin aspart into the syringe.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
The nurse should always withdraw short-acting insulin before long-acting insulin to avoid contaminating the short-acting vial. The nurse should first prepare the NPH insulin vial by filling the syringe with air equal to the amount prescribed and injecting it into the NPH vial. Then, the nurse should prepare the insulin aspart vial by filling the syringe with air equal to the amount prescribed and inject it into the insulin aspart vial. With the syringe still in the insulin aspart vial, the nurse should withdraw the correct dose of medication into the syringe. Finally, the nurse should withdraw the correct dose of NPH insulin into the syringe.
16. A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 minutes but still has emesis and diarrhea. Which if the following medications should the nurse anticipate administering to the toddler? A: Polyethylene glycol B: Bumetanide C: Loperamide D: Ondansetron -
D: Ondansetron
Rational: The nurse should anticipate administering ondansetron to the toddler. Ondansetron is administered to toddlers who have gastroenteritis and dehydration to decrease the episodes of emesis and to help eliminate the need for intravenous fluids.
- A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended dose of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen?
A: Elevated aspartate aminotransferase levels
B: Decreased skin turgor
C: Elevated WBC count
D: Decreased audio acuity
A: Elevated aspartate aminotransferase levels
Rational: The nurse should identify that an elevated aspartate aminotransferase (AST) is an indication of liver injury, which is an adverse effect of excessive doses of acetaminophen. In addition to elevated liver enzymes, other indications of liver injury include diaphoresis, nausea and vomiting, abdominal pain, and diarrhea.
18. A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? A: Heart rate 64/min B: Tall T waves C: Shortened PR interval D: QRS 0.08 seconds
B: Tall T waves
Raional: The nurse should identify that a potassium level of 6 mEq/L is above the expected reference range of 3.5 to 5 mEq/L, indicating that the client has hyperkalemia. Tall T waves are a manifestation of hyperkalemia when the potassium level is greater than 6 mEq/L, which can affect the myocardium and impact the client’s surgical risk. The nurse should report this elevated potassium level to the provider.
- A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect?
A: Absence of tears when crying
B: Loss of 6% of body weight
C: Sunken anterior fontanel
D: Capillary refill greater than 2 seconds
D: Capillary refill greater than 2 seconds
Rational: The nurse should expect an infant who has mild dehydration to have a capillary refill time of greater than 2 seconds. Other manifestations of mild dehydration include slight thirst, decreased urine output, and moist mucus membranes.
- A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect?
A: Pain with palpation to the substernal notch
B: Urinary burning
C: Ecchymosis over the flank
D: Radiating pain to the right shoulder
B: Urinary burning
Rational: A client who has acute pyelonephritis can experience burning, frequency, and urgency with urination.
- A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first?
A: Place the client in high-Fowler’s position.
B: Encourage the client to perform diaphragmatic breathing.
C: Instruct the client to perform a huff-coughing technique.
D: Administer a nebulized bronchodilator.
A: Place the client in high-Fowler’s position.
Rational: According to evidence-based practice, the first action the nurse should take is to place the client in an upright, or high-Fowler’s, position to facilitate ease of breathing.
22. A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following finding should the nurse monitor? A: Flushed, dry skin B: Seizures C: Hyperreflexia D: Positive Trousseau's sign
A: Flushed, dry skin
Rational: The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2.
23. A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? A: Hyperactive deep tendon reflexes B: Abdominal distention C: Bradycardia D: Positive Trousseau's sign
C: Bradycardia
Rational: The nurse should expect to find bradycardia in a client who has hypermagnesemia, as well as other cardiac manifestations, including peripheral vasodilation and hypotension due to a reduced membrane excitability. Clients who have severe hypermagnesemia are at an increased risk for cardiac arrest.
- A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome?
A: Serous drainage is present on the pin site dressings
B: Flushing of the skin on the right arm
C: Bounding pulse palpated in the radial artery
D: Numbness to the fingers on the right arm
D: Numbness to the fingers on the right arm
Rational: The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.
25. A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is a risk for malnutrition? A: WBC count B: Albumin level C: CD4 T cell count D: C-reactive protein level
B: Albumin level
Rational: The nurse should review albumin levels to determine a client’s risk for malnutrition. A client who is malnourished will have an albumin level below the expected reference range of 3.5 to 5 g/dL.
- A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan?
A: Elevate the client’s arm above the heart.
B: Apply heat to the client’s surgical site.
C: Instruct the client to avoid moving their fingers.
D: Monitor the client’s ability to complete wrist range-of-motion.
A: Elevate the client’s arm above the heart.
Rational: The nurse should elevate the client’s arm and hand following carpal tunnel release to minimize swelling of the surgical site and decrease discomfort.
- A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include?
A: “Cover your newborn with a light blanket while she is sleeping.”
B: “Do not bathe your newborn immediately after she eats.”
C: “Place your newborn in a crib with a bumper pad.”
D: “Wash your newborn’s face with a mild soap.”
B: “Do not bathe your newborn immediately after she eats.”
Rational: The nurse should instruct the parent to avoid bathing the newborn immediately following a feeding to decrease the risk of regurgitation. The parent should bathe the newborn every 2 to 3 days.
- A nurse is providing dietary teaching to a client who is a 13 week of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?
A: “Drink fluids between, rather than with, meals.”
B: “Eat foods that are served warm.”
C: “Do not go more than 6 hr between meals.”
D: “Have a low-protein snack at bedtime.” -
A: “Drink fluids between, rather than with, meals.”
Rational: The nurse should instruct the client to avoid drinking fluids with meals because this can increase nausea. The client should separate solid food from liquids.
- A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching?
A: “Decrease your calcium intake.”
B: “You should consume at least 2,400 milligrams of salt per day.”
C: “Limit the amount of spinach in your diet.”
D: “Increase your fluid intake to one and a half liters daily.”
C: “Limit the amount of spinach in your diet.”
Rational: The nurse should instruct the client to decrease intake of foods that contain oxalates. Restricting foods that are high in oxalates, such as spinach, tea, nuts, chocolate, and strawberries, can decrease the risk of further calculi formation.
30. A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? A: Inaudible lung sounds B: Persistent cough C: Yellow zone peak flow meter reading D: Prolonged expiration phase
A: Inaudible lung sounds
Rational: When using the airway, breathing, and circulation approach to client care, the nurse determines the priority finding is inaudible lung sounds on auscultation. Shortness of breath with an absence of lung sounds and increased respiratory rate indicates impending respiratory failure and asphyxia.
- A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which of the following client statements indicates an understanding of the teaching?
A: “I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach.”
B: “I will wash my clothes in cold water and detergent.”
C: “I will throw away my razor after using it three times.”
D: “I will apply imiquimod cream to the lesions before going to bed each night.”
Answer: A
A: “I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach.”
Rational: The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection.
32. A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse instruct the parent to report to the provider? A: Swollen cervical lymph nodes B: Exudate on tonsils C: Lack of energy D: Onset of abdominal pain
D: Onset of abdominal pain
Rational: The nurse should instruct the parent to report the onset of abdominal pain to the provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture can occur and is usually caused by trauma.
33. A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? A: Peak expiratory flow meter testing B: Spirometry monitoring C: Pulmonary function testing D: Chest x-ray
A: Peak expiratory flow meter testing
Rational: The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help.
- A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include?
A: “Wear open-toe shoes to allow air to circulate around your feet.”
B: “Use a heating pad set on low to warm your feet when they feel cold.”
C: “File your toenails straight across to prevent ingrown toenails.”
D: “Apply a thin layer of lotion between your toes twice per day.”
C: “File your toenails straight across to prevent ingrown toenails.”
Rational: The nurse should instruct the client to file toenails straight across. If the client’s toenails are rounded during clipping, the client is at risk for developing ingrown toenails, increasing the risk for infection.
35. A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? A: Hypertension B: Somnolence C: Oliguria D: Bradycardia -
C: Oliguria
Rational: client who has heat stroke will manifest a body temperature of 40° C (104° F) or greater, which can lead to dehydration and oliguria. Complications include multiple organ dysfunction syndrome, which includes renal impairment. The nurse should closely monitor the client’s urine output and specific gravity to assist with determining fluid needs.
36. A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? A: Orthostatic hypotension B: Hoarse voice C: Neck vein distention D: Muscle twitching
A: Orthostatic hypotension
Rational: The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy.
- A nurse is assessing a client whose parent recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving?
A: The client lost his house in a house fire 1 month ago.
B: The client has retired after 30 years of employment.
C: The client’s parent was an older adult.
D: The client’s parent had a chronic terminal illness
A: The client lost his house in a house fire 1 month ago.
Rational: The nurse should identify that cumulative losses, the situational loss of a house unexpectedly due to a fire, combined with the loss of a family member, increases the client’s risk for maladaptive grieving.
- A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include?
A: Soak the child’s combs and brushes in hot water for 5 min.
B: Rinse the child’s hair each day with 236.5 mL (1 cup) of vinegar.
C: Seal the child’s nonwashable toys in plastic bags for 7 days.
D: Comb the child’s hair daily with an extra fine-tooth comb. - Correct Answer: D
D: Comb the child’s hair daily with an extra fine-tooth comb.
Rational: The nurse should instruct the parent to remove nits from the child’s hair each day by combing her hair with an extra fine-tooth comb. The parent can also remove nits with tweezers or fingernails.
- A nurse is providing teaching about home care with the parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching?
A: “I should apply the cream only to the areas where there is a rash.”
B: “I should wash my child’s bed linens and clothing in hot water and detergent.”
C: “I should expect my child’s rash to go away within 72 hours after starting treatment.”
D: “I should leave the cream on my child for 4 hours before washing it off.”
B: “I should wash my child’s bed linens and clothing in hot water and detergent.”
Rational: The parent should wash the child’s clothing and bed linens in hot water and detergent, and dry all articles in a clothes dryer on the highest heat setting. This will kill the mites and prevent transmission of the infestation.
- A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?
A: Brown discoloration of the lower extremities
B: Superficial ulcer on the medial aspect of the ankle
C: Dependent rubor
D: Telangiectasias
C: Dependent rubor
Rational: The nurse should expect redness to the lower extremities, or dependent rubor, when the client’s legs are dangling or in a dependent position.
- A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. WHich of the following client statements indicates an understanding of the management of antibiotic resistant infections?
A: “I will keep the infected area open to air to help it heal.”
B: “I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours.”
C: “I should sit on upholstered chairs instead of hardback chairs.”
D: “I will wash all uninfected skin areas with a fresh washcloth.”
D: “I will wash all uninfected skin areas with a fresh washcloth.”
Rational: The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection.
- A nurse is assessing an infant whose guardian reports, “My baby has been crying nonstop, has a fever, and has been pulling at her ear.” Which of the following manifestations should the nurse expect for an infant who might have otitis media?
A: Enlarged postauricular lymph nodes
B: Increased flatulence with constipation
C: Indicates a desire to suck more frequently
D: Slow bounding heart rate
A: Enlarged postauricular lymph nodes
Rational: The nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F).
- A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication?
A: The client’s skin is warm and moist.
B: The client reports sleeping longer during the night.
C: The client is experiencing increased bowel movements.
D: The client’s weight is 1.4 kg (3.1 lb) less than baseline
B: The client reports sleeping longer during the night.
Rational: The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client’s ability to sleep longer during the night indicates a therapeutic response to the medication.
44. A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? A: Calcium 9.5 mg/dL B: Bicarbonate 23 mEq/L C: Potassium 3 mEq/L D: pH 7.4 -
C: Potassium 3 mEq/L
Rational:The nurse should expect to find hypokalemia in a client who has metabolic alkalosis due to the response to decreased blood cation levels. This decrease in potassium can lead to an increased stimulation of the nervous, neuromuscular, and cardiac systems. The client’s potassium level of 3 mEq/L is below the expected reference range of 3.5 to 5 mEq/L.
- A nurse is reviewing a client’s medical record prior to a laparoscopic appendectomy.
Which of the following findings should the nurse report to the provider?
A: Prothrombin time 12 seconds
B: History of sinusitis several times each year
C: BMI of 24
D: Report of urinating small amounts twice daily
D: Report of urinating small amounts twice daily
Rational: The nurse should recognize that a report of oliguria, or urinating only small amounts daily, indicates possible impaired kidney function. Therefore, the nurse should report this finding to the provider for further evaluation. Kidney function affects medication metabolism and impaired function increases the client’s risk for postoperative complications.
- A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take?
A: Place the client in semi-Fowler’s position.
B: Administer IV pain medication if the client is having extremity pain.
C: Heat the client’s body by using external rewarming devices.
D: Contact a specialized team to place the client on cardiopulmonary bypass.
D: Contact a specialized team to place the client on cardiopulmonary bypass.
Rational: Extracorporeal rewarming, such as cardiopulmonary bypass or hemodialysis, is the rewarming method of choice for core warming when a client has severe hypothermia. This rewarming method requires a specialized team.
- A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take?
A: Apply warm dry packs initially then apply cool moist packs to the lower extremity.
B: Elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level.
C: Gently massage the affected extremity for 10 to 15 min every shift.
D: Apply a topical corticosteroid to any open areas on the affected extremity twice per day
B: Elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level.
Rational: The nurse should elevate the client’s affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema.
- A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite?
A: Slowly institute rewarming of the affected areas.
B: Place the affected areas of frostbite in a warm water bath.
C: Massage the affected areas of frostbite.
D: Position the affected areas of frostbite flat after warming
B: Place the affected areas of frostbite in a warm water bath.
Rational: The nurse should place the client’s affected areas of frostbite in a warm water bath with a temperature of 37° to 42.2° C (98.6° to 108° F) to thaw the affected areas of frostbite.
- A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching?
A: “You can safely continue taking this medication if you become pregnant.”
B: “This medication could cause you to have thoughts of self-harm.”
C: “You should take this medication 1 hour before eating.”
D: “Take this medication with an antacid if stomach upset occurs.”
B: “This medication could cause you to have thoughts of self-harm.”
Rational: The nurse should instruct the client that this medication can cause suicidal thoughts. The nurse should monitor the client for this adverse effect and should instruct the client to notify the provider immediately if these thoughts occur.
50. A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A: Confusion B: Flushed, moist skin C: Hyperreflexia D: Bounding peripheral pulses
A: Confusion
Rational: The client who has respiratory acidosis can display mental cloudiness or confusion due to elevated carbon dioxide (CO2) retention as a result of hypoventilation
- A nurse is planning discharge for a postpartum client. The client tells the nurse she is having a subdermal implant placed for contraception at her 6 week follow-up examination and ask about the adverse effects of the implant. Which of the following manifestations should the nurse include?
A: Irregular bleeding
B: Fatigue
C: Shoulder pain
D: Recurrent urinary tract infections (UTIs)
A: Irregular bleeding
Rational: The nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal.
- A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching?
A: Bacterial infection with Escherichia coli
B: Long-term use of NSAIDs
C: Frequent use of proton pump inhibitors
D: A diet that includes spicy foods
B: Long-term use of NSAIDs
Rational: Long-term use of medications, such as NSAIDs and glucocorticoids, increases the risk for peptic ulcers.
- A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client’s adaptive use of suppression?
A: “I teach my children about healthy eating because my anxiety makes me want to overeat.”
B: “I started taking kickboxing classes to release the stress I feel from work.”
C: “I avoid thinking about problems that worry me until I have time to focus on a solution.”
D: “I let my partner choose the movie for date night since I yelled at him when I was stressed.”
C: “I avoid thinking about problems that worry me until I have time to focus on a solution.”
Rational: The nurse should recognize that this statement indicates the client’s conscious choice to avoid thinking about anxiety producing thoughts until he has time to focus on them in a positive way. This indicates an adaptive use of suppression.
- A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching?
A: Increase daily intake of foods containing vitamin A.
B: Limit alcohol consumption to 10 oz daily.
C: Perform exercises to strengthen the abdominal core.
D: Start a daily jogging regimen
C: Perform exercises to strengthen the abdominal core.
Rational: The nurse should instruct the client to perform exercises to strengthen the abdominal and back muscles to maintain stability of the spinal column and prevent vertebral fractures.
55. A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCo2 29 mmHg, and HCO3 25 following acid-base imbalances? A: Metabolic alkalosis B: Metabolic acidosis C: Respiratory alkalosis D: Respiratory acidosis
C: Respiratory alkalosis
Rational: The nurse should interpret that the client’s ABG values indicate respiratory alkalosis, which can be caused by hyperventilation as excessive loss of CO2 occurs with rapid respirations. Laboratory values will reflect an elevated pH and a decreased PaCO2. The client’s HCO3- level is within the expected reference range.
56. A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complication of diabetes mellitus. Which of the following findings should the nurse expect? A: Fruity-scented breath B: Serum glucose 350 mg/dL C: pH 7.32 D: Hypotension
D: Hypotension
Rational: The client who is in a hyperglycemic-hyperosmolar state develops hypotension as a result of highly elevated glucose levels, inability of the kidneys to regulate blood osmolarity, and increased diuresis.
- A nurse is teaching a client who recently lost his partner to a terminal illness. The client aska how his 4-year-old son is expected to react to the death of his partner. WHich of the following information should the nurse include in the teaching?
A: A preschooler has no concept of death.
B: A preschooler is often interested in what happens to the body after death.
C: A preschooler often believes that death is reversible.
D: A preschooler understands that death happens to everyone.
C: A preschooler often believes that death is reversible.
Rational: The nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die.
58. A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? A: Gonorrhea B: Herpes genitalis C: Human papillomavirus D: Bacterial vaginosis
A: Gonorrhea
Rational: Gonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention.
- A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include?
A: Apply heat to the joints following exercise.
B: Avoid aerobic exercises such as biking.
C: Perform exercise even on days when joints are painful.
D: Household chores can count as exercise
C: Perform exercise even on days when joints are painful.
Rational: The nurse should instruct the client to continue exercising even if joints are painful because consistency will help with management of the disease. The client can reduce the amount of exercise if joints are especially painful.
- A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurses assess? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A: Upper Right Quadrant
B: Lower Left Quadrant
C: Lower Right Quadrant
A: Upper Right Quadrant
Rational: The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client’s abdomen to the client’s right shoulder.
- A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client’s nutritional status is improving?
A: Intake of fluid is less than output of urine over the past 2 days
B: 1 kg (2.2 lb) weight gain over the past 2 days
C: Blood glucose 206 mg/dL
D: Prealbumin 13 mg/dL
B: 1 kg (2.2 lb) weight gain over the past 2 days
Rational: Total parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition.
62. A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? A: Megestrol B: Ondansetron C: Famotidine D: Pancrelipase
A: Megestrol
Rational: The nurse should expect the provider to prescribe megestrol for the client who is experiencing failure to thrive related to HIV/AIDS. Megestrol increases appetite in clients who have HIV/AIDS.
- A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately?
A: Flank pain with radiation toward the scrotum
B: 150 mL emesis
C: Oliguria with bladder distention
D: Blood pressure 160/90 mm Hg
C: Oliguria with bladder distention
Rational: The greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately.
- A nurse is reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect?
A: LDL 100 mg/dL
B: Total cholesterol 199 mg/dL
C: Aspartate aminotransferase (AST) 45 units/L
D: Creatine kinase (CK) 120 units/L
C: Aspartate aminotransferase (AST) 45 units/L
Rational: The nurse should identify that an aspartate aminotransferase level of 45 units/L is greater than the expected reference range of 0 to 35 units/L and indicates hepatotoxicity, an adverse effect of atorvastatin.
- A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make?
A: “You’re sad now, but the grief will pass eventually.”
B: “You should attend a grief support group to see how others cope with loss.”
C: “What are some of the best times with your partner that you remember?”
D: “How are other members of the family managing?”
C: “What are some of the best times with your partner that you remember?”
Rational: Encouraging the client to reminisce about her partner allows the client to acknowledge the loss and to progress through the grief process.
66. A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for the visual impairment? A: Male sex B: Hypertension C: Chronic obstructive pulmonary disease D: Osteoporosis
B: Hypertension
Rational: The nurse should identify that hypertension is a risk factor for the development of AMD. Other risk factors include atherosclerosis and smoking.
- A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which of the following actions should the nurse include?
A: Limit the amount of time the client spends with the newborn after birth.
B: Discourage the client from having other family members see the newborn.
C: Inform the client that an autopsy of the newborn is required by federal law.
D: Bathe, diaper, and dress the child before bringing the newborn to the client.
D: Bathe, diaper, and dress the child before bringing the newborn to the client.
Rational: The nurse should treat the child as a live newborn, including bathing, diapering, and dressing the child. Applying identification bands, a hat, and swaddling the newborn in a blanket show the client that the newborn has been cared for in a meaningful way.
68. A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? A: One small apple B: One-half cup of sweet cherries C: One-half cup of fresh pineapple D: One small orange
D: One small orange
Rational: The nurse should recommend that a client who has hypokalemia eat oranges due to the high potassium content. One orange that is 7.1 cm (2.8 in) in diameter contains 232 mg of potassium.
69. A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of the medication? A: Increased salivation B: Bradycardia C: Tinnitus D: Distended bladder
D: Distended bladder
Rational: The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client’s intake and output and assess for bladder distention.
70. A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? A: Increased urination B: Sweating C: Dizziness D: Loose stools
A: Increased urination
Rational: The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse.
- A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching?
A: “Keep your mouth open when sneezing.”
B: “Block one nostril when blowing your nose.”
C: “Use an ear wick candle to remove excess cerumen from the canal.”
D: “Lubricate cotton-tipped applicators with mineral oil to clean the ear canal.”
A: “Keep your mouth open when sneezing.”
Rational: The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum.
- A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect?
A: Presence of peristaltic waves
B: Epigastric distention
C: Large amounts of emesis of fecal material
D: Ribbon-like stools -
D: Ribbon-like stools
Rational: The client who has a partial obstruction of the large bowel will have ribbon-like stools with an alteration in bowel habits and blood in the stools. A client who has a partial obstruction of the small bowel can have diarrhea.
73. A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? A: Total bilirubin 0.8 mg/dL B: WBC count 4,000/mm3 C: Platelets 190,000/mm3 D: Creatinine 1 mg/dL
B: WBC count 4,000/mm3
Rational: Agranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication.
74. A nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items? A: Caffeinated coffee B: Shell fish C: Apple juice D: Green beans
A: Caffeinated coffee
Rational: The nurse should instruct the client who has GERD to avoid caffeinated beverages because these can decrease the tone of the lower esophageal sphincter and increase the exposure of acid to the esophagus. The client should also avoid citrus fruits, tomatoes, chocolate, peppermint, spearmint, alcohol, smoking, and the use of other tobacco products.
- A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Exhibit 1:
Nurses’ Notes
Medical history of type 2 diabetes mellitus and hypertension.
Reports weight loss, lethargy, and night sweats over the last 3 weeks. Cough with hemoptysis. Client traveled overseas 3 months prior.
Exhibit 2:
Graphic Record
Blood pressure 110/62 mm Hg Heart rate 90/min Respiratory rate 24/min SaO2 95% Temperature 38.1° C (100.6° F)
Exhibit 3:
Diagnostic Results
Casual blood glucose 132 mg/dL
A: Inform the client she will require an IV fluid bolus.
B: Perform rapid influenza testing.
C: Place a surgical mask on the client.
D: Request a prescription for a single dose of short-acting insulin
C: Place a surgical mask on the client.
Rational: Weight loss, lethargy, night sweats, and hemoptysis suggest the client might have active tuberculosis (TB). Travel outside the U.S. increases the risk for TB. Therefore, the nurse should prevent the spread of TB by implementing airborne precautions, which includes placing a surgical mask on the client to transport her to a negative pressure room.
76. A nurse is assessing a client who has developed Clostridium defficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe the treat the C. defficile? A: Vancomycin B: Magnesium hydroxide C: Rifampin D: Metoclopramide
A: Vancomycin
Rational: The nurse should expect the provider to prescribe vancomycin to treat C. difficile.
- A nurse in a provider’s office is reviewing the medical record of a client who has COPD. Which of the following findings is a priority for the nurse to report to the provider?
A: Chest x-ray results show increased lung space.
B: Sputum culture shows gram positive bacteria.
C: SpO2 level is 88%.
D: Weight loss of 1.4 kg (3 lb) since prior visit.
B: Sputum culture shows gram positive bacteria.
Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is gram positive bacteria in the client’s sputum culture. The nurse should report this finding to the provider to obtain a prescription for an antibiotic to reduce the risk for decreased gas exchange and sepsis.
- Rational: The nurse should identify that a weight loss of 1.4 kg (3 lb) since the prior visit is nonurgent because it is an expected finding for a client who has COPD. COPD can cause anorexia, fatigue, and increased metabolism from dyspnea. Therefore, there is another finding that is the nurse’s priority to report to the provider.
A nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching?
A: “Use bisacodyl suppositories to stimulate a bowel movement.”
B: “Avoid lifting objects greater than 50 pounds.”
C: “Consume a clear liquid diet until symptoms resolve.”
D: “Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea.”
C: “Consume a clear liquid diet until symptoms resolve.”
Rational: The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility.
- A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching?
A: “I should avoid taking this medication with milk.”
B: “I will return to have my cholesterol levels checked in 2 weeks.”
C: “I can expect to lose weight while taking this medication.”
D: “I understand that muscle tenderness is an expected result of this medication.”
B: “I will return to have my cholesterol levels checked in 2 weeks.”
Rational: The nurse should instruct the client that their cholesterol level will be reevaluated within 2 to 4 weeks after initiating therapy, and periodically thereafter.
- A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider?
Exhibit 1:
Diagnostic Results
Hct 42%
Hgb 14 g/dL
ECG Sinus tachycardia
Exhibit 2:
Graphic Record
Temperature 38.3°C (100.9°F)
Heart rate 106/min
Respiratory rate 22/min
Blood pressure 144/90 mm Hg
Exhibit 3:
Nurses’ Notes
Client reports pain level of 8 on a scale of 0 to 10 in casted left arm
IV morphine administered 45 min ago
Client is diaphoretic and anxious
A: Laboratory results
B: Blood pressure
C: Pain report
D: ECG results
C: Pain report
Rational:The nurse should report the client’s pain level of 8 on a scale of 0 to 10 to the provider. Excessive pain in a casted arm that is unrelieved by analgesics can be an indication of compartment syndrome, which is a medical emergency.
- A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching?
A: “I will quickly complete my household errands in the morning before taking a break.”
B: “I will breathe out slowly through pursed lips if I feel short of breath.”
C: “I will try to eat three large meals every day.”
D: “I will not get a flu shot because I might get an infection.”
B: “I will breathe out slowly through pursed lips if I feel short of breath.”
Rational: The nurse should instruct the client to perform pursed-lip breathing to assist with dyspnea. This technique includes breathing in through the nose, pursing the lips, and breathing out slowly.
- A nurse is evaluating a client’s understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices indicates an understanding of the teaching?
A: A black bean burger on a whole grain bun
B: Oatmeal with whole milk
C: A baked potato with butter
D: A pork sausage patty on a biscuit
A: A black bean burger on a whole grain bun
Rational: The nurse should identify food choices that are low in fat but high in fiber will help manage hyperlipidemia. The client’s choice of proteins that are low in solid fat and high in fiber, such as beans and a whole grain bun, indicates an understanding of the teaching.
- A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?
A: Nurse on the left holding client’s arm
B: Nurse on the right holding gait belt
C: Nurse in the front holding walker
D: Nurse on the left holding gait belt
B: Nurse on the right holding gait belt
Rational: A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client’s affected side and support the client using a gait belt
84. A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? A: BMI 26 or above B: Excessive sun exposure C: Frequent weight-bearing exercise D: Hip fracture 6 months ago
D: Hip fracture 6 months ago
Rational: The nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis.
85. A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? A: Agoraphobia B: Xenophobia C: Acrophobia D: Glossophobia
C: Acrophobia
Rational: The nurse should document that the client is experiencing acrophobia, or the fear of heights. Phobias cause an intense fear and severe anxiety when the client is exposed to the object of the phobia
- A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take?
A: Palpate the left lower quadrant of the abdomen to check for rebound pain.
B: Start IV fluid replacement.
C: Treat the client’s pain with oral opioid analgesics given with food.
D: Administer a suppository to the client in preparation for surgery.
B: Start IV fluid replacement.
Rational: The nurse should start IV fluid replacement to maintain fluid volume and electrolyte balance.
- A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child’s fever. Which of the following responses should the nurse make?
A: “Avoid giving aspirin to your child.”
B: “Place your child in a cool bath for 20 minutes twice per day.”
C: “Lower the room temperature to stimulate shivering.”
D: “Give eight doses of acetaminophen in 24 hours according to the child’s weight.”
A: “Avoid giving aspirin to your child.”
Rational: The nurse should instruct the parent to not administer aspirin to the child to treat a fever. Aspirin increases the risk for Reye syndrome in children and adolescents who have viral infections, such as chickenpox.
88. A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? A: Ginkgo biloba B: Digoxin C: Hydrochlorothiazide D: Acetaminophen
C: Hydrochlorothiazide Rational: The nurse should identify that hydrochlorothiazide, a thiazide diuretic, is the first class of medication to administer to a client who has hypertension. Hydrochlorothiazide inhibits sodium, chloride, and water reabsorption in the distal tubules of the kidneys.
- A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching?
A: Inhale the second puff of cromolyn 2 min after the first.
B: Use the cromolyn following exercise if shortness of breath occurs.
C: Use the albuterol prior to planned exercise.
D: Cleanse the albuterol mouthpiece once every 2 weeks.
C: Use the albuterol prior to planned exercise.
Rational: Albuterol is a short-acting beta adrenergic medication that causes bronchodilation. In children who have exercise-induced asthma, albuterol is used prophylactically 5 to 20 min prior to exercise.
- A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take?
A: Administer an antiviral medication to the infant.
B: Initiate droplet precautions for the infant.
C: Limit the infant’s oral intake of fluids to 60 mL/hr.
D: Monitor the infant for manifestations of increased intracranial pressure
B: Initiate droplet precautions for the infant.
Rational: The nurse should initiate droplet precautions for an infant who has pertussis. Other actions the nurse should take include providing humidified oxygen and suctioning secretions to prevent choking.
91. A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider? A: Black, tarry stools B: Ringing in the ears C: Urinary retention D: Recent hallucinations
A: Black, tarry stools
Rational: A life-threatening adverse effect of warfarin is bleeding. The nurse should identify that black, tarry stools are an indication that the client is experiencing gastrointestinal bleeding. The nurse should report this information to the provider.
92. A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? A: Congenital hypothyroidism B: Meconium staining at birth C: Macrosomic at birth D: Congenital heart disease
D: Congenital heart disease
Rational: The nurse should include congenital heart disease as a risk factor for an infant developing failure to thrive. Other risk factors include neglect, parental restriction of the infant’s intake, or genetic anomalies.
93. A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? A: Decreased salivation B: Diarrhea C: Tonsillitis D: Globus
D: Globus
Rational: The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat.
- A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching?
A: “I will have my best vision 3 weeks after my surgery.”
B: “I should report a creamy white discharge from my eye to my doctor.”
C: “I will avoid getting water in my eyes until the second day after surgery.”
D: “I should avoid using the vacuum cleaner for several weeks.”
D: “I should avoid using the vacuum cleaner for several weeks.”
Rational: The nurse should instruct the client to avoid using the vacuum cleaner for several weeks. The forward flexion and rapid, jerking movements that occur while vacuuming can increase intraocular pressure.
95. A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? A: Coolness B: Hyperpigmentation C: Swelling D: Distended, tortuous veins
C: Swelling
Rational: The nurse should identify that swelling of the affected extremity is a manifestation of a DVT. Additional manifestations include redness, warmth, and aching of the affected extremity.
96. A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? (Select all that apply.) A: Abdominal distention B: Flank pain C: Hypervolemia D: Vomiting E: Hyperactive bowel sounds
A: Abdominal distention
Rational: A client who has a small bowel obstruction will manifest abdominal distention from the buildup of intestinal contents that are unable to advance through the intestines
D: Vomiting
Rational: A client who has a small bowel obstruction can experience nausea and vomiting. Emesis might contain fecal contents.
E: Hyperactive bowel sounds
Rational: A client who has a small bowel obstruction will initially manifest increased bowel sounds, also known as borborygmi, as peristalsis heightens in an attempt to move the blocked intestinal contents forward.
97. A nurse is admitting a clent who has pepetic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? (Select all that apply.) A: Dark, tarry stools B: Bright red emesis C: Increased heart rate D: Increased blood pressure E: Bounding peripheral pulses -
A: Dark, tarry stools
Rational: The nurse should expect the client to have dark, tarry, and sticky stools containing old blood as a result of the bleed.
B: Bright red emesis
Rational: The nurse should expect the client to have bright red blood emesis, or hematemesis.
C: Increased heart rate
Rational: The nurse should expect the client to have an increase in heart rate as a result of the body’s response to the loss of blood volume caused by bleeding or hemorrhaging.
98. A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? A: Potassium level 4.2 mEq/L B: WBC count 10,000/mm3 C: Magnesium 2 mEq/L D: Creatinine 2.5 mg/dL -
D: Creatinine 2.5 mg/dL
Rational: The greatest risk to this client is injury from decreased renal function evidenced by a creatinine level greater than the expected reference range of 0.5 to 1.3 mg/dL. Aminoglycoside antibiotics, such as gentamicin, are nephrotoxic and ototoxic. Therefore, the priority finding for the nurse to report to the provider is the client’s elevated creatinine level.
- A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take?
A: Monitor intake and output.
B: Provide teaching about antibiotic therapy.
C: Administer the influenza vaccine.
D: Observe the client perform incentive spirometry
D: Observe the client perform incentive spirometry.
Rational: When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions.
100. A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? A: Focuses on the source of the anxiety B: Exhibits an inability to speak C: Experiences auditory hallucinations D: Feels surroundings are unreal
A: Focuses on the source of the anxiety
Rational: The nurse should expect a client who is experiencing a moderate level of anxiety to be focused on the cause of the anxiety. The client has a decreased attention span but is able to follow simple directions.
101. A nurse is caring for a client who has a deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescriptions should the nurse expect the provider to prescribe? A: Vitamin K B: Protamine sulfate C: Flumazenil D: Acetylcysteine
B: Protamine sulfate
Rational: The nurse should expect the provider to prescribe protamine sulfate to reverse the anticoagulant effects of the heparin. A client who is receiving heparin is at risk for increased bleeding with manifestations such as abdominal pain, frank or occult blood in stools, petechiae, and changes in level of consciousness.
- A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching?
A: “I will drink one and a half liters of fluids every day.”
B: “I will get the pneumonia vaccine yearly.”
C: “I will spray an aerosol disinfectant in my house every day.”
D: “I will wash my hands whenever I come home from the grocery store.”
D: “I will wash my hands whenever I come home from the grocery store.”
Rational: The client should wash his hands upon returning home from public places and avoid crowds during cold and flu season. Handwashing can prevent the spread of germs, which can cause illness.
103. A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? A: Jugular vein distention B: Fatigue C: Angina D: Hacking cough
A: Jugular vein distention
Rational: The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system.
- A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include?
A: Monitor the site daily for drainage.
B: Leave the pressure dressing on for 48 hr.
C: Administer aspirin if the child reports pain.
D: Resume tub baths in 24 hr.
A: Monitor the site daily for drainage.
Rational: The nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider.
105. A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? (Select all that apply.) A: Lidocaine 5% patches B: Celecoxib C: Vancomycin D: Cyclobenzaprine E: Glucosamine -
A: Lidocaine 5% patches
Rational: The nurse should identify lidocaine 5% patches as a topical medication that can relieve joint pain associated with osteoarthritis.
B: Celecoxib
Rational: The nurse should identify celecoxib as a cyclooxygenase-2 (COX-2) inhibitor that treats osteoarthritis pain. Providers usually prescribe celecoxib when over-the-counter medications, such as NSAIDs, are no longer effective in relieving osteoarthritis pain.
D: Cyclobenzaprine
Rational: The nurse should identify cyclobenzaprine as a muscle relaxant medication that relieves muscle spasms in the back that can occur with osteoarthritis of the vertebral column.
E: Glucosamine
Rational: The nurse should identify glucosamine as an over-the-counter dietary supplement that clients can take to relieve osteoarthritis discomfort.
106. A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as a part of the second stage of the grieving process? A: Persistent feelings of hopelessness B: Loss of self-esteem C: Chronic physical manifestations D: Feeling anger toward family members
D: Feeling anger toward family members
Rational: The nurse should identify that feelings of anger towards herself, her partner, and others is an expected grief reaction and is identified as the second stage of the grieving process.
107. A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? A: Methylphenidate B: Escitalopram C: Varenicline D: Lithium carbonate
B: Escitalopram
Rational: The nurse should plan to administer escitalopram, an antidepressant medication, to a client who has generalized anxiety disorder. Escitalopram is a selective serotonin reuptake inhibitor (SSRI) that decreases anxiety and panic attack.
108. A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following should the nurse identify as a risk factor for this condition? A: Heredity B: Gender C: Anemia D: Hypoglycemia
A: Heredity
Rational: The nurse should identify that a common risk factor for glaucoma is heredity. Other risk factors can include aging, central retinal vein occlusion, hypertension, diabetes mellitus, retinal detachment, and severe myopia.
109. A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? A: Cold intolerance B: Diaphoresis C: Weight loss D: Tachycardia
A: Cold intolerance
Rational: The nurse should expect a client to have cold intolerance, weight gain, poor wound healing, bradycardia, hypotension, depression, constipation, and decreased body temperature as manifestations of hypothyroidism.
- A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching?
A: “I should wash my feet with soap before I try to treat my calluses.”
B: “I should limit wearing the same shoes 2 days in a row.”
C: “I should use home remedies to treat any blisters or sores on my feet.”
D: “I should use adhesive tape to secure a dressing on my foot when I have skin breakdown.”
B: “I should limit wearing the same shoes 2 days in a row.”
Rational: The client should limit wearing the same shoes 2 days in a row to prevent tissue injury of the skin on the feet.
