Exit 23

Question 1

Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:

A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed

Answer 1

C. Loose, bloody

Option C: Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.

Question 2

Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia عمى نصفي متماثل?

A. On the client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like

Answer 2

A. On the client’s right side

Option A: The client has left visual field blindness. The client will see only from the right side.

Question 3

A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

A. Check respiration, circulation, neurological response.
B. Align the spine, check pupils, and check for hemorrhage.
C. Check respirations, stabilize spine, and check circulation.
D. Assess level of consciousness and circulation.

Answer 3

C. Check respirations, stabilize spine, and check circulation

Option C: Checking the airway would be the priority, and a neck injury should be suspected.

Question 4

In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

A. Increasing contractility and slowing heart rate.
B. Increasing AV conduction and heart rate.
C. Decreasing contractility and oxygen consumption.
D. Decreasing venous return through vasodilation.

Answer 4

D. Decreasing venous return through vasodilation.

Option D: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.

Question 5

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the precordium, and check the pulse.
D. Administer two quick blows.

Answer 5

A. Call for help and note the time.

Option A: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.

Question 6

Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:

A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
B. Monitor vital signs every 2 hours.
C. Make sure that the client takes food and medications at prescribed intervals.
D. Provide milk every 2 to 3 hours.

Answer 6

C. Make sure that the client takes food and medications at prescribed intervals.

Option C: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.

Question 7

A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

A. Stop the I.V. infusion of heparin and notify the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is lower than normal.

Answer 7

B. Continue treatment as ordered.

Option B: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.

Question 8

A client underwent ileostomy, when should the drainage appliance be applied to the stoma?

A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begins to function.
D. When the client is able to begin self-care procedures.

Answer 8

B. In the operating room.

Option B: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated مقشر.

Question 9

A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

A. On the side, to prevent obstruction of airway by tongue.
B. Flat on back.
C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned to the side.

Answer 9

B. Flat on back.

Option B: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by the seepage تسرب of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.

Question 10

While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

A. Blood pressure is decreased from 160/90 to 110/70.
B. Pulse is increased from 87 to 95, with an occasional skipped beat.
C. The client is oriented when aroused from sleep and goes back to sleep immediately.
D. The client refuses dinner because of anorexia.

Answer 10

C. The client is oriented when aroused from sleep and goes back to sleep immediately.

Option C: This finding suggests that the level of consciousness is decreasing.

Question 11

Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough

Answer 11

A. Altered mental status and dehydration

Options B, C, and D: Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia.

Option A: Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response

Question 12

A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?

A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and nausea
D. Headache and photophobia

Answer 12

B. Chills, fever, night sweats, and hemoptysis

Option B: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.

Option A: Chest pain may be present from coughing but isn’t usual.
Option C: Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C).
Option D: Nausea, headache, and photophobia aren’t usual TB symptoms.

Question 13

Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

A. Acute asthma
B. Bronchial pneumonia
C. Chronic obstructive pulmonary disease (COPD)
D. Emphysema

Answer 13

A. Acute asthma

Option A: Based on the client’s history and symptoms, acute asthma is the most likely diagnosis.

Options B, C, and D: He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too young to have developed (COPD) and emphysema.

Question 14

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

A. Asthma attack
B. Respiratory arrest
C. Seizure
D. Wake up on his own

Answer 14

B. Respiratory arrest

Option B: Narcotics can cause respiratory arrest if given in large quantities.

Options A, C, and D: It’s unlikely the client will have asthma attack or a seizure or wake up on his own.

Question 15

A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

A. Increased elastic recoil of the lungs
B. Increased number of functional capillaries in the alveoli
C. Decreased residual volume
D. Decreased vital capacity

Answer 15

D. Decreased vital capacity

Option D: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume.

Question 16

Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?

A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
B. Increase in systemic blood pressure.
C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
D. Increase in intracranial pressure (ICP).

Answer 16

C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.

Option C: Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor.

Options A, B, and D: SaO2, blood pressure, and ICP are important factors but aren’t as significant as PVCs in the situation.

Question 17

Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

A. Report incidents of diarrhea.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving.
D. Take aspirin for pain relief.

Answer 17

B. Avoid foods high in vitamin K

Option B: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation.

Option A: The client may need to report diarrhea but isn’t effect of taking an anticoagulant.
Option C: An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding.
Option D: Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief.

Question 18

Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory مزيل الشعر

Answer 18

C. Clipping the hair in the area

Option C: Hair can be a source of infection and should be removed by clipping.

Option B and D: Shaving the area can cause skin abrasions and depilatories can irritate the skin.

Question 19

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

A. Bone fracture
B. Loss of estrogen
C. Negative calcium balance
D. Dowager’s hump

Answer 19

A. Bone fracture

Option A: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones.

Option B: Estrogen deficiencies result from menopause and not osteoporosis.
Option C: Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis.
Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

Question 20

Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations.
D. Fibrocystic masses

Answer 20

C. Changes from previous examinations.

Option C: Women are instructed to examine themselves to discover changes that have occurred in the breast.

Options A, B, and D: Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

Question 21

When caring for a female client who is being treated for hyperthyroidism, it is important to:

A. Provide extra blankets and clothing to keep the client warm.
B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
C. Balance the client’s periods of activity and rest.
D. Encourage the client to be active to prevent constipation.

Answer 21

C. Balance the client’s periods of activity and rest.

Option C: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.

Question 22

Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.

Answer 22

B. Increase his activity level.

Option B: The client should be encouraged to increase his activity level.

Options A, C, and D: Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.

Question 23

Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy

Answer 23

A. Laminectomy

Option A: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning.

Options B and D: Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position.
Option C: Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

Question 24

A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?

A. Avoid lifting objects weighing more than 5 lb (2.25 kg).
B. Lie on your abdomen when in bed.
C. Keep rooms brightly lit.
D. Avoiding straining during bowel movement or bending at the waist.

Answer 24

D. Avoiding straining during bowel movement or bending at the waist.

Option D: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure.

Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb.
Option B: Instruct the client when lying in bed to lie on either the side or back.
Option C: The client should avoid bright light by wearing sunglasses.

Question 25

George should be taught about testicular examinations during:

A. when sexual activity starts
B. After age 69
C. After age 40
D. Before age 20

Answer 25

D. Before age 20.

Option D: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.

Question 26

A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:

A. Call the physician.
B. Place a saline-soaked sterile dressing on the wound.
C. Take a blood pressure and pulse.
D. Pull the dehiscence closed.

Answer 26

B. Place a saline-soaked sterile dressing on the wound.

Option B: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection.

Options A and C: Then the nurse should call the physician and take the client’s vital signs.
Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it.

Question 27

Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:

A. A progressively deeper breath followed by shallower breaths with apneic periods.
B. Rapid, deep breathing with abrupt pauses between each breath.
C. Rapid, deep breathing and irregular breathing without pauses.
D. Shallow breathing with an increased respiratory rate.

Answer 27

A progressively deeper breaths followed by shallower breaths with apneic periods.

Option A: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneas periods.

Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath.
Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.
Option D: Tachypnea is shallow breathing with increased respiratory rate.

Question 28

Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

A. Tracheal
B. Fine crackles
C. Coarse crackles
D. Friction rubs

Answer 28

B. Fine crackles

Option B: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure.

Option A: Tracheal breath sounds are auscultated over the trachea.
Option C: Coarse crackles are caused by secretion accumulation in the airways.
Option D: Friction rubs occur with pleural inflammation.

Question 29

The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:

A. The attack is over.
B. The airways are so swollen that no air cannot get through.
C. The swelling has decreased.
D. Crackles have replaced wheezes.

Answer 29

B. The airways are so swollen that no air cannot get through

Option B: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through.

Options A and C: If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern.
Option D: Crackles do not replace wheezes during an acute asthma attack.

Question 30

Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

A. Place the client on his back remove dangerous objects, and insert a bite block.
B. Place the client on his side, remove dangerous objects, and insert a bite block.
C. Place the client o his back, remove dangerous objects, and hold down his arms.
D. Place the client on his side, remove dangerous objects, and protect his head.

Answer 30

D. Place the client on his side, remove dangerous objects, and protect his head.

Option D: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury.

Options A and B: A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration.

Question 31

After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

A. Infection of the lung
B. Kinked or obstructed chest tube
C. Excessive water in the water-seal chamber
D. Excessive chest tube drainage

Answer 31

B. Kinked or obstructed chest tube

Option B: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.

Option A: Infection and excessive drainage won’t cause a tension pneumothorax.
Option C: Excessive water won’t affect the chest tube drainage.

Question 32

Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:

A. Stand him up and perform the abdominal thrust maneuver from behind.
B. Lay him down, straddle him, and perform the abdominal thrust maneuver.
C. Leave him to get assistance.
D. Stay with him but not intervene at this time.

Answer 32

D. Stay with him but not intervene at this time.

Option D: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing.

Option B: If the client is unconscious, she should lay him down.
Option C: A nurse should never leave a choking client alone.

Question 33

Nurse Ron is taking a health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?

A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.

Answer 33

B. Current health promotion activities

Option B: Recognizing an individual’s positive health measures is very useful.

Option A: General health in the previous 10 years is important, however, the current activities of an 84-year-old client are most significant in planning care.
Option C: Family history of disease for a client in later years is of minor significance.
Option D: Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem.

Question 34

When performing oral care on a comatose client, Nurse Krina should:

A. Apply lemon glycerin to the client’s lips at least every 2 hours.
B. Brush the teeth with client lying supine.
C. Place the client in a side-lying position, with the head of the bed lowered.
D. Clean the client’s mouth with hydrogen peroxide.

Answer 34

C. Place the client in a side-lying position, with the head of the bed lowered.

Option C: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions.

Option A: Lemon glycerin can be drying if used for extended periods.
Option B: Brushing the teeth with the client lying supine may lead to aspiration.
Option D: Hydrogen peroxide is caustic to tissues and should not be used.

Question 35

A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)
B. Myocardial infarction (MI)
C. Pneumonia
D. Tuberculosis

Answer 35

C. Pneumonia

Option C: Fever, productive cough and pleuritic chest pain are common signs and symptoms of pneumonia.

Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively.
Option B: Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI.
Option D: The client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions.

Question 36

Nurse Oliver is working in a outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?

A. A 16-year-old female high school student
B. A 33-year-old daycare worker
C. A 43-year-old homeless man with a history of alcoholism
D. A 54-year-old businessman

Answer 36

C. A 43-year-old homeless man with a history of alcoholism

Option C: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB.

Options A, B, and D: A high school student, daycare worker, and businessman probably have a much low risk of contracting TB.

Question 37

Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

A. To confirm the diagnosis
B. To determine if a repeat skin test is needed
C. To determine the extent of lesions
D. To determine if this is a primary or secondary infection

Answer 37

C. To determine the extent of lesions

Option C: If the lesions are large enough, the chest X-ray will show their presence in the lungs.

Option A: Sputum culture confirms the diagnosis.
Option B: There can be false-positive and false-negative skin test results.
Option D: A chest X-ray can’t determine if this is a primary or secondary infection.

Question 38

Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids

Answer 38

B. Bronchodilators

Option B: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow.

Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction.
Options C and D: Inhaled oral steroids may be given to reduce the inflammation but aren’t used for emergency relief.

Question 39

Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

Answer 39

C. Chronic obstructive bronchitis

Option C: Because of this extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis.

Option A: Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen.
Options B and D: Clients with asthma and emphysema tend not to have chronic cough or peripheral edema.

Question 40

Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

A. The patient is under local anesthesia during the procedure
B. The aspirated bone marrow is mixed with heparin.
C. The aspiration site is the posterior or anterior iliac crest.
D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.

Answer 40

A. The patient is under local anesthesia during the procedure

Option A: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.

Question 41

After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

A. Call the physician.
B. Document the patient’s status in his charts.
C. Prepare oxygen treatment.
D. Raise the side rails.

Answer 41

D. Raise the side rails

Option D: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety.

Question 42

During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

A. crowded red blood cells
B. is not responsible for the anemia.
C. uses nutrients from other cells
D. have an abnormally short lifespan of cells.

Answer 42

A. Crowd red blood cells

Option A: The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur.

Question 43

Diagnostic assessment of Francis would probably reveal:

A. Predominance of lymphoblasts
B. Leukocytosis
C. Abnormal blast cells in the bone marrow
D. Elevated thrombocyte counts

Answer 43

B. Leukocytosis

Option B: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone marrow, spleen and liver.

Question 44

Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?

A. Explain the risks of not having the surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes

Answer 44

A. Explain the risks of not having the surgery

Option A: The best initial response is to explain the risks of not having the surgery.

Options B, C, and D: If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client’s refusal in the nurses’ notes.

Question 45

During the endorsement, which of the following clients should the on-duty nurse assess first?

A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute
B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem)

Answer 45

D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem)

Option D: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring.

Options C and A: After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don’t require immediate attention).
Option B: The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures.

Question 46

Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines

Answer 46

C. Cocaine

Option C: Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction.

Option A: Barbiturate overdose may trigger respiratory depression and slow pulse.
Options B and D: Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion.

Question 47

A 51-year-old female client tells the nurse-in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?

A. Eversion of the right nipple and mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily delineated
D. Nonpalpable right axillary lymph nodes

Answer 47

B. Nonmobile mass with irregular edges

Option B: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges.

Option C: A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst.
Option D: Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass.
Option A: Nipple retraction — not eversion — may be a sign of cancer.

Question 48

A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?

A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy

Answer 48

C. Radiation

Option C: The usual treatment for vaginal cancer is external or intravaginal radiation therapy.

Option A: Less often, surgery is performed.
Option B: Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare.
Option D: Immunotherapy isn’t used to treat vaginal cancer.

Question 49

Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

Answer 49

B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Option B: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis.

Option A: No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0.
Option C: If the tumor and regional lymph nodes can’t be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0.
Option D: A progressive increase in tumor size, no demonstrable metastases of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

Question 50

Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially until you get used to the procedure.”
D. “Keep the stoma moist.”

Answer 50

D. “Keep the stoma moist.”

Option D: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated.

Option A: The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma.
Option C: The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.