Exit 24

Question 1

A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?

A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer

Answer 1

B. Lung cancer

Option B: Lung cancer is the most deadly type of cancer in both women and men.
Options A, C, and D: Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma.

Question 2

Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:

A. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
B. chest pain, dyspnea, cough, weight loss, and fever.
C. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
D. hoarseness and dysphagia.

Answer 2

A. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.

Miosis means excessive constriction (shrinking) of your pupil. In miosis, the diameter of the pupil is less than 2 millimeters (mm).
Anhidrosis is a condition in which you can’t sweat (perspire) normally in one or more areas of your body.

Option A: Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.

Option B: Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors.
Option C: Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast’s tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus.
Option D: Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus.

Question 3

Vic asks the nurse what PSA is. The nurse should reply that it stands for:

A. prostate-specific antigen, which is used to screen for prostate cancer.
B. protein serum antigen, which is used to determine protein levels.
C. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

Answer 3

A. prostate-specific antigen, which is used to screen for prostate cancer.

Option A: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.

Options B, C, and D: The other answers are incorrect.

Question 4

What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?

A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the physician.”

Answer 4

D. “Remain supine for the time specified by the physician.”

Option D: The nurse should instruct the client to remain supine for the time specified by the physician.

Option A: Local anesthetics used in a subarachnoid block don’t alter the gag reflex.
Option B: No interactions between local anesthetics and food occur.
Option C: Local anesthetics don’t cause hematuria.

Question 5

A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan

Answer 5

C. Sigmoidoscopy

Option C: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers.

Option A: Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn’t confirm the diagnosis.
Option B: CEA may be elevated in colorectal cancer but isn’t considered a confirming test.
Option D: An abdominal CT scan is used to stage the presence of colorectal cancer.

Question 6

During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

A. Slight asymmetry of the breasts
B. A fixed nodular mass with dimpling of the overlying skin
C. Bloody discharge from the nipple
D. Multiple firm, round, freely movable masses that change with the menstrual cycle

Answer 6

B. A fixed nodular mass with dimpling of the overlying skin

Option B: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer.

Option A: Many women have slightly asymmetrical breasts.
Option C: Bloody nipple discharge is a sign of intraductal papilloma, a benign condition.
Option D: Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.

Question 7

A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)

Answer 7

A. Liver

Option A: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain.

Options B, C, and D: The colon, reproductive tract, and WBCs are occasional metastasis sites.

Question 8

Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.

Answer 8

D. The client wears a watch and wedding band.

Option D: During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others.

Options A and B: The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel.
Option C: The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.

Question 9

Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
B. To avoid fractures, the client should avoid strenuous exercise.
C. The recommended daily allowance of calcium may be found in a wide variety of foods.
D. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

Answer 9

C. The recommended daily allowance of calcium may be found in a wide variety of foods.

Option C: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It’s often, though not always, possible to get the recommended daily requirement in the foods we eat.

Option D: Supplements are available but not always necessary.
Option A: Osteoporosis doesn’t show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry قياس الكثافة can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk.
Option B: Strenuous exercise won’t cause fractures.

Question 10

Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness

Answer 10

C. Joint flexion of less than 50%

Option C: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections.

Option A: Joint pain may be an indication, not a contraindication, for arthroscopy.
Options B and D: Joint deformity and joint stiffness aren’t contraindications for this procedure.

Question 11

Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?

A. Septic arthritis
B. Traumatic arthritis
C. Intermittent arthritis
D. Gouty arthritis

Answer 11

D. Gouty arthritis

Option D: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don’t occur in septic or traumatic arthritis.

Option A: Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining.
Option B: Traumatic arthritis results from blunt trauma to a joint or ligament.
Option C: Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees.

Question 12

A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?

A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour

Answer 12

B. 30 ml/hour

Option B: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.

25000 u ÷ 500 ml = 50 u/ml
1500 u/hr ÷ 50 u/ml = 30 ml/hr

Question 13

A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?

A. Elbow contracture secondary to spasticity
B. Loss of muscle contraction decreasing venous return
C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus

Answer 13

B. Loss of muscle contraction decreasing venous return

Option B: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity.

Option A: Contractures or bony calcifications may occur with a stroke, but don’t appear with swelling.
Option C: DVT may develop in clients with a stroke but is more likely to occur in the lower extremities.
Option D: A stroke isn’t linked to protein loss.

Question 14

Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?

A. It appears only in men
B. It appears on the distal interphalangeal joint
C. It appears on the proximal interphalangeal joint
D. It appears on the dorsolateral aspect of the interphalangeal joint.

Answer 14

B. It appears on the distal interphalangeal joint

Option B: Heberden’s nodes appear on the distal interphalangeal joint on both men and women.

Option D: Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal joint.

Question 15

Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?

A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
D. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t

Answer 15

B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic

Option B: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic.

Option A: Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is.
Option D: Clients have dislocations and subluxations in both disorders.

Question 16

Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?

A. A walker is a better choice than a cane
B. The cane should be used on the affected side
C. The cane should be used on the unaffected side
D. A client with osteoarthritis should be encouraged to ambulate without the cane

Answer 16

C. The cane should be used on the unaffected side

Option C: A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints.

Question 17

A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
B. 21 U regular insulin and 9 U NPH.
C. 10 U regular insulin and 20 U NPH.
D. 20 U regular insulin and 10 U NPH.’

Answer 17

A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).

Option A: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin.

Options B, C, and D: The other choices are incorrect dosages for the prescribed insulin.

Question 18

Nurse Len should expect to administer which medication to a client with gout?

A. aspirin
B. furosemide (Lasix)
C. colchicines
D. calcium gluconate (Kalcinate)

Answer 18

C. colchicines

Option C: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation.

Option A: Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn’t indicated for gout because it has no effect on urate crystal formation.
Option B: Furosemide, a diuretic, doesn’t relieve gout.
Option D: Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout.

Question 19

Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?

A. Adrenal cortex
B. Pancreas
C. Adrenal medulla
D. Parathyroid

Answer 19

A. Adrenal cortex

Option A: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions.

Option B: The pancreas mainly secretes hormones involved in fuel metabolism.
Option C: The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine.
Option D: The parathyroids secrete parathyroid hormone.

Question 20

For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

A. They contain exudate and provide a moist wound environment.
B. They protect the wound from mechanical trauma and promote healing.
C. They debride the wound and promote healing by secondary intention.
D. They prevent the entrance of microorganisms and minimize wound discomfort.

Answer 20

C. They debride the wound and promote healing by secondary intention

Option C: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention.

Option A: Moist, transparent dressings contain exudate and provide a moist wound environment.
Option D: Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.
Option B: Dry sterile dressings protect the wound from mechanical trauma and promote healing.

Question 21

Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

A. Hyperkalemia
B. Reduced blood urea nitrogen (BUN)
C. Hypernatremia
D. Hyperglycemia

Answer 21

A. Hyperkalemia

Option A: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion.

Option B: BUN increases as the glomerular filtration rate is reduced.
Option C: Hyponatremia is caused by reduced aldosterone secretion.
Option D: Reduced cortisol secretion leads to impaired gluconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

Question 22

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

A. Infusing I.V. fluids rapidly as ordered
B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V. fluids as ordered

Answer 22

C. Restricting fluids

Option C: To reduce water retention in a client with the SIADH, the nurse should restrict fluids.

Options A, B, and D: Administering fluids by any route would further increase the client’s already heightened fluid load.

Question 23

A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:

A. urine glucose level.
B. fasting blood glucose level.
C. serum fructosamine level.
D. glycosylated hemoglobin level.

Answer 23

D. glycosylated hemoglobin level.

Option D: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day lifespan of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months.

Options A and B: Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained.
Option C: Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

Question 24

Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

A. 10:00 am
B. Noon
C. 4:00 pm
D. 10:00 pm

Answer 24

C. 4:00 pm

Option C: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.

Question 25

The adrenal cortex is responsible for producing which substances?

A. Glucocorticoids and androgens
B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
D. Norepinephrine and epinephrine

Answer 25

A. Glucocorticoids and androgens

Option A: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens.

Options B and D: The medulla produces catecholamines — epinephrine and norepinephrine.

Question 26

On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia

Answer 26

A. Hypocalcemia

Option A: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn’t directly cause serum sodium, potassium, or magnesium abnormalities.

Option B: Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery.
Options C and D: Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.

Question 27

Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?

A. Acid phosphatase level
B. Serum calcitonin level
C. Alkaline phosphatase level
D. Carcinoembryonic antigen level

Answer 27

D. Carcinoembryonic antigen level

Option D: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can’t be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful.

Option A: An elevated acid phosphatase level may indicate prostate cancer.
Option C: An elevated alkaline phosphatase level may reflect bone metastasis.
Option B: An elevated serum calcitonin level usually signals thyroid cancer.

Question 28

Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

A. Nights sweats, weight loss, and diarrhea
B. Dyspnea, tachycardia, and pallor
C. Nausea, vomiting, and anorexia
D. Itching, rash, and jaundice

Answer 28

B. Dyspnea, tachycardia, and pallor

Option B: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache.

Option A: Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS).
Option C: Nausea, vomiting, and anorexia may be signs of hepatitis B.
Option D: Itching, rash, and jaundice may result from an allergic or hemolytic reaction.

Question 29

In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:

A. “The baby can get the virus from my placenta.”
B. “I’m planning on starting on birth control pills.”
C. “Not everyone who has the virus gives birth to a baby who has the virus.”
D. “I’ll need to have a C-section if I become pregnant and have a baby.”

Answer 29

D. “I’ll need to have a C-section if I become pregnant and have a baby.”

Option D: A Cesarean section delivery isn’t necessary when the mother is HIV-positive.

Option A: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route.
Option B: The use of birth control will prevent the conception of a child who might have HIV.
Option C: It’s true that a mother who’s HIV positive can give birth to a baby who’s HIV negative.

Question 30

When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?

A. “Put on disposable gloves before bathing.”
B. “Sterilize all plates and utensils in boiling water.”
C. “Avoid sharing such articles as toothbrushes and razors.”
D. “Avoid eating foods from serving dishes shared by other family members.”

Answer 30

C. “Avoid sharing such articles as toothbrushes and razors.”

Option C: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn’t share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members.

Options A, B, and D: HIV isn’t transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.

Question 31

Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

A. Pallor, bradycardia, and reduced pulse pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia

Answer 31

B. Pallor, tachycardia, and a sore tongue

Option B: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet.

Options A, C, and D: Bradycardia, reduced pulse pressure, weight gain, and double vision aren’t characteristic findings in pernicious anemia.

Question 32

After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?

A. Page an anesthesiologist immediately and prepare to intubate the client.
B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

Answer 32

B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.

Option B: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed.

Option A: The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don’t relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client.
Option C: No antidote for penicillin exists; however, the nurse should continue to monitor the client’s vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

Question 33

Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

A. weight gain.
B. fine motor tremors.
C. respiratory acidosis.
D. bilateral hearing loss.

Answer 33

D. bilateral hearing loss.

Option D: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued.

Options A and B: Aspirin doesn’t lead to weight gain or fine motor tremors.
Option C: Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis.

Question 34

A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?

A. Neutrophil
B. Basophil
C. Monocyte
D. Lymphocyte

Answer 34

D. Lymphocyte

Option D: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively.

Option A: The neutrophil is crucial to phagocytosis.
Option B: The basophil plays an important role in the release of inflammatory mediators.
Option C: The monocyte functions in phagocytosis and monokine production.

Question 35

In an individual with Sjögren’s syndrome, nursing care should focus on:

A. moisture replacement.
B. electrolyte balance.
C. nutritional supplementation.
D. arrhythmia management.

Answer 35

A. moisture replacement.

Option A: Sjogren’s syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy.

Options B and C: Though malnutrition and electrolyte imbalance may occur as a result of Sjogren’s syndrome effect on the GI tract, it isn’t the predominant problem.
Option D: Arrhythmias aren’t a problem associated with Sjogren’s syndrome.

Question 36

During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:

A. enzyme-linked immunosuppressant assay (ELISA) test.
B. electrolyte panel and hemogram.
C. stool for Clostridium difficile test.
D. flat plate X-ray of the abdomen.

Answer 36

C. stool for Clostridium difficile test.

Option C: Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes “horse barn” smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test.

Option A: The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn’t indicated in this case.
Option B: An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren’t diagnostic for specific causes of diarrhea.
Option D: A flat plate of the abdomen may provide useful information about bowel function but isn’t indicated in the case of “horse barn” smelling diarrhea.

Question 37

A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:

A. E-rosette immunofluorescence.
B. Quantification of T-lymphocytes.
C. Enzyme-linked immunosorbent assay (ELISA).
D. Western blot test with ELISA.

Answer 37

D. Western blot test with ELISA.

Option D: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn’t specific when used alone.

Option A: E-rosette immunofluorescence is used to detect viruses in general; it doesn’t confirm HIV infection.
Option B: Quantification of T-lymphocytes is a useful monitoring test but isn’t diagnostic for HIV.
Option C: The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.

Question 38

A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?

A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
B. Low levels of urine constituents normally excreted in the urine
C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly

Answer 38

C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

Option C: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases.

Option A: Possible renal failure is indicated by elevated BUN or creatinine levels.
Option B: Urine constituents aren’t found in the blood.
Option D: Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.

Question 39

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

A. Platelet count, prothrombin time, and partial thromboplastin time
B. Platelet count, blood glucose levels, and white blood cell (WBC) count
C. Thrombin time, calcium levels, and potassium levels
D. Fibrinogen level, WBC, and platelet count

Answer 39

A. Platelet count, prothrombin time, and partial thromboplastin time

Option A: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors.

Options B, C, and D: Blood glucose levels, WBC count, calcium levels, and potassium levels aren’t used to confirm a diagnosis of DIC.

Question 40

When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?

A. Bread
B. Carrots
C. Orange
D. Strawberries

Answer 40

D. Strawberries

Option D: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.

Options A, B, and C: Bread, carrots, and oranges rarely cause allergic reactions.

Question 41

Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?

A. A client with hepatitis A who states, “My arms and legs are itching.”
B. A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
C. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”

Answer 41

B. A client with cast on the right leg who states, “I have a funny feeling in my right leg.”

Option B: It may indicate neurovascular compromise, requires immediate assessment.

Question 42

Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?

A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
D. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

Answer 42

D. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

Option D: The client is at risk for peritonitis; should be assessed for further symptoms and infection.

Question 43

Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?

A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
B. The client supports his head and neck when turning his head to the right.
C. The client spontaneously flexes his wrist when the blood pressure is obtained.
D. The client is drowsy and complains of sore throat.

Answer 43

C. The client spontaneously flexes his wrist when the blood pressure is obtained.

Option C: Carpal spasms indicate hypocalcemia.

Question 44

Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?

A. Encourage the client to change positions frequently in bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the client.

Answer 44

D. Use comfort measures and pillows to position the client.

Option D: Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief.

Question 45

Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?

A. Assess for a bruit and a thrill.
B. Warm the dialysate solution.
C. Position the client on the left side.
D. Insert a Foley catheter.

Answer 45

B. Warm the dialysate solution.

Option B: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven.

Question 46

Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?

A. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
B. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
D. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

Answer 46

C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.

Option C: The cane acts as a support and aids in weight bearing for the weaker right leg.

Question 47

An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?

A. Ask the woman’s family to provide personal items such as photos or mementos.
B. Select a room with a bed by the door so the woman can look down the hall.
C. Suggest the woman eat her meals in the room with her roommate.
D. Encourage the woman to ambulate in the halls twice a day.

Answer 47

A. Ask the woman’s family to provide personal items such as photos or mementos.

Option A: Photos and mementos provide visual stimulation to reduce sensory deprivation.

Question 48

Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?

A. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
C. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
D. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.

Answer 48

B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.

Option B: A walker needs to be picked up, placed down on all legs.

Question 49

Nurse Derek is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?

A. Increased sensitivity to the side effects of medications.
B. Decreased visual, auditory, and gustatory abilities.
C. Isolation from their families and familiar surroundings.
D. Decrease musculoskeletal function and mobility.

Answer 49

B. Decreased visual, auditory, and gustatory الطعم abilities.

Option B: Gradual loss of sight, hearing, and taste interferes with normal functioning.

Question 50

A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?

A. Encourage the client to perform pursed-lip breathing.
B. Check the client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.

Answer 50

A. Encourage the client to perform pursed-lip breathing.

Option A: Pursed lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.