Exit 5

Question 1

A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is NOT expected?

A. Increased urinary output.
B. Decreased edema.
C. Decreased pain.
D. Decreased blood pressure.

Answer 1

C. Decreased pain.

Furosemide, a loop diuretic, does not alter pain. It acts on the kidneys to increase urinary output, which can reduce fluid load, thus decreasing edema and blood pressure.

Question 2

There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?

A. Obesity.
B. Heredity.
C. Gender.
D. Age.

Answer 2

A. Obesity.

Obesity is a modifiable risk factor for coronary artery disease that can be managed through diet and weight loss. Family history, gender, and age are non-modifiable risk factors.

Question 3

Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?

A. Worsening chest pain that began earlier in the evening.
B. History of cerebral hemorrhage.
C. History of prior myocardial infarction.
D. Hypertension.

Answer 3

B. History of cerebral hemorrhage.

A history of cerebral hemorrhage is a contraindication to tPA because it increases the risk of bleeding. tPA works by dissolving clots but can cause significant bleeding complications in those with a history of cerebral hemorrhage.

Question 4

Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?

A. Increases fitness and prevents future heart attacks.
B. Prevents bedsores.
C. Prevents DVT (deep vein thrombosis).
D. Prevent constipation.

Answer 4

C. Prevents DVT (deep vein thrombosis).

Exercise is important for hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities.

Question 5

A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?

A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.

Answer 5

D. Confusion.

Cardiogenic shock impairs the heart’s pumping function, reducing blood flow to organs, including the brain, leading to confusion. It is characterized by hypotension, tachycardia, and weak pulse.

Question 6

A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?

A. Ask the patient to lie down on the exam table.
B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.

Answer 6

D. Check blood pressure.

Checking blood pressure is crucial as dyspnea in congestive heart failure patients may indicate pulmonary edema and severe hypertension.

Question 7

A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?

A. “Stop taking the nitroglycerin and see if the headaches improve.”
B. “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”
C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
D. “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.”

Answer 7

C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”

Nitroglycerin causes vasodilation, leading to headaches, dizziness, and hypotension. Patients should be advised on managing these side effects while continuing the medication.

Question 8

A patient received surgery and chemotherapy for colon cancer, completing therapy three (3) months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms?

A. The symptoms may be the result of anemia caused by chemotherapy.
B. The patient may be immunosuppressed.
C. The patient may be depressed.
D. The patient may be dehydrated.

Answer 8

A. The symptoms may be the result of anemia caused by chemotherapy.

Chemotherapy can cause anemia due to bone marrow suppression, leading to fatigue and difficulty concentrating.

Question 9

A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate?

A. The diet is providing adequate sources of iron and requires no changes.
B. The patient should add meat to her diet; a vegetarian diet is not advised.
C. The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables and legumes, which are high in iron.
D. A cup of coffee or tea should be added to every meal.

Answer 9

C. The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables and legumes, which are high in iron.

Iron cookware increases the iron content of food. Dark green leafy vegetables and legumes are good sources of iron, beneficial for a vegetarian with mild anemia.

Question 10

A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?

A. Transfusion reaction is most likely immediately after the infusion is completed.
B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution.
D. A nurse should remain in the room during the first 15 minutes of infusion.

Answer 10

D. A nurse should remain in the room during the first 15 minutes of infusion.

Transfusion reactions are most likely during the first 15 minutes of infusion, requiring the nurse’s presence to monitor for any adverse reactions.

Question 11

A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?

A. An increase in neutrophil count.
B. An increase in hematocrit.
C. An increase in platelet count.
D. An increase in serum iron.

Answer 11

B. An increase in hematocrit.

Epoetin stimulates red blood cell production, increasing hematocrit levels. It does not affect neutrophils, platelets, or serum iron levels.

Question 12

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply.

A. Weight loss.
B. Increased clotting time.
C. Hypertension.
D. Headaches.

Answer 12

B, C, and D.

Polycythemia vera increases blood viscosity, causing hypertension, headaches, and delayed clotting. Weight loss is not a typical symptom.

Question 13

A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?

A. Observe for evidence of spontaneous bleeding.
B. Limit visitors to family only.
C. Give aspirin in case of headaches.
D. Impose immune precautions.

Answer 13

A. Observe for evidence of spontaneous bleeding.

Platelet counts below 30,000/microliter can cause spontaneous petechiae and bruising. Below 15,000, spontaneous bleeding can occur, so monitoring for these signs is crucial.

Question 14

A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct.

A. Hypertension.
B. Cushingoid features.
C. Hyponatremia.
D. Low serum albumin.

Answer 14

A, B, and D.

Long-term corticosteroid use can cause hypertension, Cushingoid features, and low serum albumin due to fluid retention and protein metabolism changes. It typically causes hypernatremia, not hyponatremia.

Cushingoid Syndrome refers to the physical changes and clinical features that occur as a result of prolonged glucocorticoid administration, including truncal obesity, thinning of subcutaneous tissues, hypertension, and skin changes such as hirsutism and acne.

Question 15

A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

A. Change the disposable mask immediately after use.
B. Change gloves immediately after use.
C. Minimize patient contact.
D. Minimize conversation with the patient.

Answer 15

B. Change gloves immediately after use.

Neutropenic patients are highly susceptible to infections. Changing gloves immediately after use prevents the spread of contaminants and infections.

Question 16

A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?

A. We will bring in books and magazines for entertainment.
B. We will bring in personal care items for comfort.
C. We will bring in fresh flowers to brighten the room.
D. We will bring in family pictures and get well cards.

Answer 16

C. We will bring in fresh flowers to brighten the room.

Fresh flowers can carry microbes that are hazardous to immunocompromised patients. Books, magazines, personal care items, and family pictures can be sanitized to minimize infection risk.

Question 17

A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?

A. 3-10 years.
B. 25-35 years.
C. 45-55 years.
D. Over 60 years.

Answer 17

A. 3-10 years.

The peak incidence of ALL is between 3-10 years of age. It is less common in older age groups.

Question 18

A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?

A. Painful cervical lymph nodes.
B. Night sweats and fatigue.
C. Nausea and vomiting.
D. Weight gain.

Answer 18

B. Night sweats and fatigue.

Hodgkin’s disease typically presents with night sweats, fatigue, and painless, enlarged cervical lymph nodes.

Question 19

The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?

A. Reed-Sternberg cells.
B. Lymphoblastic cells.
C. Gaucher’s cells.
D. Rieder’s cells.

Answer 19

A. Reed-Sternberg cells.

Reed-Sternberg cells are characteristic of Hodgkin’s disease and are used for definitive diagnosis.

Question 20

A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?

A. Warn the patient to stay very still because the smallest movement will increase her pain.
B. Encourage the family to stay in the room for the procedure.
C. Stay with the patient and focus on slow, deep breathing for relaxation.
D. Delay the procedure to allow the patient to deal with her feelings.

Answer 20

C. Stay with the patient and focus on slow, deep breathing for relaxation.

Focusing on slow, deep breathing helps reduce anxiety and stress, promoting relaxation during the procedure.

Question 21

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

A. Body temperature of 99°F or less.
B. Toes moved in active range of motion.
C. Sensation reported when soles of feet are touched.
D. Capillary refill of < 3 seconds.

Answer 21

D. Capillary refill of < 3 seconds.

Assessing capillary refill helps monitor peripheral circulation, which is crucial in patients with sickle cell anemia to detect occlusions.

Question 22

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

A. Side-lying with knees flexed.
B. Knee-chest.
C. High Fowler’s with knees flexed.
D. Semi-Fowler’s with legs extended on the bed.

Answer 22

D. Semi-Fowler’s with legs extended on the bed.

Semi-Fowler’s position with legs extended promotes better oxygenation and reduces circulation impedance, crucial for managing sickle cell crisis.

Question 23

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

A. Taking hourly blood pressures with mechanical cuff.
B. Encouraging fluid intake of at least 200mL per hour.
C. Position in high Fowler’s with knee gatch raised.
D. Administering Tylenol as ordered.

Answer 23

B. Encouraging fluid intake of at least 200mL per hour.

Keeping the patient hydrated is crucial to prevent further sickling of blood cells.

Question 24

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

A. Peaches.
B. Cottage cheese.
C. Popsicle.
D. Lima beans.

Answer 24

C. Popsicle.

Popsicles help with hydration, which is essential in preventing thrombus formation in sickle cell crisis.

Question 25

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

A. Adjust the room temperature.
B. Give a bolus of IV fluids.
C. Start O2.
D. Administer meperidine (Demerol) 75 mg IV push.

Answer 25

C. Start O2.

Oxygenation takes precedence as low oxygen levels can worsen sickle cell crisis. Pain management and hydration follow as secondary interventions.

Question 26

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

A. Roast beef, gelatin salad, green beans, and peach pie.
B. Chicken salad sandwich, coleslaw, French fries, ice cream.
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie.
D. Pork chop, creamed potatoes, corn, and coconut cake.

Answer 26

C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie.

This meal plan includes foods high in iron, such as egg yolks, wheat bread, and raisins, which are important for treating iron-deficiency anemia.

Question 27

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

A. A family vacation in the Rocky Mountains.
B. Chaperoning the local boys club on a snow-skiing trip.
C. Traveling by airplane for business trips.
D. A bus trip to the Museum of Natural History.

Answer 27

D. A bus trip to the Museum of Natural History.

This activity does not pose a risk of hypoxia or hypoxemia, unlike high-altitude, cold-temperature, or air travel activities that can trigger sickling episodes.

Question 28

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

A. Palpate the spleen.
B. Take the blood pressure.
C. Examine the feet for petechiae.
D. Examine the tongue.

Answer 28

D. Examine the tongue.

Vitamin B12 deficiency causes a smooth, beefy red tongue. Other symptoms do not include splenomegaly, blood pressure changes, or petechiae.

Question 29

An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

A. Conjunctiva of the eye.
B. Soles of the feet.
C. Roof of the mouth.
D. Shins.

Answer 29

C. Roof of the mouth.

The hard palate is the best indicator of jaundice in dark-skinned individuals, as it can show yellow discoloration more distinctly.

The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. Skin assessment of patients with dark skin should be done in natural light when possible in order to ascertain the condition; it may be necessary to check mucous membranes, sclera, lips, nail beds, palms, and soles of feet for accurate assessment.

Question 30

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

A. BP 146/88.
B. Respirations 28 shallow.
C. Weight gain of 10 pounds in 6 months.
D. Pink complexion.

Answer 30

B. Respirations 28 shallow.

Anemia results in decreased oxygen-carrying capacity of the blood, leading to increased respiratory rate to compensate for hypoxia.

When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath. The client with anemia is often pale in color, has weight loss, and may be hypotensive.

Question 31

The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

A. “I will drink 500mL of fluid or less each day.”
B. “I will wear support hose when I am up.”
C. “I will use an electric razor for shaving.”
D. “I will eat foods low in iron.”

Answer 31

A. “I will drink 500mL of fluid or less each day.”

Patients with polycythemia vera should stay well-hydrated to prevent thrombosis. Drinking only 500mL of fluid daily is insufficient and increases the risk of clot formation.

The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation. Polycythemia vera is a slow-growing blood cancer in which the bone marrow makes too many red blood cells. These excess cells thicken blood, slowing its flow and causes complications, such as blood clots.

Question 32

A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
D. The client’s brother had leukemia as a child.

Answer 32

C. The client had radiation for treatment of Hodgkin’s disease as a teenager.

Previous radiation treatment for Hodgkin’s disease increases the risk of developing leukemia.

Question 33

An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

A. The abdomen.
B. The thorax.
C. The earlobes.
D. The soles of the feet.

Answer 33

D. The soles of the feet.

The soles of the feet are lighter in color and more likely to show petechiae in dark-skinned individuals.

Question 34

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

A. “Have you noticed a change in sleeping habits recently?”
B. “Have you had a respiratory infection in the last 6 months?”
C. “Have you lost weight recently?”
D. “Have you noticed changes in your alertness?”

Answer 34

B. “Have you had a respiratory infection in the last 6 months?”.

Clients with leukemia are immunocompromised and often have recurrent infections. It is crucial to assess for recent infections.

Question 35

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member

Answer 35

B. Risk for injury related to thrombocytopenia.

Thrombocytopenia increases the risk of bleeding, making injury prevention the priority.

Question 36

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A. Sexual dysfunction related to radiation therapy.
B. Anticipatory grieving related to terminal illness.
C. Tissue integrity related to prolonged bed rest.
D. Fatigue related to chemotherapy.

Answer 36

A. Sexual dysfunction related to radiation therapy.

Radiation therapy often causes sterility in male clients, significantly impacting this young patient’s life plans and relationships.

Question 37

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)

Answer 37

A. Platelet count.

The primary issue in autoimmune thrombocytopenic purpura (ATP) is low platelet count, which needs to be monitored to assess treatment efficacy.

Question 38

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:

A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy

Answer 38

A. Bleeding precautions.

With a low platelet count, bleeding precautions are critical to prevent complications from minor injuries or spontaneous bleeding.

Question 39

A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?

A. Place the client in Trendelenburg position for postural drainage
B. Encourage coughing and deep breathing every 2 hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel movements

Answer 39

C. Elevate the head of the bed 30°.

Elevating the head of the bed helps reduce intracranial pressure and promotes venous drainage, which is essential post-surgery.

Question 40

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

A. Measure the urinary output.
B. Check the vital signs.
C. Encourage increased fluid intake.
D. Weigh the client.

Answer 40

B. Check the vital signs.

Checking vital signs helps assess for potential complications like dehydration or electrolyte imbalances that can cause mental confusion.

Question 41

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

A. Place the client in a sitting position with the head hyperextended.
B. Pack the nares tightly with gauze to apply pressure to the source of bleeding.
C. Pinch the soft lower part of the nose for a minimum of 5 minutes.
D. Apply ice packs to the forehead and back of the neck.

Answer 41

C. Pinch the soft lower part of the nose for a minimum of 5 minutes.

Pinching the soft part of the nose applies direct pressure to the bleeding site, effectively controlling the bleeding.

Question 42

A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is:

A. Blood pressure.
B. Temperature.
C. Output.
D. Specific gravity.

Answer 42

A. Blood pressure.

Blood pressure monitoring is crucial as the remaining adrenal gland might be suppressed, leading to hypotension or other cardiovascular issues.

Question 43

A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A. Glucometer readings as ordered.
B. Intake/output measurements.
C. Sodium and potassium levels monitored.
D. Daily weights.

Answer 43

A. Glucometer readings as ordered.

IV glucocorticoids can elevate blood glucose levels, necessitating regular monitoring.

Question 44

A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be?

A. Obtain a crash cart.
B. Check the calcium level.
C. Assess the dressing for drainage.
D. Assess the blood pressure for hypertension.

Answer 44

B. Check the calcium level.

Tingling around the mouth and extremities suggests hypocalcemia, likely due to inadvertent removal or damage to the parathyroid glands during surgery.

Question 45

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

A. Impaired physical mobility related to decreased endurance.
B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia

Answer 45

D. Decreased cardiac output r/t bradycardia.

Bradycardia associated with hypothyroidism can severely affect cardiac output, making it the highest priority for intervention.