FINAL study questions

Question 1

1.	The nurse auscultates popping, discontinuous sounds over the client’s anterior chest. How does the nurse classify these sounds?
Select One:
a.	Pleural Rub
b.	Crackles
c.	Rhonchi
d.	Wheezes

Answer 1

CRACKLES

Question 2

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)

a. Age
b. Obesity
c. Stress
d. Smoking
e. Hypertension

Answer 2

b. Obesity
c. Stress
d. Smoking
e. Hypertension

Question 3

3.	The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias?
Select one:
a.	Sinus bradycardia
b.	Sinus tachycardia
c.	Ventricular fibrillation
d.	Atrial fibrillation

Answer 3

d. Atrial fibrillation

Question 4

4. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
   Select one:
   a. Notify the surgeon immediately
   b. Assess distal pulses and skin color
   c. Administer pain medication as ordered
   d. Document the findings in the client’s chart

Answer 4

b. Assess distal pulses and skin color

Question 5

5. After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first?
   Select one:
   a. Listen for breath sounds
   b. Check the patency of the chest tubes
   c. Assess the airway, breathing, and circulation
   d. Call for the Rapid Response Team

Answer 5

c. Assess the airway, breathing, and circulation

Question 6

6. Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?
   Select one:
   a. 82-year-old female on antibiotics for pneumonia
   b. 56-year-old male with a history of alcohol abuse and chronic pancreatitis
   c. 24-year-old male admitted with blunt chest trauma and aspiration
   d. 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells

Answer 6

c. 24-year-old male admitted with blunt chest trauma and aspiration

Question 7

7. The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority?
   Select one:
   a. Potential for infection related to leukocytosis
   b. Hypoxemia related to ventilation-perfusion mismatch
   c. Inadequate nutrition related to food-drug interactions and anticoagulant therapy
   d. Insufficient knowledge related to the cause of PE

Answer 7

b. Hypoxemia related to ventilation-perfusion mismatch

Question 8

8. Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse’s immediate attention?
   Select one:
   a. Patient with lung cancer with cough
   b. Patient with dyspnea on exertion
   c. Patient with acute allergic reaction
   d. Patient with sinus infection and fever

Answer 8

c. Patient with acute allergic reaction

Question 9

9. The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment?
   Select one:
   a. Arrange for a health care worker to watch the client take the medication
   b. Instruct the patient about the possible consequences of nonadherence
   c. Give the patient written instructions about how to take prescribed medications
   d. Have the patient repeat medication names and side effects

Answer 9

a. Arrange for a health care worker to watch the client take the medication

Question 10

10.	A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)
Select one or more:
a.	No relief from taking nitroglycerin  
b.	Lasts less than 15 minutes
c.	Feelings of fear or anxiety  
d.	Accompanied by shortness of breath
e.	Pain occurs without known cause

Answer 10

a. No relief from taking nitroglycerin

c. Feelings of fear or anxiety
d. Accompanied by shortness of breath
e. Pain occurs without known cause

Question 11

11.	A client with heart failure reports an 8-pound weight gain in the past week. How many liters of fluid is the patient retaining?
Select one:
a.	8 liters of fluid
b.	17.6 liters of fluid 
c.	3.6 liters of fluid
d.	4.4 liters of fluid

Answer 11

c. 3.6 liters of fluid

Question 12

12.	Four patients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?
Select one:
a.	Pain radiating to the shoulder 
b.	Pain on deep inspiration 
c.	Pain on palpation
d.	Pain that is rubbing in nature

Answer 12

a. Pain radiating to the shoulder

Question 13

13. When using a 5-electrode lead ECG monitoring system, the nurse recognizes which lead is most optimal for detecting dysrhythmias?
    a. Select one:
    b. aVR
    c. V1
    d. V5
    e. III

Answer 13

c. V1

Question 14

14. The nurse understands that the expected assessment for the older adult related to the natural aging process of the respiratory system includes which finding?
    Select one:
    a. Tightening of the vocal cords
    b. Decrease in the anteroposterior diameter
    c. Decrease in residule volume
    d. Decrease in respiratory muscle strength

Answer 14

d. Decrease in respiratory muscle strength

Question 15

15. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?
    Select one:
    a. Increase the setting on the suction
    b. Re-position the chest tube
    c. Take the tubing apart to assess for clots
    d. Notify the provider immediately

Answer 15

d. Notify the provider immediately

Question 16

16. You instruct your patient with COPD on pursed lip breathing, explaining that it improves ventilation because it:
    Select one:
    a. Keeps airways open longer so your lungs can eliminate more stale, trapped air
    b. Improves the exchange of oxygen and carbon dioxide
    c. Increases vital capacity
    d. Improves airflow by changing the position of the trachea
    e. A & B
    f. A, B, & C

Answer 16

A&B

Question 17

17. People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? (Select all that apply.)Select one or more:
    a. Office workers
    b. Bakers
    c. Plumbers
    d. Potters
    e. Furniture refinishers
    f. Coal miners

Answer 17

b. Bakers

d. Potters
e. Furniture refinishers
f. Coal miners

Question 18

18. An older person presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client’s chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client?
    Select one:
    a. It would not be beneficial for this patient.
    b. It would decrease the patient’s pain on inspiration
    c. It would help decrease the bronchospasm
    d. It would clear up the density in the bases of the patient’s

Answer 18

c. It would help decrease the bronchospasm

Question 19

19.	Where does gas exchange occur?
Select one:
a.	Alveolus 
b.	Bronchus
c.	Acinus
d.	Carina

Answer 19

a. Alveolus

Question 20

20. The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? Select one:
    a. “If bleeding develops, we will give you platelets to reverse the anticoagulant.”
    b. “Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3.”
    c. “Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin.” Incorrect
    d. “You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days.”

Answer 20

b. “Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3.”

Question 21

21.	What is the greatest risk factor for lung cancer?
Select one:
a.	Asbestos exposure
b.	Cigarette smoking 
c.	Smoking marijuana
d.	Alcohol consumption

Answer 21

b. Cigarette smoking

Question 22

22. What does the nurse do first when setting up a safe environment for the new client on oxygen? Select one:
    a. Sets the oxygen delivery to maintain no fewer than 16 breaths/min
    b. Uses a pulse oximetry unit
    c. Ensures that no combustion hazards are present in the room
    d. Ensures that staff members wear protective clothing

Answer 22

c. Ensures that no combustion hazards are present in the room

Question 23

23.	The nurse is caring for a group of clients who have sustained myocardial Infarction (MI). The nurse observes the patient with which type of MI most carefully for the development of left ventricular heart failure?
Select one:
a.	Inferior wall
b.	Lateral wall
c.	Anterior wall 
d.	Posterior wall

Answer 23

c. Anterior wall

Question 24

24. The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.) Select one or more:
    a. Nasal mask to deliver BiPAP
    b. Medication to increase daytime slepiness
    c. Weight Loss
    d. Position-fixing device that prevents tongue subluxation
    e. A change in sleeping position

Answer 24

a. Nasal mask to deliver BiPAP

c. Weight Loss
d. Position-fixing device that prevents tongue subluxation
e. A change in sleeping position

Question 25

25. A patient is admitted with asthma. How is this disease differentiated from other chronic lung disorders? Select one:
    a. It only affects young people
    b. The patient is coughing
    c. The patient is symptom free between exacerbations
    d. The patient has dyspnea

Answer 25

c. The patient is symptom free between exacerbations

Question 26

26. The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? Select one:
    a. Weakness
    b. Fever
    c. Cough
    d. Confusion

Answer 26

d. Confusion

Question 27

27. A patient is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis? Select one:
    a. Computed tomography (CT) scan
    b. Thoracoscopy
    c. Bronchoscopy
    d. Chest X-ray

Answer 27

a. Computed tomography (CT) scan

Question 28

28. A patient with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? Select one:
    a. “I need to tell my wife I’ve had a heart attack.”
    b. “Angina is just a temporary interruption of blood flow to my heart.”
    c. “Because this was temporary, I will not need to take any medications for my heart.”
    d. “This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year.”

Answer 28

d. “This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year.”

Question 29

29. The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)?
    Select one:
    a. 32-year-old female with a family history of PH
    b. 29-year old male who is overweight
    c. 50-year-old female with history of blood clots in the pulmonary artery
    d. 43-year-old male with history of right-sided heart failure

Answer 29

a. 32-year-old female with a family history of PH

Question 30

30. On a telemetry monitor, the nurse observes that a patient’s heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse’s first action?Select one:
    a. Administration of oxygen and observation of the heart rhythm
    b. CPR and immeditae defibrillation
    c. Synchronized cardioversion
    d. Administration of IV amiodarone (Cordarone) and dextrose

Answer 30

a. Administration of oxygen and observation of the heart rhythm

Question 31

31. The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? Select one:
    a. Increased myocardial contractility Incorrect
    b. Improved activity intolerance
    c. Improved urinary output
    d. Increased myocardial oxygen

Answer 31

b. Improved activity intolerance

Question 32

32. A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? Select one:
    a. “I should make a doctor’s appointment for weekly blood draws”
    b. “I should take the medication at the same time every day”
    c. “I should limit my alcohol consumption”
    d. “I should eat more green leafy vegtables like spinach”

Answer 32

d. “I should eat more green leafy vegtables like spinach”

Question 33

33. A patient comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? Select one:
    a. Pink, frothy sputum
    b. Mucoid sputum
    c. Blood in sputum
    d. Yellow sputum

Answer 33

a. Pink, frothy sputum

Question 34

34. Prompt pain management with myocardial infarction is essential for which reason? Select one:
    a. Relief of pain indicates that the MI is resolving
    b. The discomfort will increase client anxiety and reduce coping
    c. Pain relief improves oxygen supply and decreases oxygen demand
    d. Pain medication should not be used until a definitive diagnosis has been established

Answer 34

c. Pain relief improves oxygen supply and decreases oxygen demand

Question 35

35. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? Select one:
    a. Prepare to administer antidysrhythmic medication
    b. Assess for any hemodynamic effects of the rhythm
    c. Notify the provider or call the Rapid Response Team
    d. Turn the alarms off on the cardiac monitor

Answer 35

b. Assess for any hemodynamic effects of the rhythm

Question 36

36. To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? Select one:
    a. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol
    b. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase
    c. CK-MB and troponin
    d. Homocysteine and C-reactive protein

Answer 36

c. CK-MB and troponin

Question 37

37. Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? Select one:
    a. Cough
    b. Dyspnea
    c. Barrel chest
    d. Reduced lung exchange

Answer 37

c. Barrel chest

Question 38

38. What is the most common symptom associated with hypertension? Select one:
    a. Slurred speech
    b. Fainting and dizziness
    c. Hypertension is often asymptomatic
    d. Headache

Answer 38

c. Hypertension is often asymptomatic

Question 39

39. Which client needs immediate attention by the nurse? Select one:
    a. A 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
    b. A 57-year-old who was recently extubated and is reporting a sore throat
    c. A 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezing
    d. A 54-year-old who is mechanically ventilated and has tracheal deviation

Answer 39

d. A 54-year-old who is mechanically ventilated and has tracheal deviation

Question 40

40. A patient had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? Select one:
    a. Pneumonia
    b. Pneumothorax
    c. Abcess
    d. Pulmonary Embolism

Answer 40

b. Pneumothorax

Question 41

41. The older patient with coronary artery disease (CAD) is more likely to have what symptom if experiencing cardiac ischemia? Select one:
    a. Depression
    b. Dyspnea
    c. Syncope
    d. Chest Pain

Answer 41

b. Dyspnea

Question 42

42. The nurse is caring for a group of patients. Which patient does the nurse identify as having the highest risk for pulmonary embolism (PE) ? Select one:
    a. A patient with hypokalemia receiving potassium supplements
    b. A patient with diabetes and cellulitis of the leg
    c. A patient receiving IV fluids through a peripheral line
    d. A patient returning from an open reduction and internal fixation of the tibia

Answer 42

d. A patient returning from an open reduction and internal fixation of the tibia

Question 43

43. A patient with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? Select one:
    a. Plan to teach the patient about treatment with modafinil (Provigil)
    b. Ask the patient whether CPAP has been used consistently at night
    c. Discuss the use of auto-titrating positive airway pressure (APAP)
    d. Suggest that a nasal mask be used instead of a full facemask

Answer 43

b. Ask the patient whether CPAP has been used consistently at night

Question 44

44. Which assessment finding is of greatest concern in a client with emphysema? Select one:
    a. Hyperresonance to percussion of the chest
    b. Ribs lying horizontal
    c. Bronchial breath sounds heard at the bases
    d. Barrel-shaped chest

Answer 44

c. Bronchial breath sounds heard at the bases

Question 45

45. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? Select one:
    a. A 74-year-old with a chronic cough and thick, tenacious secretions
    b. A 52-year-old in a tripod position using accessory muscles to breathe
    c. A 46-year-old with a 30–pack-year history of smoking
    d. A 68-year-old who has dependent edema and clubbed fingers

Answer 45

b. A 52-year-old in a tripod position using accessory muscles to breathe

Question 46

46. Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) Select one or more:
    a. Continuous removal of subglottic secretions and good oral care
    b. Placing a nasogastric tube
    c. Administering antibiotic prophylaxis
    d. Placing the client in a negative-airflow room
    e. Handwashing before and after contact with the patient
    f. Elevating the head of the bed at least 30 degrees whenever possible

Answer 46

a. Continuous removal of subglottic secretions and good oral care

e. Handwashing before and after contact with the patient
f. Elevating the head of the bed at least 30 degrees whenever possible

Question 47

47. Identify appropriate interventions for a patient experiencing inadequate oxygenation and tissue perfusion as a result of coronary artery disease. (Select all that apply.) Select one or more:
    a. Encourage interaction with family
    b. Administer Tylenol for pain
    c. Maintain or initiate an IV line
    d. Notify the provider
    e. Administer nitroglycerin sublingually
    f. Apply oxygen via nasal cannula as ordered

Answer 47

c. Maintain or initiate an IV line
d. Notify the provider
e. Administer nitroglycerin sublingually
f. Apply oxygen via nasal cannula as ordered

Question 48

48. In the older adult client, which respiratory change requires no further assessment by the nurse? Select one:
    a. Increased anteroposterior (AP) diameter
    b. Increased respiratory rate
    c. Sputum production
    d. Shortness of breath

Answer 48

a. Increased anteroposterior (AP) diameter

Question 49

49. The nurse is assessing a patient who received a heart transplant. Which symptom suggests that the patient may be experiencing organ rejection? Select one:
    a. Tachycardia
    b. Fever
    c. Hypertension
    d. Weight gain

Answer 49

d. Weight gain

Question 50

50. Which cardiovascular disease results in the highest number of hospital admissions in the United States? Select one:
    a. Heart failure
    b. Rheumatic carditis
    c. Mitral valve disease
    d. Infective endocarditis

Answer 50

a. Heart failure

Question 51

1) A 51-year-old man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5’ 8” tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table.

Which action should you take first?

A.Take his vital signs.
B.Replace the nasal cannula.
C.Sit him up in a bedside chair.
D.Call the Rapid Response Team.

Answer 51

B.Replace the nasal cannula.

Question 52

Fifteen minutes after the oxygen is replaced via nasal cannula and he has rested, the patient denies being short of breath. You obtain an oxygen saturation, which is 96%.
Based on this result, what should you do next?

A.Call the provider as soon as possible.
B.Encourage the patient to take some deep breaths.
C.Increase the oxygen level to 5 L per nasal cannula.
D.Continue the assessment, as 96% is considered acceptable.

Answer 52

D.Continue the assessment, as 96% is considered acceptable.

Question 53

3) After assessing the patient, you document the following:
Jugular venous distention
2+ edema in feet and ankles
Swollen hands and fingers
Distended abdomen
Bibasilar crackles on auscultation
Productive cough with pink-tinged sputum
What is your most likely interpretation of these findings?
A.Biventricular failure
B.Class IV heart failure
C.Left-sided heart failure
D.Right-sided heart failure

Answer 53

A. Biventricular failure

Question 54

4) During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%.
Based on this finding, which medications might the provider order? (Select all that apply.)

A.Multivitamin 1 PO each day
B.Lisinopril (Zestril) 5 mg PO daily
C.Digoxin (Lanoxin) 0.25 mg PO daily
D.Ibuprofen (Advil) 200 PO mg twice daily
E.Furosemide (Lasix) 20

Answer 54

B.Lisinopril (Zestril) 5 mg PO daily
C.Digoxin (Lanoxin) 0.25 mg PO daily

E.Furosemide (Lasix) 20

Question 55

5) Which cardiovascular disease results in the highest number of hospital admissions in the United States?

A.Heart failure
B.Rheumatic carditis
C.Mitral valve disease
D.Infective endocarditis

Answer 55

A.Heart failure

Question 56

2) At the end of the visit, the provider prescribes hydrochlorothiazide (HydroDIURIL) 25 mg PO each morning to manage the patient’s hypertension.
Which statement do you include when teaching the patient about this drug?

A.“This is a loop diuretic that decreases sodium reabsorption.”
B.“Eat foods rich in potassium, such as bananas and orange juice.”
C.“A potassium supplement will be prescribed along with this drug.”
D.“HydroDIURIL is a potassium-sparing diuretic that helps prevent the loss of essential potassium.”

Answer 56

B.“Eat foods rich in potassium, such as bananas and orange juice.”

Question 57

In 2013, the ACA/AHA developed guidelines to reduce cardiovascular risk and decrease blood pressure. Which interventions relate to these guidelines? (Select all that apply.)

A.Use only sugar in beverages.
B.Engage in aerobic exercise 3 to 4 times per week.
C.Develop a dietary plan that includes fish, legumes, and nuts.
D.Include at least 3000 mg of sodium per day in the dietary plan.
E.Encourage a dietary pattern of vegetables, fruits, and whole grains.

Answer 57

B.Engage in aerobic exercise 3 to 4 times per week.
C.Develop a dietary plan that includes fish, legumes, and nuts.

E.Encourage a dietary pattern of vegetables, fruits, and whole grains.

Question 58

A patient with cardiovascular disease is prescribed a potassium-wasting diuretic. The nurse will recommend that the patient consume which food to help prevent hypokalemia?

A.Dried figs
B.Red apples
C.Raw avocados
D.Baked potatoes

Answer 58

D.Baked potatoes

Question 59

Your patient exhibits no ST elevation on EKG, yet is positive for biomarkers. You assess the following:

a. STEMI
b. NSTEMI
c. Unstable angina
d. stable angina
e. Chest Pain

Answer 59

b. NSTEMI

Question 60

Classic symptoms of TB include which of the following:

a. Anorexia
b. Night sweats
c. Hemoptysis
d. Both A and C
e. All of the above

Answer 60

a. Anorexia
b. Night sweats
c. Hemoptysis

Question 61

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider?

a. Dietary Consult
b. Sodium Restriction
c. Daily Weights
d. All the above

Answer 61

a. Dietary Consult
b. Sodium Restriction
c. Daily Weights
d. All the above

Question 62

Risk factors for the development of pulmonary emboli include:
	a. Varicose veins or venous stasis
	b Diabetes
	c. Obesity
	d. Both a and c
	e. All of the above

Answer 62

a. Varicose veins or venous stasis
b Diabetes
c. Obesity

e. All of the above

Question 63

Which symptom of pneumonia may present differently in the older adult than in the younger adult?

a. Wheezing
b. Crackles at the lung bases
c. Fever
d. Coughing

Answer 63

c. Fever

Question 64

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels?

a. Try replacing your usual breakfast with oatmeal or Cream of Wheat
b. Drink more Milk and milk products
c. Increase red meat in the diet
d. Eat baked potatoes and melons

Answer 64

d. Eat baked potatoes and melons

Question 65

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?

a. Carotid pulses
b. Femoral pulses
c. Dye allergies
d. Pedal pulses

Answer 65

d. Pedal pulses

Question 66

Which symptom reported by a client who has had a total hip replacement requires emergency action?

a. Localized Swelling of one of the lower extremities
b. Shortness of breath and Chest pain
c. Positive Homan’s sign
d. Redness and tenderness at the IV site

Answer 66

b. Shortness of breath and Chest pain

Question 67

Obstructive sleep apnea is recognized as an independent risk factor for:

a. disruption in normal cardiac rhythm
b. Hypertension
c. Venous insufficiency
d. Both a and b

Answer 67

a. disruption in normal cardiac rhythm
b. Hypertension

d. Both a and b

Question 68

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure?

a. Pedal edema
b. Urine output of 1500 mL on the preceding day
c. Crackles in the lung fields
d. Expectoration of yellow sputum

Answer 68

c. Crackles in the lung fields

Question 69

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the?

a. Feet
b. Hands
c. Neck
d. Sacrum

Answer 69

c. Neck

Question 70

The nurse is preparing to admit an adult patient with pertussis. Which symptoms does the nurse anticipate finding in the EMR?
	a. Hemostasis
	b. Mild cold like symptoms
C. Post cough Emesis
d. “Whooping” after a cough

Answer 70

C. Post cough Emesis

Question 71

51. An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? Select one:
    a. Tolerance of increasing activity
    b. Presence of fever and chills
    c. Daily white blood cell count
    d. Change in behavior

Answer 71

d. Change in behavior

Question 72

52. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? Select one:
    a. Hemoglobin: 14.8 mg/dL
    b. Potassium: 2.9 mEq/L
    c. Creatinine: 1.2 mg/dl.
    d. Sodium: 134 mEq/L

Answer 72

b. Potassium: 2.9 mEq/L

Question 73

53. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? Select one:
    a. Deep breathing and coughing techniques
    b. Care for the surgical incision
    c. Oral antibiotic therapy after discharged home
    d. Medications used during surgery

Answer 73

a. Deep breathing and coughing techniques

Question 74

54. A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to: (Select one)
    a. a blood glucose measurement before any insulin administration.
    b. the usual scheduled insulin dose because the patient is NPO.
    c. a lower dose of insulin because there will be no oral intake before surgery.
    d. the patient the usual insulin dose because stress will increase the blood glucose.

Answer 74

a. a blood glucose measurement before any insulin administration.

Question 75

55. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to? Select one:
    a. administer oxygen therapy at 100% per mask.
    b. notify the anesthesia care provider immediately.
    c. increase the rate of IV fluid replacement.
    d. continue to take vital signs every 15 minutes.

Answer 75

d. continue to take vital signs every 15 minutes.

Question 76

56. While at the scrub sink, the scrub person informs the circulating nurse that she now wears artificial nails because her own nails break frequently posing a risk for a glove puncture. What is the nurse’s best response? Select one:
    a. Support the scrub person’s rationale that broken nails are a serious source of cross contamination.
    b. Confirm with the scrub person that artificial nails are acceptable and do not affect hand hygiene.
    c. Ask the scrub person to wear double-gloves to prevent puncture or contamination.
    d. Remind the scrub personnel that artificial nails alter skin flora, impede hand hygiene, and are not permitted.

Answer 76

d. Remind the scrub personnel that artificial nails alter skin flora, impede hand hygiene, and are not permitted.

Question 77

57. Which change in the anesthetized client alerts the nurse to the possibility of Malignant Hyperthermia (MH)? Select one:
    a. Widening pulse pressure
    b. Increasing end-tidal carbon dioxide level
    c. Increasing output of dilute urine
    d. Ascending flaccid paralysis of skeletal muscles

Answer 77

b. Increasing end-tidal carbon dioxide level

Question 78

58. What is Malignant Hyperthermia (MH) and what is it triggered by? Select one:
    a. By changing the temperature in the OR
    b. Fluid overload
    c. Metabolic Alkalosis
    d. By exposure to inhalation agents or Succinylcholine in susceptible patients

Answer 78

d. By exposure to inhalation agents or Succinylcholine in susceptible patients

Question 79

59. A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? Select one:
    a. Decreasing environmental stimuli
    b. Strict monitoring of hourly intake and output
    c. Managing pain through drug and nondrug methods
    d. Assessing neurologic status at least every 2 to 4 hours

Answer 79

d. Assessing neurologic status at least every 2 to 4 hours

Question 80

60. What are the clinical signs of MH? Choose all that are applicable. Select one or more:
    a. Skin mottling
    b. Hypothermia
    c. Dark urine (myoglobinuria)
    d. Tachycardia
    e. Hypercarbia
    f. Muscle rigidity
    g. All of the above

Answer 80

a. Skin mottling

c. Dark urine (myoglobinuria)
d. Tachycardia
e. Hypercarbia
f. Muscle rigidity

Question 81

61. Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? Select one:
    a. Decreased protein
    b. Increased glucose
    c. Cloudy turbid CSF
    d. Decreased white blood cells

Answer 81

c. Cloudy turbid CSF

Question 82

62. When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? Select one:
    a. The patient is more difficult to arouse.
    b. The patient’s blood pressure increases from 120/54 to 136/62 mm Hg.
    c. The patient complains of headache at a pain level 5 of a 10 point scale.
    d. The patient’s pulse is slightly irregular.

Answer 82

a. The patient is more difficult to arouse.

Question 83

63. What pain management does a client who has been admitted to the postanesthesia care unit typically receive? Select one:
    a. Intraveneous opiod analgesics
    b. Intraveneous nonopiod analgesics
    c. Intramuscular nonopiod analgesics
    d. Intramuscular opiod analgesics

Answer 83

a. Intraveneous opioid analgesics

Question 84

64. The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? Select one:
    a. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home.
    b. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing.
    c. A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing
    d. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

Answer 84

b. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing.

Question 85

65. Colostomy surgery is categorized as what type of surgery? Select one:
    a. Palliative
    b. Curative
    c. Cosmetic
    d. Diagnostic

Answer 85

a. Palliative

Question 86

66. The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be essential for the nurse to report to the health care provider? Select one:
    a. Previous surgery on the other knee
    b. Knee pain at a level of 9 (0-to-10 scale)
    c. Warm, red, and swollen knee
    d. Allergy to shellfish and iodine

Answer 86

c. Warm, red, and swollen knee

Question 87

67. Care of the older adult may be affected by which physiologic change in the musculoskeletal system? Select one:
    a. Narrower gait
    b. Regeneration of cartilage
    c. Decreased range of motion (ROM)
    d. Increased bone density

Answer 87

c. Decreased range of motion (ROM)

Question 88

68. A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test? Select one:
    a. ‘It will be important to lie still in a reclined position for 20 minutes.”
    b. “You can have the MRI if you have an internal pacemaker.”
    c. “Do not eat or drink for 8 hours before the test.”
    d. “All jewelry and clothing with zippers or metal fasteners must be removed.”

Answer 88

d. “All jewelry and clothing with zippers or metal fasteners must be removed.”

Question 89

69. Which aspect of a musculoskeletal assessment will the physical therapist and the nurse plan to collaborate on? Select one:
    a. Nutritional intake of the client before admission.
    b. The need for ambulatory devices.
    c. Medications that the client is currently taking.
    d. Current list of the client’s medical conditions.

Answer 89

b. The need for ambulatory devices.

Question 90

70. Which client information is most essential for the nurse to report to the health care provider before a client with knee pain undergoes magnetic resonance imaging (MRI)? Select one:
    a. Swollen and tender knee
    b. History of claustrophobia
    c. Presence of a permanent pacemaker
    d. Daily use of aspirin

Answer 90

c. Presence of a permanent pacemaker

Question 91

71. When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor will be the priority for client teaching? Select one:
    a. Postmenopausal status
    b. Positive family history
    c. Previous use of steroids
    d. Low calcium intake

Answer 91

d. Low calcium intake

Question 92

72. The nurse is reviewing the medication history for a client scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the client is taking which medication? Select one:
    a. Prednisone (Deltasone) to treat asthma
    b. Magnesium hydroxide (Milk of Magnesia) to treat heartburn
    c. Bupropion (Wellbutrin) for smoking cessation
    d. Acetaminophen (Tylenol) for pain relief

Answer 92

a. Prednisone (Deltasone) to treat asthma

Question 93

73. The nurse is concerned that a client who had an ankle open reduction and internal fixation is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? Select all that apply. Select one or more:
    a. Increased sweating
    b. Muscle weakness
    c. Edema
    d. Burning Pain
    e. Absent pedal pulse

Answer 93

a. Increased sweating

c. Edema
d. Burning Pain

Question 94

74. A client who had an elective above-the-knee amputation (AKA) reports pain in the foot that was amputated. What is the nurse’s best response to the client’s pain? Select one:
    a. “The pain is not real, so we don’t treat it.”
    b. “That’s phantom limb pain and every amputee has that.”
    c. “On a scale of 0 to 10, how would you rate your pain?”
    d. The pain will go away in a few days or so.”

Answer 94

c. “On a scale of 0 to 10, how would you rate your pain?”

Question 95

75. A client returns to the postanesthesia care unit (PACU) after an arthroscopy for a shoulder rotator cuff tear. What is the nurse’s priority when caring for this client? Select one:
    a. Keep the affected arm immobilized.
    b. Ensure that the patient uses the patient-controlled analgesia (PCA) pump.
    c. Check the neurovascular status of the affected arm
    d. Perform passive range-of-motion exercises.

Answer 95

c. Check the neurovascular status of the affected arm

Question 96

76. A nurse is performing a musculoskeletal assessment on an older adult living independently in a senior housing apartment. What normal physiologic changes of aging does the nurse expect? Select all that apply. Select one or more:
    a. Lordosis
    b. Decreased coordination
    c. Muscle contractures
    d. Slowed movement
    e. Antalgic gait

Answer 96

b. Decreased coordination

d. Slowed movement

Question 97

77. A patient returns to the same-day surgical unit after having an ankle open reduction internal fixation (ORIF). What is the nurse’s priority action when caring for this patient? Select one:
    a. Keep the client’s affected leg on a pillow.
    b. Encourage the client to drink fluids.
    c. Assess the client’s abdomen for bowel sounds.
    d. Monitor the client’s vital signs frequently.

Answer 97

d. Monitor the client’s vital signs frequently.

Question 98

78. The nurse plans to use which tool to measure joint range of motion (ROM)? Select one:
    a. Doppler device
    b. Tonometer
    c. Goniometer
    d. Reflex Hammer

Answer 98

c. Goniometer

Question 99

79. A patient with Parkinson’s disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority? Select one:
    a. Ineffective self-health management
    b. Activity intolerance
    c. Self-care deficit: toileting
    d. Imbalanced nutrition: less than body requirements

Answer 99

d. Imbalanced nutrition: less than body requirements

Question 100

80. Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer’s disease (AD)? Select one:
    a. Maintain a consistent daily routine for the patient’s care.
    b. Encourage the patient to discuss events from the past.
    c. Reorient the patient to the date and time every 2 to 3 hours.
    d. Provide the patient with current newspapers and magazines.

Answer 100

a. Maintain a consistent daily routine for the patient’s care.

Question 101

81. The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? Select one:
    a. The patient complains of chronic severe back pain.
    b. The patient starts to cry and says, “I feel hopeless.”
    c. The patient expresses anxiety about having surgery.
    d. The patient has new onset weakness of both legs.

Answer 101

d. The patient has new onset weakness of both legs.

Question 102

82. The nurse plans to refer a client diagnosed with osteoporosis to which community resource? Select one:
    a. National Osteoporosis Foundation
    b. Community Coping Services
    c. American Bone Society
    d. Meals on Wheels

Answer 102

a. National Osteoporosis Foundation

Question 103

83. After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? Select one:
    a. Check the nasal drainage for glucose
    b. Assure the patient that rhinorrhea is normal after a head injury.
    c. Obtain a specimen of the fluid to send for culture and sensitivity.
    d. Have the patient blow the nose

Answer 103

a. Check the nasal drainage for glucose

Question 104

84. An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? Select one:
    a. Cluster nursing interventions to provide uninterrupted rest periods.
    b. Position the patient with the knees and hips flexed.
    c. Encourage coughing and deep breathing to improve oxygenation.
    d. Keep the head of the bed elevated to 30 degrees.

Answer 104

d. Keep the head of the bed elevated to 30 degrees.

Question 105

85. An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as Select one:
    a. potential complication: venous thromboembolism
    b. potential complication: fluid and electrolyte imbalance
    c. potential complication: impaired surgical wound healing.
    d. potential complication: hypovolemic shock.

Answer 105

a. potential complication: venous thromboembolism

Question 106

86. While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first Select one:
    a. take the patient’s vital signs.
    b. reinforce the dressing.
    c. recheck the dressing in 1 hour for increased drainage.
    d. call a rapid response

Answer 106

a. take the patient’s vital signs.

Question 107

87. While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider? Select one:
    a. The patient complains of abdominal pain at level 6 (0-10 scale).
    b. The patient’s temperature is 100.3° F (37.9° C).
    c. The 24-hour oral intake is 600 ml greater than the total output.
    d. the right calf is swollen, warm, and painful.

Answer 107

d. the right calf is swollen, warm, and painful.

Question 108

88. When assessing a patient diagnosed with osteoarthritis (OA), the healthcare provider looks for which characteristic of this condition? Select one:
    a. Joint crepitus
    b. Bilateral joint swelling
    c. Decreased grip strength
    d. Waddling gait

Answer 108

a. Joint crepitus

Question 109

89. A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first: Select one:
    a. Client taking risedronate (Actonel) who reports occasional dyspepsia
    b. Client taking ibandronate (Boniva) who cannot remember when the last dose was
    c. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago
    d. Client taking raloxifene (Evista) who reports unilateral calf swelling

Answer 109

d. Client taking raloxifene (Evista) who reports unilateral calf swelling

Question 110

90. A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? Select one or more:
    a. Serious cardiac events
    b. Thromboebolism
    c. Stroke
    d. Infection
    e. Hemorrhage

Answer 110

a. Serious cardiac events
b. Thromboebolism

d. Infection

Question 111

91. During a client’s neurologic assessment, the nurse finds that he is arousable after light touch combined with a loud voice. How does the nurse document this client’s level of consciousness?
    a. “Stuporous”
    b. “Drowsy”
    c. “Lethargic”
    d. “Comatose”

Answer 111

c. “Lethargic”

Question 112

92. A client with possible Parkinson’s disease is scheduled to have magnetic resonance imaging (MRI). The daughter asks the nurse how this test is different from a computed tomography (CT) scan. What is the nurse’s best response? Select one:
    a. The CT scan does not provide a view of deep brain structures like the region where Parkinson’s.
    b. The MRI scan provides better contrast between normal tissue and pathologic tissue.
    c. The MRI will not require contrast material.
    d. They are not different; both use ionizing radiation.

Answer 112

b. The MRI scan provides better contrast between normal tissue and pathologic tissue.

Question 113

93. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do? Select one:
    a. Positions the client on the side
    b. Documents the length and time of the seizure
    c. Restrains the client.
    d. Forces a tongue blade in the mouth.

Answer 113

a. Positions the client on the side

Question 114

94. A mother who is a carrier of muscular dystrophy (MD) has a daughter. The client asks the nurse what the daughter’s genetic risk is for having MD. What is the nurse’s best response? Select one:
    a. “She will not have MD nor will she be a carrier.”
    b. “Because you are a carrier of the MD gene, your daughter will develop MD.”
    c. “Your daughter is X-linked dominant for the MD gene.”
    d. “There is a 50% chance that your daughter may carry the gene.”

Answer 114

d. “There is a 50% chance that your daughter may carry the gene.”

Question 115

95. A patient has been diagnosed with Huntington disease (HD). The nurse is teaching the patient and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse’s teaching? Select one:
    a. “She could only have gotten the disease from both of us.”
    b. “If she has children, she’ll pass the gene on to her kids.”
    c. “More testing should definitely be done to see if she’s really got the gene.”
    b. “If she has children, she’ll pass the gene on to her kids.”

Answer 115

b. “If she has children, she’ll pass the gene on to her kids.”

Question 116

96. Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Select one:
    a. Frequent ambulation
    b. Encouraging nutrition
    c. Pressure relieving devices
    d. Regular turning and re-positioning of body alignment

Answer 116

d. Regular turning and re-positioning of body alignment

Question 117

97. What health history question will give the nurse the most information when evaluating a patient for Guillain-Barre’ syndrome? Select one:
    a. Did you get a flu vaccine in the past year?”
    b. Have you had a respiratory virus in the past 2 weeks?”
    c. “Has anyone else in your family ever had GBS?”
    d. Have you ever been exposed to Epstein-Barr virus?”

Answer 117

b. Have you had a respiratory virus in the past 2 weeks?”

Question 118

98. The nurse is caring for a patient with a diagnosis of Bell’s palsy. The nurse understands that for a patient with Bell’s palsy the symptoms are the most severe during which time period after beginning? Select one:
    a. 12 hours after onset
    b. 48 hours after onset
    c. 1 - 2 weeks after onset
    d. 96 hours after onset

Answer 118

b. 48 hours after onset

Question 119

99. As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do first? Select one:
    a. Calls the anesthesiologist
    b. Calls the surgeon
    c. Holds the ordered medication until the consent is signed
    d. Give the ordered medication as prescribed

Answer 119

c. Holds the ordered medication until the consent is signed

Question 120

100. The client with a traumatic brain injury from a motor vehicle accident is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? Choose all that apply.
     a. Headaches
     b. Hypotension
     c. Changes in breathing pattern
     d. Pupils that do not respond to light
     e. Double vision

Answer 120

a. Headaches

c. Changes in breathing pattern
d. Pupils that do not respond to light
e. Double vision

Question 121

18) To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication about the patient includes which elements? (Select all that apply.)

• Providing a recent patient history
• Communicating vital signs, allergy, and medication updates
• Verbally verifying that the operating room nurse understands the report
• Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE)
• Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report

Answer 121

• Providing a recent patient history
• Communicating vital signs, allergy, and medication updates
• Verbally verifying that the operating room nurse understands the report
• Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE)

Question 122

19) When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, the nurse understand which laboratory value may result in cancellation of the surgery?

A. Hemoglobin 10.5 g/dL
B. Serum potassium 2.7 mEq/L
C. Serum sodium level 149 mEq/L
D. Fasting blood glucose 120 mg/dL

Answer 122

B. Serum potassium 2.7 mEq/L

Question 123

During a preoperative assessment, the nurse asks the patient about allergies. Which allergy cited by the patient would be of greatest concern during the surgical procedure?

A. Kiwi
B. Codeine
C. Shellfish
D. Sulfa drugs

Answer 123

A. Kiwi

Question 124

The nurse is monitoring a patient who is receiving moderate sedation. An expected outcome for conscious sedation is:

A. Blocked multiple peripheral nerves in a specific region
B. Decreased motor function in the targeted limb
C. Decreased level of consciousness, yet able to respond to verbal commands
D. CNS depression, resulting in analgesia and amnesia, with loss of muscle tone and reflexes

Answer 124

C. Decreased level of consciousness, yet able to respond to verbal commands

Question 125

During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention?

A. Communicate the discrepancy to the surgical team immediately.
B. Complete appropriate documentation concerning the error in sponge count.
C. Examine the environmental distractions, refocus, and count the sponges again.
D. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively.

Answer 125

A. Communicate the discrepancy to the surgical team immediately.

Question 126

The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present?

A. Diabetes mellitus
B. Age greater than 65
C. Impaired liver function
D. Insertion of a surgical drain

Answer 126

A. Diabetes mellitus

Question 127

A patient has had bowel surgery. Which symptom, assessed by the nurse, is the best indicator of intestinal activity?

A. Passage of flatus or stool
B. Patient’s report of hunger
C. Abdominal cramping with distention
D. Detection of bowel sounds upon auscultation

Answer 127

A. Passage of flatus or stool

Question 128

What is the priority nursing assessment when a patient is admitted to the PACU?

A. Level of consciousness
B. Airway and gas exchange
C. Dressing and incision status
D. Vital signs and body temperature

Answer 128

B. Airway and gas exchange

Question 129

When positioning to decrease pain in the postoperative patient, which intervention is most appropriate?

A. Raise the knee gatch of the bed.
B. Place pillows under the patient’s knees.
C. Reposition the patient at least every 2 hours.
D. Allow the patient to get out of bed as soon as possible.

Answer 129

C. Reposition the patient at least every 2 hours.

Question 130

2. Which change in the anesthetized client alerts the nurse to the possibility of malignant hyperthermia?
   A. Widening pulse pressure
   B. Increasing output of dilute urine
   C. Increasing end-tidal carbon dioxide level
   D. Ascending flaccid paralysis of skeletal muscles

Answer 130

C. Increasing end-tidal carbon dioxide level

Question 131

3. What is Malignant Hyperthermia (MH) and what is it triggered by?
   A. By exposure to inhalation agents or SUCCINYLCHOLINE in susceptible
   Individuals
   A. By the change in temperature in the OR
   B. Fluid overload
   C. Metabolic Alkalosis

Answer 131

A. By exposure to inhalation agents or SUCCINYLCHOLINE in susceptible

Question 132

4. What are the clinical signs of MH? Choose all that are applicable.
   A. Muscle rigidity (difficult to ventilate, increased peak pressures)
   B. Hypercarbia
   C. Tachycardia
   D. Skin mottling
   E. Hyperthermia (may be a late sign - d/t inc in muscle metabolism = heat production)
   F. Dark urine (myoglobinuria)
   G. All of the above

Answer 132

A. Muscle rigidity (difficult to ventilate, increased peak pressures)
B. Hypercarbia
C. Tachycardia
D. Skin mottling
E. Hyperthermia (may be a late sign - d/t inc in muscle metabolism = heat production)
F. Dark urine (myoglobinuria)

Question 133

5. A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?
   A. Assessing neurologic status at least every 2 to 4 hours
   B. Decreasing environmental stimuli
   C. Managing pain through drug and nondrug methods
   D. Strict monitoring of hourly intake and output

Answer 133

A. Assessing neurologic status at least every 2 to 4 hours

Question 134

6.	Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis?
A.	Cloudy, turbid CSF
B.	Decreased white blood cells
C.	Decreased protein
D.	Increased glucose

Answer 134

A. Cloudy, turbid CSF

Question 135

7.	What pain management does a client who has been admitted to the postanesthesia care unit typically receive?
A.	Intramuscular nonopiod analgestics
B.	Intramuscular opiod anagesics
C.	Intravenous nonopioid analgesics
D.	Intravenous opioid analgesics

Answer 135

D. Intravenous opioid analgesics

Question 136

8. The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first?
   A. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing
   B. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home
   C. A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing
   D. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

Answer 136

A. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing

Question 137

9.	Colostomy surgery is categorized as what type of surgery?
A.	Cosmetic surgery
B.	Curative
C.	Diagnostic
D.	Palliative

Answer 137

D. Palliative

Question 138

10.	Who is the most likely person to administer blood products in an operating suite?
A.	Circulating nurse
B.	Holding area nurse 
C.	Scrub nurse
D.	Specialty nurse

Answer 138

A. Circulating nurse

Question 139

11.	During surgery, who is most responsible for monitoring for possible breaks in sterile technique?
A.	Circulating nurse
B.	Holding nurse 
C.	Anesthesiologist
D.	Surgeon

Answer 139

A. Circulating nurse

Question 140

12.	Which assessment finding in a postoperative client after general anesthesia requires immediate intervention?
A.	Heart rate of 58 beats/min
B.	Pale, cool extremities
C.	Respiratory rate of 6 breaths/min
D.	Suppressed gaga reflex

Answer 140

C. Respiratory rate of 6 breaths/min

Question 141

13.	In conducting a postoperative assessment of a client, what is important for the nurse to examine first?
A.	Breathing Pattern
B.	Level of consciousness
C.	Oxygen saturations
D.	Surgical site

Answer 141

A. Breathing Pattern

Question 142

14.	The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal?
A.	Decerebrate posturing
B.	Increased lethargy
C.	Minimal response to stimulation
D.	Constriction of pupils

Answer 142

D. Constriction of pupils

Question 143

15. Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning?
    A. Apply elastic stockings to the lower extremities
    B. Monitor for excessive blood loss
    C. Secure joints on a board in proper anatomical positions
    D. Pad boney prominences

Answer 143

D. Pad boney prominences

Question 144

16.	Which is the most effective way for a college student to minimize the risk for bacterial meningitis?
A.	Avoid large crowds
B.	Get the meningococcal vaccine
C.	Take a multivitamin daily
D.	Take prophylactic antibiotics

Answer 144

B. Get the meningococcal vaccine

Question 145

17. A client with dementia and Alzheimer’s disease is discharged to home. The client’s daughter says, “He wanders so much, I am afraid he’ll slip away from me.” What resource does the nurse suggest?
    A. Alzheimer’s Wandering Association
    B. National Alzheimer’s Group
    C. Safe Return Program
    D. Lost Family Members Tracking Association

Answer 145

C. Safe Return Program

Question 146

18. A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?
    A. Bending forward from the hips
    B. Sitting upright with arms outstretched
    C. Walking across the room and back
    D. Walking with both eyes closed

Answer 146

A. Bending forward from the hips

Question 147

19. A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.)
    A. Bone changes lead to potential safety risks
    B. Increased bone density leads to stiffness
    C. Osteoarthritis occurs due to cartilage degeneration
    D. Osteoporosis is a universal occurrence
    E. Some muscle tissue atrophy occurs with aging

Answer 147

A. Bone changes lead to potential safety risks

C. Osteoarthritis occurs due to cartilage degeneration

E. Some muscle tissue atrophy occurs with aging

Question 148

20.	When assessing gait, what features does the nurse inspect? (Select all that apply.)
A.	Balance
B.	Ease of stride
C.	Goniometer readings
D.	Length of stride
E.	Steadiness

Answer 148

A. Balance
B. Ease of stride

D. Length of stride
E. Steadiness

Question 149

21. Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease?
    A. Increased nutritional intake of calcium
    B. Engage in high-impact exercise, such as running
    C. Increase nutritional intake of phosphorus
    D. Walk for 30 minutes three times a week

Answer 149

D. Walk for 30 minutes three times a week

Question 150

22. A mother who is a carrier of muscular dystrophy (MD) has a daughter. The client asks the nurse what the daughter’s genetic risk is for having MD. What is the nurse’s best response?
    A. “Because you are a carrier of the MD gene, your daughter will develop MD.”
    B. “She will not have MD nor will she be a carrier.”
    C. “There is a 50% chance that your daughter may carry the gene.”
    D. “Your daughter is X-linked dominant for the MD gene”

Answer 150

C. “There is a 50% chance that your daughter may carry the gene.”

Question 151

23. A client returns to the postanesthesia care unit (PACU) after an arthroscopy for a shoulder rotator cuff tear. What is the nurse’s priority when caring for this client?
    A. Perform passive range-of-motion exercises.
    B. Keep the affected arm immobilized.
    C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump.
    D. Check the neurovascular status of the affected arm

Answer 151

D. Check the neurovascular status of the affected arm

Question 152

28. Priorities in nursing Interventions for the care of the patient undergoing orthopedic surgical procedures? Select all that apply

A. Muscle setting; ankle and calf-pumping exercises
B. Measures to ensure adequate nutrition and hydration
C. Calcium supplements and nutritional counseling
D. Skin care measures, including frequent turning and positioning

Answer 152

A. Muscle setting; ankle and calf-pumping exercises
B. Measures to ensure adequate nutrition and hydration
C. Calcium supplements and nutritional counseling
D. Skin care measures, including frequent turning and positioning

Question 153

29. The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider?
    A. Knee pain at a level of 9 (0-to-10 scale)
    B. Warm, red, and swollen knee
    C. Allergy to shellfish and iodine
    D. Previous surgery on the other knee

Answer 153

B. Warm, red, and swollen knee

Question 154

101. The nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client’s score to be 36. How should the nurse plan care for this client? Select one:
     a. The client will need safety precautions.
     b. The client will need cuing only.
     c. The client will be discharged home.
     d. The client will need near-total care.

Answer 154

d. The client will need near-total care.

Question 155

102. A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.)
     a. Indigestion or trouble swallowing
     b. A sore that does not heal
     c. Changes in menstrual patterns
     d. Obvious change in a mole
     e. Abdominal cramps

Answer 155

a. Indigestion or trouble swallowing
b. A sore that does not heal
c. Changes in menstrual patterns
d. Obvious change in a mole

Question 156

103. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? Select one:
     a. Chooses preferred items from the menu.
     b. Has clear lung sounds on auscultation.
     c. Gains 2 pounds after 1 week.
     d. Eats 75% to 100% of all meals and snacks.

Answer 156

b. Has clear lung sounds on auscultation.

Question 157

104. When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? Select one:
     a. Hypertension
     b. Drug toxicity
     c. Polycythemia
     d. Infection

Answer 157

d. Infection

Question 158

105. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? Select one:
     a. Double-gloving before body fluid exposure
     b. Labeling charts and armbands “HIV+”
     c. Consistent use of Standard Precautions
     d. Wearing a mask within 3 feet of the client

Answer 158

c. Consistent use of Standard Precautions

Question 159

106. A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best Select one:
     a. Assess the client for more specific signs.
     b. Request that the provider order blood cultures.
     c. Document findings and continue to monitor.
     d. Conclude that an infection is not present.

Answer 159

a. Assess the client for more specific signs.

Question 160

107. The nurse is caring for a client diagnosed with human immune deficiency virus. The client’s CD4+ cell count is 399/mm3. What action by the nurse is best? Select one:
     a. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
     b. Encourage the client to abstain from alcohol.
     c. Help the client plan high-protein/iron meals.
     d. Counsel the client on safer sex practices/abstinence.

Answer 160

d. Counsel the client on safer sex practices/abstinence.

Question 161

108. A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? Select one:
     a. “I try not to use cosmetics that contain any type of sunblock.”
     b. “Since I can’t be exposed to the sun, I have been using a tanning bed.”
     c. “Since I tend to sweat a lot, I use a lot of baby powder.”
     d. “I always wear long sleeves, pants, and a hat when outdoors.”

Answer 161

d. “I always wear long sleeves, pants, and a hat when outdoors.”

Question 162

109. The patient in the orthopedic clinic has a self-reported history of osteoarthritis. The patient reports a low-grade fever that started when the weather changed and several joints started “acting up,” especially both hips and knees. What action by the nurse is best? Select one:
     a. Inspect the client’s feet and hands for podagra and tophi on fingers and toes.
     b. Assess the patient for the presence of subcutaneous nodules or Baker’s cysts.
     c. Reassure the client that the problems will fade as the weather changes again.
     d. Prepare to teach the client about an acetaminophen (Tylenol) regimen.

Answer 162

b. Assess the patient for the presence of subcutaneous nodules or Baker’s cysts.

Question 163

110. Which statement about carcinogenesis is accurate? Select one:
     a. An initiated cell will always become clinical cancer.
     b. Cancer becomes a health problem once it is 1 cm in size.
     c. Tumor cells need to develop their own blood supply.
     d. Normal hormones and proteins do not promote cancer growth.

Answer 163

c. Tumor cells need to develop their own blood supply.

Question 164

111. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? Select one:
     a. The patient’s speech is difficult to understand.
     b. The patient’s blood pressure is 144/90 mm Hg.
     c. The patient takes a diuretic because of a history of hypertension.
     d. The patient has atrial fibrillation and takes warfarin (Coumadin)

Answer 164

d. The patient has atrial fibrillation and takes warfarin (Coumadin)

Question 165

112. What is the single greatest risk for developing any type of cancer? Select one:
     a. Advancing age
     b. Genetic predisposition
     c. Declining immune function
     d. Cigarette smoking

Answer 165

a. Advancing age

Question 166

113. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Select one:
     a. Increase the client’s oxygen during activity.
     b. Pace activities, allowing for adequate rest
     c. Perform most activities for the client.
     d. Administer sleeping medication.

Answer 166

b. Pace activities, allowing for adequate rest

Question 167

114. A nurse is working with a community group promoting health aging. What recommendation is best to help prevent osteoarthritis (OA) ? Select one:
     a. Avoid contact sports.
     b. Engage in weight-bearing exercise.
     c. Get plenty of calcium.
     d. Lose weight if needed.

Answer 167

d. Lose weight if needed.

Question 168

client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? Select one:

a. “Check over-the-counter meds for acetaminophen.”
b. “You have a higher risk of developing cancer.”
c. “Take this medicine exactly as prescribed.”
d. “Avoid large crowds and people who are ill.”

Answer 168

d. “Avoid large crowds and people who are ill.”

Question 169

116. Antiretroviral therapy (ART) is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. Which factor is most important to consider when determining whether ART will be started for this patient? Select one:
     a. Patient ability to comply with ART schedule
     b. Potential medication side effects
     c. Patient social support system
     d. HIV genotype and phenotype

Answer 169

a. Patient ability to comply with ART schedule

Question 170

117. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? Select one:
     a. Notify the provider about the CD4+ results.
     b. Initiate Droplet Precautions for the client.
     c. Place the client under Airborne Precautions.
     d. Use Standard Precautions to provide care.

Answer 170

c. Place the client under Airborne Precautions.

Question 171

118. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as: Select one:
     a. decelerate posturing
     b. localization of pain
     c. decorticate posturing
     d. flexion withdrawal

Answer 171

c. decorticate posturing

Question 172

119. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? Select one:
     a. There are no distant metastases noted in the report.
     b. Regional lymph nodes could not be assessed.
     c. The primary site of the cancer cannot be determined.
     d. There are multiple lymph nodes involved already.

Answer 172

a. There are no distant metastases noted in the report.

Question 173

120. A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? Select one:
     a. Teaching hand hygiene to prevent the spread of microbes.
     b. Encouraging the client to eat a nutritious diet.
     c. Instructing the client to wash minor wounds carefully.
     d. Assessing vaccination records for booster shot needs.

Answer 173

d. Assessing vaccination records for booster shot needs.

Question 174

122. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? Select one:
     a. “Weigh yourself every day on the same scale.”
     b. “Eat plenty of high-protein, high-iron foods.”
     c. Notify your provider at once if you get a fever.”
     d. “Be sure you get enough sleep at night.”

Answer 174

c. Notify your provider at once if you get a fever.”

Question 175

123. The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess?(Select all that apply.)
     a. Alcohol intake
     b. Obesity
     c. Smoking
     d. Diabetes
     e. High Fat Diet

Answer 175

a. Alcohol intake
b. Obesity
c. Smoking

e. High Fat Diet

Question 176

124. A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client’s mental status is deteriorating. What action by the nurse is most appropriate? Select one:
     a. Sign the consent form for the client.
     b. Attempt to find the family to sign a consent.
     c. Inform the provider that the procedure cannot occur.
     d. Nothing; no consent is needed in an emergency.

Answer 176

b. Attempt to find the family to sign a consent.

Question 177

125. The nurse is caring for a patient with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the patient is the goal of palliative surgery? Select one:
     a. Allowing other therapies to be more effective
     b. Prolonging the patients survival time
     c. Cure of the cancer
     d. Relief of symptoms or improved quality of life

Answer 177

d. Relief of symptoms or improved quality of life

Question 178

126. Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy? Select one:
     a. Apply pressure to all injection sites for 5 minutes.
     b. Assist the client in all ambulatory activities.
     c. Monitor electrocardiograph rhythms every hour during therapy.
     d. Ensure that the client has a fluid intake of 3000 to 5000 mL per day

Answer 178

d. Ensure that the client has a fluid intake of 3000 to 5000 mL per day

Question 179

127. A patient with fibromyalgia is in the hospital for an unrelated issue. The patient reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)
     a. Offer a massage or warm shower at night.
     b. Limit environmental noise as much as possible
     c. Allow the client uninterrupted rest time
     d. Request an order for a strong sleeping pill.
     e. Assess the client’s usual bedtime routine.

Answer 179

a. Offer a massage or warm shower at night.
b. Limit environmental noise as much as possible
c. Allow the client uninterrupted rest time

e. Assess the client’s usual bedtime routine.

Question 180

128. For which types of cancer is radiation therapy most effective? Select one:
     a. Cancers that are large, with evidence of distant metastasis
     b. Cancers of the blood, such as leukemia
     c. Superficial cancers on the outside of the body
     d. Cancers that are localized to one tissue or body area

Answer 180

d. Cancers that are localized to one tissue or body area

Question 181

129. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? Select one:
     a. The patient is 25 pounds above the ideal weight.
     b. The patient’s blood pressure (BP) is usually about 180/90 mm Hg.
     c. The patient has a daily glass of wine to relax.
     d. The patient works at a desk and relaxes by watching television.

Answer 181

The patient’s blood pressure (BP) is usually about 180/90 mm Hg.

Question 182

130. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? Select one:
     a. White blood cell count: 4400/mm
     b. Red blood cell count: 5.2/mm3
     c. Platelet count: 210,000/mm
     d. Creatinine: 3.9 mg/dL

Answer 182

d. Creatinine: 3.9 mg/dL

Question 183

131. The nurse working in the rheumatology clinic assesses patients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)
     a. Joint deformity
     b. Felty’s syndrome
     c. Weight loss
     d. Anorexia
     e. Low grade fever

Answer 183

a. Joint deformity
b. Felty’s syndrome
c. Weight loss

Question 184

132. A patient has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.)
     a. Supplements
     b. Vigorous aerobics
     c. Tai chi
     d. Acupuncture
     e. Stretching

Answer 184

c. Tai chi
d. Acupuncture
e. Stretching

Question 185

133. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? Select one:
     a. “Drink 1 to 2 liters of water each day.”
     b. “Have 10 to 12 ounces of juice a day.”
     c. “Liver is a good source of iron.”
     d. “Always eat hard cheeses or sardines.”

Answer 185

a. “Drink 1 to 2 liters of water each day.”

Question 186

134. Which are steps in the process of making an antigen-specific antibody? Select all that apply.
     a. Antibody-antigen binding
     b. Invasion
     c. Opsonization
     d. Sensitization
     e. Recognition

Answer 186

a. Antibody-antigen binding
b. Invasion

e. Recognition

Question 187

135. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? Select one:
     a. Determine if the client has any new sexual partners.
     b. Ask the client about travel to any foreign countries.
     c. Assess the client for adherence to the drug regimen.
     d. Request information about new living quarters or pets.

Answer 187

c. Assess the client for adherence to the drug regimen.

Question 188

136. A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
     a. Meeting goals for nutrition within 1 week
     b. Providing and charting stroke education
     c. Discharging the client on a statin medication.
     d. Providing the client with comprehensive therapies

Answer 188

b. Providing and charting stroke education

c. Discharging the client on a statin medication.

Question 189

137. A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?
     a. Facilitate a consultation with physical therapy.
     b. Notify the health care provider immediately.
     c. Assess medication records for steroid use.
     d. Measure the range of motion in both hips.

Answer 189

c. Assess medication records for steroid use.

Question 190

138. A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
     a. “Vegetables, fruit, and high-fiber grains are important.”
     b. “I’m so glad I don’t have to give up my juicy steaks”
     c. “I’ll have to cut down on the amount of bacon I eat”
     d. “Foods high in vitamin A and vitamin C are important.”

Answer 190

b. “I’m so glad I don’t have to give up my juicy steaks”

Question 191

139. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? Select one or more:
     a. Morning stiffness is rare.
     b. Permanent damage is inevitable.
     c. Antibodies lead to inflammation
     d. It consists of an autoimmune process.
     e. It affects single joints only.

Answer 191

c. Antibodies lead to inflammation

d. It consists of an autoimmune process.

Question 192

140. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? Select one:
     a. Severe osteoporosis
     b. Needs multiple dental fillings
     c. Over age 85
     d. Urinary tract infection

Answer 192

a. Severe osteoporosis

Question 193

141. A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?
     a. A 30-year-old who drinks a beer a day
     b. A 40-year-old who uses seasonal antihistamines
     c. A 27-year-old heavy cocaine user
     d. A 65-year-old who is active and on no medications

Answer 193

c. A 27-year-old heavy cocaine user

Question 194

142. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? Select one:
     a. Help the client create backup plans to minimize disruption
     b. Offer to talk to the family and educate them about SLE.
     c. Tell the client to remain compliant with treatment plans.
     d. Explain to the client that SLE is an unpredictable disease.

Answer 194

a. Help the client create backup plans to minimize disruption

Question 195

143. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? Select one:
     a. Risk for impaired skin integrity related to immobility
     b. Disturbed sensory perception related to brain injury
     c. Impaired physical mobility related to weakness
     d. Risk for aspiration related to inability to protect airway

Answer 195

d. Risk for aspiration related to inability to protect airway

Question 196

144. For which type of cancer is chemotherapy most beneficial? Select one:
     a. Cancers that are localized to one tissue or body area
     b. Superficial cancers on the outside of the body
     c. Brain tumors
     d. Cancers that are large, with evidence of distant metastasis

Answer 196

d. Cancers that are large, with evidence of distant metastasis

Question 197

145. A patent comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the patient for Heberden’s nodules. What assessment technique is correct? Select one:
     a. Perform range of motion on the patient’s wrists
     b. Inspect the patient’s distal finger joints.
     c. Palpate the patient’s upper body lymph nodes.
     d. Palpate the patient’s abdomen for tenderness.

Answer 197

b. Inspect the patient’s distal finger joints.

Question 198

146. The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.)
     a. Normal doubling time
     b. State of euploidy
     c. Immune function
     d. Genetic predisposition
     e. Exposure to carcinogens

Answer 198

c. Immune function
d. Genetic predisposition
e. Exposure to carcinogens

Question 199

147. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? Select one:
     a. Splints
     b. Heating pads
     c. Ice packs
     d. Wax dips

Answer 199

c. Ice packs

Question 200

148. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? Select one or more:
     a. Education about healthy and safe habits
     b. Providing vaccinations against certain cancers
     c. Support groups that allow members to share strategies for living well
     d. Instructing people on the use of chemoprevention
     e. Teaching teens the dangers of tanning booths

Answer 200

a. Education about healthy and safe habits
b. Providing vaccinations against certain cancers

d. Instructing people on the use of chemoprevention
e. Teaching teens the dangers of tanning booths

Question 201

149. A nurse works in the rheumatology clinic and sees patients with rheumatoid arthritis (RA). Which patient should the nurse see first? Select one:
     a. A patient with a red, hot, swollen right wrist.
     b. A patient who has a puffy-looking area behind the knee.
     c. A patient who reports jaw pain when eating.
     d. A patient with a worsen joint deformity since the last visit.

Answer 201

a. A patient with a red, hot, swollen right wrist.

Question 202

150. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.)
     a. Pulselessness
     b. Redness
     c. Pallor
     d. Edema
     e. Warmth

Answer 202

b. Redness

d. Edema
e. Warmth

Question 203

A patient with a systemic bacterial infection has “goose pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for
 	A.	skin flushing.
 	B.	muscle cramps.
	C.	rising body temperature.
 	D.	decreasing blood pressure.

Answer 203

C. rising body temperature.

Question 204

While the nurse is obtaining an assessment and health history from a patient, which statement by the patient will alert the nurse to a possible immunodeficiency disorder?
A. “I take one baby aspirin every day to prevent stroke.”
B. “I usually eat eggs or meat for at least 2 meals a day.”
C. “I had my spleen removed many years ago after a car accident.”
D. “I had a chest x-ray 6 months ago when I had walking pneumonia.”

Answer 204

C. “I had my spleen removed many years ago after a car accident.”

Question 205

A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate
A. administration of immunosuppressant medications.
B. insertion of an arteriovenous graft for hemodialysis.
C. placement of the patient on the transplant waiting list.
D. drawing blood for human leukocyte antigen (HLA) and ABO compatibility
matching.

Answer 205

A. administration of immunosuppressant medications.

Question 206

A patient who is diagnosed with AIDS tells the nurse, “I have lots of thoughts about dying. Do you think I am just being morbid?” Which response by the nurse is best?
A. “Thinking about dying will not improve the course of AIDS.”
B. “It is important to focus on the good things about your life now.”
C. “Do you think that taking an antidepressant might be helpful to you?”
D. “Can you tell me more about the kind of thoughts that you are having?”

Answer 206

D. “Can you tell me more about the kind of thoughts that you are having?”

Question 207

When the nurse is caring for a patient whose HIV status in unknown, which of these patient exposures is most likely to require post exposure prophylaxis?
A. Needle stick with a needle and syringe used to draw blood
B. Splash into the eyes when emptying a bedpan containing stool
C. Contamination of open skin lesions with patient vaginal secretions
D. Needle stick injury with a suture needle during a surgical procedure

Answer 207

A. Needle stick with a needle and syringe used to draw blood

Question 208

To evaluate the effectiveness of ART, the nurse will schedule the patient for
	A.	viral load testing.
 	B.	enzyme immunoassay.
 	C.	rapid HIV antibody testing.
 	D.	immunofluorescence assay.

Answer 208

A. viral load testing.

Question 209

While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
A. “Benign tumors do not cause damage to other tissues.”
B. “Benign tumors are likely to recur in the same location.”
C. “Malignant tumors may spread to other tissues or organs.”
D. “Malignant cells reproduce more rapidly than normal cells.”

Answer 209

C. “Malignant tumors may spread to other tissues or organs.”