Q3

Question 1

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further
teaching?

1. Daily range-of-motion exercises are important to keep my joints flexible.”
2. “I can use a moist heat pack to help with joint stiffness.”
3. I should elevate my knees with pillows when I’m sleeping.
4. “I will make sure to rest in between activities throughout the day.”

Answer 1

3. I should elevate my knees with pillows when I’m sleeping.

Question 2

A client with a hip fracture is placed in Buck traction. Which activities are appropriate
for the nurse to include in the client’s plan of care? Select all that apply.

1. Assess for skin breakdown of the limb in traction
2. Ensure adequate pain relief
3. Keep the limb in a neutral position
4. Perform frequent neurovascular checks on the limb in traction
5. Reposition the client and use a wedge pillow

Answer 2

1. Assess for skin breakdown of the limb in traction
2. Ensure adequate pain relief
3. Keep the limb in a neutral position
4. Perform frequent neurovascular checks on the limb in traction

Question 3

The nurse reinforces the physical therapist’s teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching?

1. “I will hold the cane in my right hand.”
2. “I will move my left leg forward after moving the cane.”
3. “I will place the cane several inches in front of and to the side of my right foot.”
4. “My cane should equal the distance from my waist to the floor.”

Answer 3

4. “My cane should equal the distance from my waist to the floor.”

Question 4

An elderly client with osteoporosis falls onto an out-stretched hand and injures the
wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain
scale of 0-10. What should be the nurse’s first action?
1. Administer analgesia
2. Apply an ice pack to the wrist
3. Assess capillary refill and sensation
4. Elevate the wrist above heart level

Answer 4

3. Assess capillary refill and sensation

Question 5

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask?

1. “Have the assistive devices helped with dressing and grooming?”
2. “How do you feel about the changes in your appearance?”
3. “How is your pain control with the current medication regimen?”
4. “Is your level of energy adequate for completing your daily activities?”

Answer 5

3. “How is your pain control with the current medication regimen?”

Question 6

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck’s traction. The RN intervenes when the GN performs which action?

1. Elevates the head of the bed 45 degrees
2. Holds the weight while the client is repositioned up in bed
3. Loosens the Velcro straps when the client reports that the boot is too tight
4. Provides the client with a fracture pan for elimination needs

Answer 6

1. Elevates the head of the bed 45 degrees

Question 7

The nurse plans teaching for an adolescent client being discharged home with a
Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan?

1. Apply body lotion or powder under the brace to prevent skin irritation
2. Avoid any exercises that require the use of spinal muscles
3. Keep the brake on for all activities, including showering
4. Wear a cotton t-shirt under the brace at all times

Answer 7

4. Wear a cotton t-shirt under the brace at all times

Question 8

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply.

1. Crepitus with joint movement
2. Low-grade fever
3. Morning stiffness lasting 10 to 15 minutes
4. Pain exacerbated by weight-bearing activities
5. Positive serum rheumatoid factor

Answer 8

1. Crepitus with joint movement
2. Morning stiffness lasting 10 to 15 minutes
3. Pain exacerbated by weight-bearing activities

Question 9

A client who underwent open reduction and internal fixation of a right tibial fracture 10 hours ago reports worsening leg pain that is unrelieved by PRN morphine. The nurse assesses that the client’s right foot is cooler than the left. What is the nurse’s
priority action?

1. Administer the client’s next dose of pain medication
2. Assess the client’s vital signs
3. Maintain the extremity in a dependent position to promote blood flow
4. Report these findings to the health care provider immediately

Answer 9

4. Report these findings to the health care provider immediately

Question 10

A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for which finding is most important?

1. Biceps muscle spasm
2. Forearm swelling
3. Hand and wrist weakness
4. Shoulder range of motion

Answer 10

3. Hand and wrist weakness

Question 11

A client involved in a motor vehicle collision reports severe pelvic and right heel
pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider immediately?

1. Distended abdomen and absent bowel sounds
2. Ecchymosis over the pelvic bones
3. Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34)
4. Tenderness over the right heel

Answer 11

1. Distended abdomen and absent bowel sounds

Question 12

The nurse provides discharge teaching to a client who had total hip replacement 4
days ago. Which client statement indicates that additional teaching is necessary?

1. “I will concentrate on leaning forward as I carefully sit down in a chair.”
2. “I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day.”
   3.”I will use the sock puller that the therapist gave me when I get dressed.”
   4.”My child got me a riser for the toilet seat at home. I hope my feet reach
   the floor!”

Answer 12

1. “I will concentrate on leaning forward as I carefully sit down in a chair.”

Question 13

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?

1. “I have to give myself shots in the belly because my spouse is afraid of needles!”
2. “I have to use a walker because I can’t bear any weight on this knee yet.”
3. “I will call my health care provider if I get short of breath or sore or swollen below my knee.”
4. “The raised toilet seat makes it easier for me to get on and off the toilet by myself.”

Answer 13

2. “I have to use a walker because I can’t bear any weight on this knee yet.”

Question 14

The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the following instructions should the nurse include? Select all that apply.

1. Assess the residual limb daily for redness or irritation
2. Keep limb socks and elastic wraps clean and dry
3. Lie on your stomach three times a day for 30 minutes
4. Massage the residual limb with lotion each day
5. Wash the residual limb daily with soap and water

Answer 14

1. Assess the residual limb daily for redness or irritation
2. Keep limb socks and elastic wraps clean and dry
3. Lie on your stomach three times a day for 30 minutes
4. Wash the residual limb daily with soap and water

Question 15

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client
who has had multiple long bone fractures. Which findings does the nurse expect to
assess to support this diagnosis? Select all that apply.

1. Confusion and restlessness
2. Increasing pain despite the opioid analgesia
3. Paresthesia of the affected extremity
4. Petechiae over neck and chest
5. Pulse oximeter showing hypoxia

Answer 15

1. Confusion and restlessness
2. Petechiae over neck and chest
3. Pulse oximeter showing hypoxia

Question 16

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply.

1. Apply heat to reduce swelling during the first 24 hours
2. Begin an exercise rehabilitation program when the pain subsides
3. Elevate the leg above the heart level on 2 pillows
4. Flex and dorsiflex the foot to prevent stiffness during the first 24 hours
5. Take ibuprofen every 6 hours as needed
6. Wrap the ankle with an elastic compression bandage

Answer 16

2. Begin an exercise rehabilitation program when the pain subsides
3. Elevate the leg above the heart level on 2 pillows
4. Take ibuprofen every 6 hours as needed
5. Wrap the ankle with an elastic compression bandage

Question 17

A nurse in the emergency department cares for 4 clients with orthopedic injuries.
Which client should the nurse assess first?

1. Client who sustained a closed, incomplete ulnar fracture while playing
   sports
2. Client with bilateral metacarpal fractures after falling out of bed
3. Client with multiple myeloma who has a vertebral fracture and aching
   back pain
4. Client with pain and obvious shoulder deformity reporting a “pins-and-
   needles” sensation

Answer 17

4. Client with pain and obvious shoulder deformity reporting a “pins-and-
   needles” sensation

Question 18

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.

1. Cleans around the pin sites using sterile water
2. Gently tightens the device screws if they become loose
3. Holds the frame of the device when logrolling the client
4. Places a small pillow under the head when client is supine
5. Uses a blow-dryer on the cool setting to dry the vest when wet

Answer 18

1. Cleans around the pin sites using sterile water
2. Places a small pillow under the head when client is supine
3. Uses a blow-dryer on the cool setting to dry the vest when wet

Question 19

The nurse receives laboratory reports on 4 clients. Which report is most concerning
and should be reported to the health care provider?

1. The client admitted with asthma exacerbation who has a PaCO, of 32 mm Hg (4.26 kPa)
2. The client diagnosed with chronic obstructive pulmonary disease whose latest arterial blood gas shows a PaO, of 85 mm Hg (11.33 kPa)
3. The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5
4. The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L)

Answer 19

4. The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L)

Question 20

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further?

1. “I am having problems extending my fingers since this morning.”
2. “I can’t take any of the pain medicine because it makes me feel sick.”
3. “I have to scratch under the cast with a nail file because of the itching.”
4. “I noticed a warm spot on my cast, and a bad smell is coming from it.”

Answer 20

1. “I am having problems extending my fingers since this morning.”

Question 21

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.

1. Contact the clinic if any hot areas or foul odors develop in the cast
2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
3. Elevate the affected extremity above heart level for the first 48 hours
4. Expect some numbness and tingling of the fingers during the first week
5. Use only soft, padded objects to scratch the skin under the cast

Answer 21

1. Contact the clinic if any hot areas or foul odors develop in the cast
2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
3. Elevate the affected extremity above heart level for the first 48 hours

Question 22

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice?

1. Broiled chicken breast
2. Canned sardines
3. Egg white omelet
4. Peanut butter

Answer 22

2. Canned sardines

Question 23

A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply.

1. “I will avoid foods high in calcium and phosphorus.”
2. “I will avoid going outside on sunny days.”
3. “I will decrease activity to prevent bone injury.”
4. “I will eat foods that are fortified with vitamin D.”
5. “I will use a cane to help me get around better.”

Answer 23

1. “I will avoid foods high in calcium and phosphorus.”
2. “I will avoid going outside on sunny days.”
3. “I will decrease activity to prevent bone injury.”

Question 24

The client has just returned from having a cast placed on the right forearm and is
found putting a lead pencil in the cast to “reach the itch.” What is the nurse’s
priority action?
1. Offer the client a straw to reach the itch instead of a lead pencil
2. Perform a peripheral neurovascular check of the casted extremity
3. Pour a generous amount of baby powder or corn starch in the cast to
reach the itch
4. Review appropriate itch relief technique using the cool setting of a hair dryer

Answer 24

4. Review appropriate itch relief technique using the cool setting of a hair dryer

Question 25

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client
has oliguria, dark amber urine, and muscle pain. The nurse should implement which
prescription first?
1. ECG
2. IV morphine 2 mg
3. Normal saline bolus
4. Urine sample

Answer 25

3. Normal saline bolus

Question 26

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture
reduction with cast placement. Which finding requires priority action?
1. Blood-tinged stain on the inner aspect of the cast
2. Capillary refill of 2 seconds on the affected extremity
3. Mild swelling of toes on the right foot
4. Pain of 9/10 an hour after a dose of morphine

Answer 26

4. Pain of 9/10 an hour after a dose of morphine

Question 27

A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?

1. Client reporting a tingling sensation
2. Client reporting itching under the cast
3. Client reporting pain of 5/10 on movement
4. Client reporting throbbing on dependent positioning

Answer 27

1. Client reporting a tingling sensation

Question 28

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification?

1. Atorvastatin for hyperlipidemia in a client with angina pectoris
2. Bupropion for smoking cessation in a client with emphysema
3. Cyclobenzaprine for muscle spasms in a client with hepatitis
4. Metronidazole for trichomoniasis in a client with Crohn disease

Answer 28

3. Cyclobenzaprine for muscle spasms in a client with hepatitis

Question 29

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery?

1. Has allergy to strawberries
2. Is experiencing burning on urination starting yesterday
3. Rates knee pain as a 9 on a 0-10 scale
4. Stopped taking celecoxib 7 days ago

Answer 29

2. Is experiencing burning on urination starting yesterday

Question 30

A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier. Which intervention by the GN would cause the supervising nurse to intervene?

1. Applies a cold pack over the operative knee
2. Initiates a continual passive motion device
3. Obtains a leg-immobilizing device for ambulation
4. Places a support pillow under the operative knee

Answer 30

4. Places a support pillow under the operative knee

Question 31

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client’s care plan to help prevent a hip fracture? Select all that apply.

1. Calcium supplements
2. Encourage bed rest
3. Use of full bed rails during the night
4. Vitamin D supplements
5. Weight-bearing exercises

Answer 31

1. Calcium supplements
2. Vitamin D supplements
3. Weight-bearing exercises

Question 32

The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli?

1. Administering prophylactic enoxaparin as prescribed
2. Frequent use of incentive spirometry
3. Minimizing movement of the fractured extremity
4. Use of an intermittent pneumatic compression device

Answer 32

3. Minimizing movement of the fractured extremity

Question 33

The nurse has provided education for a client with newly diagnosed ankylosing
spondylitis. Which client statements indicate a correct understanding of teaching?
Select all that apply.
1. “I should continue strenuous exercise during flare-ups.”
2. “I should include spine-stretching activities such as swimming.”
3. “I should quit smoking and perform breathing exercises.”
4. “I will sleep on a soft mattress to decrease my morning stiffness.”
5. “I will take the prescribed ibuprofen on an empty stomach.”

Answer 33

2. “I should include spine-stretching activities such as swimming.”
3. “I should quit smoking and perform breathing exercises.”

Question 34

The nurse is caring for a client who is 12 hours postoperative total hip replacement.
Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis?
1. Instructing the client to cross the legs only at the ankles
2. Maintaining the head of the bed at ≥60-90 degrees
3. Placing an abductor pillow between the legs when turning the client
4. Turning the client to the affected side to alleviate lateral muscle pulling

Answer 34

3. Placing an abductor pillow between the legs when turning the client

Question 35

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching?

1. “Even with appropriate treatment joint damage and disability are inevitable.”
2. “My arthritis can be resolved if I can improve my diet and lose weight.”
3. “My methotrexate should be taken even when my joints aren’t hurting.”
4. “When my joints hurt, I should rest frequently and try not to move them.”

Answer 35

3. “My methotrexate should be taken even when my joints aren’t hurting.”

Question 36

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.

1. Cleans around the pin sites using sterile water
2. Gently tightens the device screws if they become loose
3. Holds the frame of the device when logrolling the client
4. Places a small pillow under the head when client is supine
5. Uses a blow-dryer on the cool setting to dry the vest when wet

Answer 36

1. Cleans around the pin sites using sterile water
2. Places a small pillow under the head when client is supine
3. Uses a blow-dryer on the cool setting to dry the vest when wet

Question 37

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply.

1. Achieve and maintain a healthy weight
2. Avoid foods containing protein
3. Drink plenty of fluids
4. Increase meat intake
5. Limit alcohol consumption

Answer 37

1. Achieve and maintain a healthy weight
2. Drink plenty of fluids
3. Limit alcohol consumption

Question 38

The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports “numbness and tingling” in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take?

1. Ask if the client wants pain medication for the “numbness and tingling”
2. Ask the client if the “numbness and tingling” were present before surgery
3. Continue assessment by observing the surgical dressing
4. Notify the health care provider (HCP) immediately

Answer 38

2. Ask the client if the “numbness and tingling” were present before surgery

Question 39

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to assess?

1. Asymmetrical pain in the large weight bearing joints
2. Low back pain and stiffness that is worse in the morning
3. Pain, swelling, and redness of the great toe
4. Symmetrical pain and swelling in the small joints of the hands

Answer 39

4. Symmetrical pain and swelling in the small joints of the hands

Question 40

The nurse is caring for a woman with obesity who is 3 days postoperative total hip joint replacement.
Which laboratory value is of greatest concern and should be reported to the health care provider
(HCP) immediately?
1. Blood urea nitrogen (BUN) 22 mg/dL (7.9 mmoVL)
2. Glucose 158 mg/dL (8.7 mmolL)
3. Hematocrit 33% (0.33) and hemoglobin 11 g/dL (110 g/L)
4. White blood cell count (WBC) 16,000/mm

Answer 40

4. White blood cell count (WBC) 16,000/mm

Question 41

A client with rheumatoid arthritis (RA) tells the home health nurse, “My fatigue and stiffness are getting worse and I’m having trouble moving around, especially in the morning. What can I do?” Which intervention would be best for the client to perform first?

1. Eat a high-calorie carbohydrate breakfast immediately after awakening
2. Perform range of motion exercises before getting out of bed
3. Take a warm shower or bath immediately after getting out of bed
4. Take prescribed nonsteroidal anti-inflammatory medication on awakening

Answer 41

3. Take a warm shower or bath immediately after getting out of bed

Question 42

A client comes to the emergency department after being assaulted. Imaging studies
show a simple fracture of the mandible. The nurse assesses edema of the face and
jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What
is the priority nursing intervention?
1. Administer nasal oxygen at 3 L/min
2. Administer opioids for pain
3. Apply ice pack to face for 20 minutes each hour
4. Suction the mouth and oropharynx

Answer 42

4. Suction the mouth and oropharynx

Question 43

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.

1. Cleans around the pin sites using sterile water
2. Gently tightens the device screws if they become loose
3. Holds the frame of the device when logrolling the client
4. Places a small pillow under the head when client is supine
5. Uses a blow-dryer on the cool setting to dry the vest when wet

Answer 43

1. Cleans around the pin sites using sterile water
2. Places a small pillow under the head when client is supine
3. Uses a blow-dryer on the cool setting to dry the vest when wet

Question 44

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply.

1. Achieve and maintain a healthy weight
2. Avoid foods containing protein
3. Drink plenty of fluids
4. Increase meat intake
5. Limit alcohol consumption

Answer 44

1. Achieve and maintain a healthy weight
2. Drink plenty of fluids
3. Limit alcohol consumption

Question 45

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan?

1. Apply elastic compression hose to wrists
2. Avoid use of caffeinated or tobacco products
3. Perform repetitive hand exercises daily
4. Wear a wrist immobilization splint

Answer 45

4. Wear a wrist immobilization splint

Question 46

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most likely assess which of the following?

1. Complete stiffness of the shoulder joint
2. Paresthesia over the first 3½ fingers
3. Shoulder pain with arm abduction
4. Tenderness over the lateral epicondyle

Answer 46

3. Shoulder pain with arm abduction

Question 47

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply.

1. Ecchymosis over the thigh and hip
2. Groin and hip pain with weight bearing
3. Internal rotation of the affected extremity
4. Muscle spasm around the affected area
5. Shortening of the affected extremity

Answer 47

1. Ecchymosis over the thigh and hip
2. Groin and hip pain with weight bearing
3. Muscle spasm around the affected area
4. Shortening of the affected extremity

Question 48

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first?

1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf
2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago
3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers
4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice

Answer 48

1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf

Question 49

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client’s nail beds appear dusky. What are the nurse’s appropriate actions? Select all that apply.

1. Apply a heating pad and encourage range-of-motion exercises
2. Assess the temperature and movement of the fingers
3. Elevate the arm on pillows above the level of the heart
4. Notify the health care provider
5. Reassure the client, document findings, and reassess in 1 hour

Answer 49

2. Assess the temperature and movement of the fingers

4. Notify the health care provider

Question 50

The nurse is assigned to care for a client who had a total hip replacement an hour

ago. Which of the following should the nurse assess first?
1. Amount of drainage in suction drainage device
2. Client’s level of pain and last dose of pain medication
3. Proper placement of the abduction pillow
4. Urine in the catheter bag for presence of cloudiness or pus

Answer 50

1. Amount of drainage in suction drainage device

Question 51

The nurse working on an orthopedic unit is receiving report on 4 clients with recent

fractures. Which client should the nurse assess first?
1. Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness
2. Client who has purulent drainage oozing from a skeletal traction pin insertion site and a temperature of 100.8 F (38.2 C)
3. Client with a hip fracture receiving continuous IV saline with bilateral 2+ pitting leg edema and a blood pressure of 176/89 mm Hg
4. Client with a rib fracture who is breathing at a rate of 23/min and is reporting 8/10 pain that is worse with inspiration

Answer 51

1. Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness

Question 52

The nurse is caring for a client admitted for a seizure diso dot. The nurse witnesses the cient having
a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all
that apply.
1. Call for help
2. Hold down the client’s arms
3. Insert a tongue depressor to move the tongue
Prepare for suctioning
5. Turn the client on the side

Answer 52

1. Call for help
   Prepare for suctioning
2. Turn the client on the side

Question 53

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?

1. Expressive speech, vision
2. Light touch, hearing
3. Sense of position, graphesthesia
4. Weber tuning fork tost, cranial nerve I

Answer 53

1. Expressive speech, vision

Question 54

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, “My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson’s disease?” Which response from the nurse is the most helpful?

1. “It can’t be Parkinson’s disease because you aren’t old enough.”
2. “Make sure you tell the physician about your concerns.”
3. “Parkinson’s disease does not cause that kind of hand shaking.”
4. “Tell me more about your symptoms. When did they start?”

Answer 54

4.”Tell me more about your symptoms. When did they start?”

Question 55

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the
client to a chair, what should the nurse do?
1. Bend at the waist
2. Keep the feet close together
3. Pivot on the foot proximal to the chair
4. Use a transfer belt

Answer 55

4. Use a transfer belt

Question 56

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with
incorrect word choices. The nurse documents the presence of which communication deficit?
1. Aphasia
2. Apraxia
3. Dysarthria
4. Dysphagia

Answer 56

1. Aphasia

Question 57

The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?

1. To lower the blood alcohol level
2. To prevent gross tremors
3. To prevent Wernicke encephalopathy
4. To treat seizures related to acute alcohol withdrawal

Answer 57

3. To prevent Wernicke encephalopathy

Question 58

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first?

1. Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura
2. Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position
3. Client with myasthenia gravis who has a fever and increasing difficulty swallowing
4. Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream

Answer 58

3. Client with myasthenia gravis who has a fever and increasing difficulty swallowing

Question 59

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

1. History of Bell’s palsy with unilateral facial droop and drooling
2. History of multiple sclerosis and reporting recent blurred vision
3. Reports unilateral facial pain when consuming hot foods
4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

Answer 59

4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

Question 60

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply.

1. Administer PRN stool softeners daily
2. Administer scheduled enoxaparin injection
3. Implement seizure precautions
4. Keep client NPO until swallow screen is performed
5. Perform frequent neurological assessment

Answer 60

1. Administer PRN stool softeners daily
2. Implement seizure precautions
3. Keep client NPO until swallow screen is performed
4. Perform frequent neurological assessment

Question 61

The nurse moves a finger in a horizontal and vertical motion in front of the client’s face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? Select all that apply. (3, 4, 6)

1. II
2. III
3. IV
4. V
5. VI

Answer 61

2. III
3. IV
4. VI

Question 62

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to
the health care provider?
1. “I got short of breath this morning when I worked out.”
2. “I have cut down on smoking to 1/2 pack per day.”
3. “| haven’t been feeling well, so I have been sleeping a lot.”
4. “I took an acetaminophen in the waiting room for this bad headache.”

Answer 62

4. “I took an acetaminophen in the waiting room for this bad headache.”

Question 63

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating,”One of my parents has Huntington disease, and I am afraid my child will get it.” How should the nurse respond?
1. “Genetic counseling is recommended. You will receive a referral before you leave.”
2. “Huntington disease inheritance requires both biological parents to carry the gene.”
3.”There are other ways to grow your family. You should consider adoption.”
4 “This disease occurs spontaneously and is not likely to affect your children.”

Answer 63

1. “Genetic counseling is recommended. You will receive a referral before you leave.”

Question 64

A client is diagnosed with right-sided Bell’s palsy. What instructions should the nurse give this client
for care at home? Select all that apply.
1. Apply a patch to the right eye at night
2. Avoid driving
3. Chew on the left side
4. Maintain meticulous oral hygiene
5. Use a cane on the left side

Answer 64

1. Apply a patch to the right eye at night
2. Chew on the left side
3. Maintain meticulous oral hygiene

Question 65

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the
nurse expect? Select all that apply.
1. Diarrhea
2. Difficulty breathing
3. Difficulty swallowing
4. Muscle weakness
5. Resting tremor

Answer 65

2. Difficulty breathing
3. Difficulty swallowing
4. Muscle weakness

Question 66

• The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UP) asks if the client will “shake and jerk” when having a seizure. Which response from the nurse is the most helpful?
  1. “No, absence seizures can look like daydreaming or staring off into space.”
  2. “No, you are wrong. Don’t worry about that.”
  3. “Yes, so please let me know if you see the client do that.”
  4. “You don’t have to monitor the client for seizures.”

Answer 66

1. “No, absence seizures can look like daydreaming or staring off into space.”

Question 67

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?

1. Administer rectal diazepam
2. Assess for neck stiffness and Brudzinski sign
3. Draw blood for laboratory studies
4. Transport the client to CT for assessment of shunt malfunction

Answer 67

1. Administer rectal diazepam

Question 68

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism?

1. Boil water if unsure of its source
2. Discard canned food with a bulging end
3. Keep milk cold
4. Wash hands

Answer 68

2. Discard canned food with a bulging end

Question 69

The nurse receives report for 4 clients in the emergency department. Which client should be seen first?

1. 30-year-old with a spinal cord injury at L3 sustained in a motorcycle accident who reports lower abdominal pain and difficulty urinating
2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait
3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL
4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

Answer 69

4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

Question 70

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply.

1. Add a thickening agent to the fluids (aspiration)
2. Avoid administering sedating medications before meals (aspiration)
3. Place the client in an upright position during meals (aspiration)
4. Restrict visitors who show signs of illness
5. Teach the client to flex the neck while swallowing (aspiration)

Answer 70

1. Add a thickening agent to the fluids (aspiration)
2. Avoid administering sedating medications before meals (aspiration)
3. Place the client in an upright position during meals (aspiration)
4. Teach the client to flex the neck while swallowing (aspiration)

Question 71

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, “I guess I can anticipate getting this disease myself at some point.” What is an appropriate
response by the nurse?
1.”Engaging in regular exercise decreases the risk of AD.”
2. “Having a family history of AD is not a risk factor.”
3. “Try not to worry about this now as you can’t do anything to prevent AD.”
4.”You should avoid aluminum cans and cookware to prevent AD.”

Answer 71

1.”Engaging in regular exercise decreases the risk of AD.”

Question 72

The nurse is caring for a female client newly diagnosed with epilepsy who has been
prescribed phenytoin. Which of the following should the nurse include in client teaching?
Select all that apply.
1. “Avoid drinking alcoholic beverages.”
2. “Do not abruptly stop taking your phenytoin.”
3. “Go to the emergency department every time a seizure occurs.”
4 “Wear an epilepsy medical identification bracelet.”
5. “You may need to start using a nonhormonal birth control method.”

Answer 72

1. “Avoid drinking alcoholic beverages.”
2. “Do not abruptly stop taking your phenytoin.”
   4 “Wear an epilepsy medical identification bracelet.”
3. “You may need to start using a nonhormonal birth control method.”

Question 73

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply.

1. Identify the number “8” traced on the palm
2. Shrug the shoulders against resistance
3. Swallow water
4. Touch each finger of one hand to the hand’s thumb
5. Walk heel-to-toe

Answer 73

4. Touch each finger of one hand to the hand’s thumb

5. Walk heel-to-toe

Question 74

The nurse reinforces education about safety modifications in the home for the spouse of a client
diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that
apply.
1. Arrange furniture to allow for free movement
2. Keep frequently used Items within easy reach
3. Lock doors leading to stairwells and outside areas
4. Place an identifying symbol on the bathroom door
5. Provide a dark room free of shadows for sleeping

Answer 74

1. Arrange furniture to allow for free movement
2. Keep frequently used Items within easy reach
3. Lock doors leading to stairwells and outside areas
4. Place an identifying symbol on the bathroom door

Question 75

The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first? Click on the exhibit button for additional
information.
1. Administer IV push naloxone once now
2. Draw specimen for blood alcohol content testing STAT
3. Initiate continuous lactated Ringer solution infusion
4. Obtain urine sample for drug abuse screening ASAP

Answer 75

1. Administer IV push naloxone once now

Question 76

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The
nurse prepares the prescribed nicardipine intravenous (IV) infusion solution
correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to
infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse’s
priority action at this time?
1. Assess hourly urinary output (19%)
2. Increase pump setting to correct administration rate to 100 mL/hr
3. Keep systolic blood pressure above 170 mm Hg
4. Monitor for a widening QT interval

Answer 76

3. Keep systolic blood pressure above 170 mm Hg

Question 77

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?

1. “I am very tired, and it’s hard for me to keep my eyes open.”
2. “I don’t feel good, and I want to be seen.”
3. “I have not taken my blood pressure medicine in over a week.”
4. “I have the worst headache I’ve ever had in my life.”

Answer 77

4. “I have the worst headache I’ve ever had in my life.”

Question 78

The emergency department nurse is assessing a client brought in after a car accident in which the client’s head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply.

1. Breath smells of alcohol
2. Client disoriented to place
3. Client reports eyes burning
4. History of multiple sclerosis
5. Point tenderness over spine

Answer 78

1. Breath smells of alcohol
2. Client disoriented to place
3. Point tenderness over spine

Question 79

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?

1. Consume a low-fat, low-salt diet
2. Do not smoke cigarettes
3. Exercise and lose weight
4. Take prescribed antihypertensive medications

Answer 79

4. Take prescribed antihypertensive medications

Question 80

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply.

1. Administer an analgesic as needed
2. Determine if there is bladder distention
3. Measure the client’s blood pressure
4. Place the client in the Sims’ position
5. Remove constrictive clothing

Answer 80

2. Determine if there is bladder distention
3. Measure the client’s blood pressure
4. Remove constrictive clothing

Question 81

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP),brequired lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, “That’s weird. I didn’t even feel nauseated.” Which action by the nurse is the most appropriate?

1. Document the amount of emesis
2. Lower the head of the bed
3. Notify the health care provider (HCP)
4. Ofer anti-nausea medication

Answer 81

3. Notify the health care provider (HCP)

Question 82

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve?

1. “Close your eyes and identify this smell.”
2. “Follow my finger with your eyes without moving your head.”
3. “Look straight ahead and let me know when you can see my finger.”
4. “Raise your eyebrows, smile, and frown.”

Answer 82

4. “Raise your eyebrows, smile, and frown.”

Question 83

The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.

1. Encourage the client to speak slowly and pause to take deep breaths periodically
2. Identify and promote the client’s capabilities and strengths throughout the sessions
3. Provide client teaching during times of day when the client has the most energy
4. Reserve discussion of important or complex teaching for the client’s caregiver
5. Schedule teaching sessions at times with low risk of rushing or interruptions

Answer 83

1. Encourage the client to speak slowly and pause to take deep breaths periodically
2. Identify and promote the client’s capabilities and strengths throughout the sessions
3. Provide client teaching during times of day when the client has the most energy
4. Schedule teaching sessions at times with low risk of rushing or interruptions

Question 84

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the cient’s risk for
developing aspiration pneumonia?
1. Assessing client’s breath sounds every 2 hours
2. Placing client in the side lying position in bed
3. Titrating client’s oxygen to maintain saturation 293%
4. Turning and repositioning the client every 2 hours

Answer 84

2. Placing client in the side lying position in bed

Question 85

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client’s safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? Select all that apply.
1”Grab bars should be installed in the shower and beside the toilet.”
2. “I will place a safe return bracelet on the client’s wrist.”
3.”Keyed deadbolts should be placed on all exterior doors.”
4. “Medications will be placed in a weekly pill dispenser.”
5.”Throw rugs and clutter will be removed from the floors.”

Answer 85

1”Grab bars should be installed in the shower and beside the toilet.”

2. “I will place a safe return bracelet on the client’s wrist.”
3. “Keyed deadbolts should be placed on all exterior doors.”
4. “Throw rugs and clutter will be removed from the floors.”

Question 86

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? Select all that apply.

1. Cannot flex the chin toward the chest
2. Eyes move in opposite direction of head when head is turned to side
3. New onset of right arm drift
4. Pupils 8 mm in diameter bilaterally
5. Toes point downward when sole of foot is stimulated

Answer 86

1. Cannot flex the chin toward the chest
2. New onset of right arm drift
3. Pupils 8 mm in diameter bilaterally

Question 87

The nurse is caring for a client after a motor vehicle accident. The client’s injuries include 2 fractured ribs and a concussion. The
nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply.
1. Asymmetrical pupillary constriction
2. Brief loss of consciousness
3. Headache
4. Loss of vision
5. Retrograde amnesia

Answer 87

2. Brief loss of consciousness
3. Headache
4. Retrograde amnesia

Question 88

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

1. Auscultate breath sounds to assess for crackles
2. Monitor for >50 mL/hr urine output
3. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
4. Press over the tibia to assess for pitting edema

Answer 88

1. Auscultate breath sounds to assess for crackles

Question 89

The home health nurse teaches an elderly client with dysphagia some strategies to help limit
repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs
further teaching?
1. I have to remember to raise my chin slightly upward when I swallow.”
2. “I have to remember to swallow 2 times before taking another bite of food.”
3. “I should avoid taking over-the-counter cold medications when I’m sick.”
4. *I should sit upright for at least 30-40 minutes after | eat.”

Answer 89

1. I have to remember to raise my chin slightly upward when I swallow.”

Question 90

**A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the
appropriate nursing actions? Select all that apply.

1. Administer an anticholinesterase drug AC
2. Anticipate a need for an anticholinergic drug
3. Develop a bladder training schedule
4. Encourage semi-solid food consumption
5. Teach the necessity for annual flu vaccination

Answer 90

1. Administer an anticholinesterase drug AC
2. Encourage semi-solid food consumption
3. Teach the necessity for annual flu vaccination

Question 91

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what
action first?
1. Check for Kernig’s and Brudzinskis signs
2. Establish IV access
3. Place the client on droplet precautions
4.Prepare the client for lumbar puncture

Answer 91

3. Place the client on droplet precautions

Question 92

The nurse is caring for a client after a lumbar puncture (spinal tap). Which dient assessment is mest
concerning and requires a nursing response?
1. Consumes 600 mL liquid over 4 hours
2. Insertion site dressing saturated with clear fluid
3. Observed lying in the right-sided Sim’s position
4. Reports a headache rated 6/10

Answer 92

2. Insertion site dressing saturated with clear fluid

Question 93

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply.

1. Ask simple questions that require “yes” or “no” answers
2. If the client becomes frustrated, seek a different care provider to complete ADL
3. Remain calm and allow the client time to understand each instruction
4. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures
5. Speak slowly but loudly while looking directly at the client

Answer 93

1. Ask simple questions that require “yes” or “no” answers
2. Remain calm and allow the client time to understand each instruction
3. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures

Question 94

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? (9= swallowing/gag reflex, 10= voice, 12= tongue)
1”I will ask the health care provider to explain the consequences of your procedure.”
2. “This is a common complication that will require you to have a hearing test every year.”
3.”This is a common complication; your health care provider will order a consult for the speech pathologist.”
4. “This is the reason you are using a special swallowing technique when you eat and drink.”

Answer 94

4. “This is the reason you are using a special swallowing technique when you eat and drink.”

Question 95

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first?

1. Administer IV antibiotics
2. Infuse bolus of IV normal saline
3. Prepare to assist with lumbar puncture
4. Transport client for head CT scan

Answer 95

2. Infuse bolus of IV normal saline

Question 96

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client’s vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the registered nurse? Click on the exhibit button for additional information.

Vitals
Temp: 98.7 F, BP 110/64, HR 92, RR 22, Oxygen Sat 90% RA
1. “I need to assess the client.”
2.”It sounds like the client is not satisfied with the care provided. I’ll
see if we can make the client more comfortable.”
3.”Just leave the client alone now and try âgain later.”
4.”The client probably has dementia and is under a lot of stress with
the change of environment.”

Answer 96

1. “I need to assess the client.”

Question 97

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client?

1. Risk for ineffective airway maintenance
2. Risk for knowledge deficit
3. Risk for poor fluid intake
4. Risk for self-neglect

Answer 97

4. Risk for self-neglect

Question 98

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client’s seizure activity?

1. Aural phase
2. Ictal phase
3. Postictal phase
4. Prodromal phase

Answer 98

3. Postictal phase

Question 99

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take?

1. Arouse the client and ask what the current month is
2. Document relief apparently obtained* and recheck at 03:00 AM
3. Let the client sleep but verify respiratory rate
4. Wake the client up and check for paresthesia

Answer 99

1. Arouse the client and ask what the current month is

Question 100

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client’s current Glasgow Coma Scale (GCS) score is a “10.” Which client assessment is most important for the reporting nurse to include?

1. Belief that the current surroundings are a racetrack
2. GCS score was “11” one hour ago
3. Recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min
4. Reported allergy to penicillin and vancomycin

Answer 100

2. GCS score was “11” one hour ago

Question 101

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

1. Give the antihypertensive medication
2. Monitor the blood pressure
3. Notify the health care provider
4. Question the prescription

Answer 101

2. Monitor the blood pressure

Question 102

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.
1. Complete activities such as bathing and dressing as quickly as
possible
2. Decrease the client’s anxiety by limiting the number of choices offered
3. Redirect the client if agitated by asking for help with a task or going for a walk
4.Remember to interact with the client as an adult, regardless of childlike affect
5. Use open-ended questions when communicating with the client

Answer 102

2. Decrease the client’s anxiety by limiting the number of choices offered
3. Redirect the client if agitated by asking for help with a task or going for a walk
4. Remember to interact with the client as an adult, regardless of childlike affect

Question 103

• *The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
  1. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
  2. Client admitted with multiple sclerosis exacerbation has scanning speech
  3. Client with epilepsy puts on call light and reports having an aura
  4. Client with fibromyalgia reports pain in the neck and shoulders

Answer 103

3. Client with epilepsy puts on call light and reports having an aura

Question 104

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next?

1. Administer atropine for bradycardia
2. Administer nifedipine for hypertension
3. Have CT scan performed to rule out an intracranial bleed
4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

Answer 104

3. Have CT scan performed to rule out an intracranial bleed

Question 105

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, “I’m hungry. You didn’t feed me.” The nurse should take which action?

1. Give the client gentle reminders that the client has already eaten
2. Say that the client can have a snack in a couple of hours
3. Serve the client half of the meal initially and offer the other half later
4. Take a picture of the client having a meal and show it when the client becomes upset

Answer 105

3. Serve the client half of the meal initially and offer the other half later

Question 106

The graduate nurse cares for several poststroke clients. Which of the following nursing interventions
are appropriate? Select all that apply.
1. Implement fall precautions for the client with cerebellum stroke
2. Increase lighting for the client with cranial nerve VIl affected
3. Initiate swallow precautions for the client with cranial nerves IX and X affected
4. Place spoon within fold of vision for the client with homonymous hemianopsia
5. Speak louder in front of the client who has receptive aphasia

Answer 106

1. Implement fall precautions for the client with cerebellum stroke
2. Initiate swallow precautions for the client with cranial nerves IX and X affected
3. Place spoon within fold of vision for the client with homonymous hemianopsia

Question 107

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are
likely contributing to the client’s delirium? Select all that apply.
1. Multiple doses of IV hydromorphone administered in the past 12 hours
2, Serum sodium of 123 mEq/L (123 mmol/L)
3. SpO, of 82% on room air
4. Temperature of 103.1 F (39.5 C)
5. Urine culture positive for gram-positive cocci in chains

Answer 107

1. Multiple doses of IV hydromorphone administered in the past 12 hours
   2, Serum sodium of 123 mEq/L (123 mmol/L)
2. SpO, of 82% on room air
3. Temperature of 103.1 F (39.5 C)
4. Urine culture positive for gram-positive cocci in chains

Question 108

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply.

1. Client coughs and gasps when swallowing food and liquids
2. Client is easily frustrated while attempting to speak
3. Client is unable to understand speech and is completely nonverbal
4. Client misunderstands and inappropriately responds to verbal instruction
5. Client’s speech is limited to short phrases that require effort

Answer 108

2. Client is easily frustrated while attempting to speak

5. Client’s speech is limited to short phrases that require effort

Question 109

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale?
1. The nurse applies pressure to the nail bed, and the client tries to push the nurse’s hand
away. The nurse scores motor response as “localization of pain.”
2. The nurse asks the client what day it is and the client says “banana.” The nurse scores
verbal response as “confused.”
3. The nurse speaks with client and then the client’s eyes open. The nurse scores eye
opening as “spontaneous.”
4. The nurse walks in the room and the client states “Hi honey. How are you?” The nurse
scores verbal response as “oriented.”

Answer 109

1. The nurse applies pressure to the nail bed, and the client tries to push the nurse’s hand
   away. The nurse scores motor response as “localization of pain.”

Question 110

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply.

1. Change in lacrimation on the affected side
2. Electric shock-like pain in the lips and gums
3. Flattening of the nasolabial fold
4. Inability to smile symmetrically
5. Severe pain along the cheekbone

Answer 110

1. Change in lacrimation on the affected side
2. Flattening of the nasolabial fold
3. Inability to smile symmetrically

Question 111

The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse’s priority action?

1. Ask about client’s chronic medical conditions
2. Assess for level and duration of pain
3. Obtain a Glasgow Coma Scale score
4. Perform a head-to-toe assessment

Answer 111

3. Obtain a Glasgow Coma Scale score

Question 112

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

1. “I will raise the head of the bed so it is easier to see the television.”
2. “I will turn down the lights when I leave.”
3. “Let me move your belongings closer so you can reach them.”
4. “You should do deep breathing and coughing exercises.” (never do this for ICP)

Answer 112

4. “You should do deep breathing and coughing exercises.” (never do this for ICP)

Question 113

A client is brought to the emergency department by emergency medical services with a flaccid right arm and log and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

1. Determine onset of symptoms
2. Ensure that the dient has 2 largo-bore intravenous (M) lines
3. Maintain patent airway
4. Prepare for head CT scan

Answer 113

3. Maintain patent airway

Question 114

A nurse cares for a client with impairment of cranial nerve VIll. What instructions will the nurse provide the unlicensed assistive
personnel prior to delegating interventions related to the client’s activities of daily living?
1. “Be aware of the client’s shoulder weakness and provide support as needed.”
2. ‘Ensure that the client sits upright and tucks the chin when swallowing food.”
3. “Explain all procedures in step-by-step detail before performing them.”
4. “Make sure the items needed by the client are within reach.”

Answer 114

4. “Make sure the items needed by the client are within reach.”

Question 115

• 52. A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time?
      
      1. “Avoid excess stretching of your lower extremities.”
      2. “Build strength by increasing the duration of daily exercise.”
      3. “Let me speak with your health care provider about getting a wheelchair.”
      4. “You should keep your feet apart and use a cane when walking.”

Answer 115

4. “You should keep your feet apart and use a cane when walking.”

Question 116

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe?

1. Decreased rate and depth of respirations
2. Deficits in visual perception
3. Expressive aphasia
4. Inability to recognize touch

Answer 116

2. Deficits in visual perception

Question 117

The nurse is planning care for a client with suspected stroke who has just arrived at the emergency
department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago.
Which of the following interventions should the nurse anticipate including in the initial plan of care?
Select all that apply.
1. Arrange for a speech pathologist consult
2. Discuss community resources with family
3. Obtain a STAT CT scan of the head
4. Perform a baseline neurologic assessment
5. Prepare to initiate alteplase within the next 3 hours

Answer 117

3. Obtain a STAT CT scan of the head
4. Perform a baseline neurologic assessment
5. Prepare to initiate alteplase within the next 3 hours

Question 118

*A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse?
1”I may feel a sharp pain that shoots to my leg, but it should pass soon.”
2.”I will go to the bathroom and try to urinate before the procedure.”
3”I will need to lie on my stomach during the procedure.”
4”The physician will insert a needle between the bones in my lower spine.”

Answer 118

3”I will need to lie on my stomach during the procedure.”

Question 119

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply.

1. Client should abstain from alcohol
2. Client should remain awake all night
3. Client should return if having difficulty walking
4. Responsible adult should be taught neurological examination
5. Responsible adult should stay with the client

Answer 119

1. Client should abstain from alcohol
2. Client should return if having difficulty walking
3. Responsible adult should stay with the client

Question 120

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (Gl) illness. Monitoring for which of the following is a nursing care priority for this client?

1. Diaphoresis with facial flushing
2. Hypoactive or absent bowel sounds
3. Inability to cough or lift the head
4. Warm, tender, and swollen leg

Answer 120

3. Inability to cough or lift the head

Question 121

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply.

1. Decreased serum sodium
2. Excess oral water intake
3. High urine output
4. Increased serum osmolality
5. Increased urine specific gravity

Answer 121

2. Excess oral water intake
3. High urine output
4. Increased serum osmolality

Question 122

The nurse is caring for a client in the immediate postoperative period following a carotid
endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause
the nurse to notify the healthcare provider immediately?
1. Diminished gag reflex after endotracheal tube removal
2. Increased agitation level and pulling at linens
3. Left arm drift during bilateral arm extension
4. Responds to verbal commands with eyes closed

Answer 122

3. Left arm drift during bilateral arm extension

Question 123

The nurse is preparing to discharge a client who is stable following a head injury. Which statement
by the client indicates a need for further discharge instructions?
1. “I have a leftover prescription at home I can use if I have pain.”
2. “I will cancel the wine tasting I have planned for this weekend.”
3. “I will have someone drive me home and will take a couple of days off work.”
4. “I will have someone stay with me and make sure I am okay.”

Answer 123

1. “I have a leftover prescription at home I can use if I have pain.”

Question 124

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the maneuver when defecating? Select all that apply.

1. 22-year-old man with a head injury sustained during a college football game
2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty
3. 56-year-old man 2 weeks post myocardial infarction
4. 68-year-old woman recently diagnosed with pancreatic cancer
5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis
6. 82-year-old woman 1 week post cataract surgery

Answer 124

1. 22-year-old man with a head injury sustained during a college football game
2. 56-year-old man 2 weeks post myocardial infarction
3. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis
4. 82-year-old woman 1 week post cataract surgery

Question 125

A client comes to the clinic for a follow-up visit after a Billroth Il surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate?

1. Check serum blood glucose for hypoglycemia
2. Ensure that the client consumes fluids with meals
3. Take the client’s blood pressure while lying and standing
4. Teach the client to lie down after eating

Answer 125

4. Teach the client to lie down after eating

Question 126

The nurse teaching a group of clients about celiac disease will include which meal in the teaching plan?

1. Baked salmon with rice, steamed vegetables, and dinner roll
2. Breaded pork chops, corn on the cob, and steamed snow peas
3. Grilled chicken, green beans, and mashed potatoes
4. Spaghetti with Italian tomato sauce and meatballs

Answer 126

3. Grilled chicken, green beans, and mashed potatoes

Question 127

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply.

1. Helps prevent colorectal cancer
2. Improves glycemic control
3. Promotes weight loss
4. Reduces risk of vascular disease
5. Regulates bowel movements

Answer 127

1. Helps prevent colorectal cancer
2. Improves glycemic control
3. Promotes weight loss
4. Reduces risk of vascular disease
5. Regulates bowel movements

Question 128

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply.

1. Apple juice
2. Cherry popsicle
3. Chicken broth
4. Frozen yogurt
5. Unsweetened tea
6. Vanilla ice cream

Answer 128

1. Apple juice
2. Chicken broth
3. Unsweetened tea

Question 129

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene?

1. “Elevate your scrotum and apply an ice bag to reduce swelling.”
2. “Practice coughing to clear secretions and prevent pneumonia.”
3. “Stand up to use the urinal if you have difficulty voiding.”
4. “Turn in bed and perform deep breathing every 2 hours.”

Answer 129

2. “Practice coughing to clear secretions and prevent pneumonia.”

Question 130

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area?

1. Left flank radiating to the left groin area
2. Left upper quadrant radiating to the back
3. Periumbilical area shifting to the right lower quadrant
4. Right upper quadrant radiating to the right shoulder

Answer 130

2. Left upper quadrant radiating to the back

Question 131

The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority?

1. Administer promethazine 25 mg suppository
2. Infuse normal saline 100 mL/hour
3. Insert nasogastric tube to low suction
4. Maintain nothing-by-mouth (NPO) status

Answer 131

4. Maintain nothing-by-mouth (NPO) status

Question 132

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication?

1. Assess mental status and orientation
2. Give on an empty stomach for rapid effect
3. Hold if 3 soft stools occur in a day
4. Mix with fruit juice to improve flavor

Answer 132

3. Hold if 3 soft stools occur in a day

Question 133

• *A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome?
  1. Phosphorus 2.0 mg/dL (0.65 mmol/L), potassium 2.9 mEg/L (2.9 mmol/L), magnesium 1.0 mEq/L (0.5 mmol/L)
  2. Phosphorus 4.0 mg/dL (1.29 mmol/L), potassium 3.5 mEq/L (3.5 mmol/L), magnesium 2.0 mEq/L (1.0 mmol/L)
  3. Random blood glucose 60 mg/dL (3.3 mmol/L), sodium 120 mEq/dL (120 mmol/L), calcium 7.0 mg/dL (1.75 mmol/L)
  4. Random blood glucose 100 mg/dL (5.6 mmol/L), sodium 140 mEq/dL (140 mmol/L), calcium 10.0 mg/dL (2.50 mmol/L)

Answer 133

1. Phosphorus 2.0 mg/dL (0.65 mmol/L), potassium 2.9 mEg/L (2.9 mmol/L), magnesium 1.0 mEq/L (0.5 mmol/L)

Question 134

A healthy 50-year-old client asks the nurse, “What must I do in preparation for my screening colonoscopy?” Which statements by the nurse correctly answer the client’s question? Select all that apply.

1. “No food or drink is allowed 8 hours prior to the test.”
2. “Prophylactic antibiotics are taken as prescribed.”
3. “Smoking must be avoided after midnight.”
4. “The day prior to the procedure your diet will be clear liquids.”
5. “You will drink polyethylene glycol as directed the day before.”

Answer 134

1. “No food or drink is allowed 8 hours prior to the test.”
2. “The day prior to the procedure your diet will be clear liquids.”
3. “You will drink polyethylene glycol as directed the day before.”

Question 135

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? Select all that apply.

1. Bananas
2. Broccoli with cheese
3. Multigrain bagel
4. Popcorn
5. Spaghetti with sauce

Answer 135

2. Broccoli with cheese
3. Multigrain bagel
4. Popcorn

Question 136

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.

1. Choose foods that are low in fat
2. Do not consume any foods containing dairy
3. Eat three large meals a day and minimize snacking
4. Limit or eliminate the use of alcohol and tobacco
5. Try to avoid caffeine, chocolate, and peppermint

Answer 136

1. Choose foods that are low in fat
2. Limit or eliminate the use of alcohol and tobacco
3. Try to avoid caffeine, chocolate, and peppermint

Question 137

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.

1. Drink plenty of fluids
2. Exercise regularly
3. Follow a low-residue diet
4. Include whole grains, fruits, and vegetables in the diet
5. Increase intake of red meat

Answer 137

1. Drink plenty of fluids
2. Exercise regularly
3. Include whole grains, fruits, and vegetables in the diet

Question 138

Client returned from GI lab, drowsy but oriented x4. Client rates throat pain as 2 on a scale of 0-10 and new onset abdominal pain as 4 on a scale of 0-1.0. Family at bedside.

The nurse is assessing a client who had an esophagogastroduodenoscopy 3 hours ago. The client is reporting increasing abdominal pain. Which clinical finding requires an immediate report to the health care provider? Click the exhibit button for additional information.

1. Blood pressure 108/72 mm Hg
2. Gag reflex has not returned
3. Sore throat when swallowing
4. Temperature 100.6 F (38.1 C)

Answer 138

4. Temperature 100.6 F (38.1 C)

Question 139

The nurse is caring for a client with right upper quadrant pain and jaundice. The client’s alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for
these findings? Select all that apply.
1. Do you have black tarry stool?
2. Do you use intravenous (IV) illicit drugs?
3. How much alcohol do you typically drink?
4. Were you recently immunized for pneumonia?
5. What over-the-counter drugs do you take?

Answer 139

2. Do you use intravenous (IV) illicit drugs?
3. How much alcohol do you typically drink?
4. What over-the-counter drugs do you take?

Question 140

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client’s electronic health record, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information.

1. Ascites
2. Bruising
3. Constipation
4. Itching
5. Lethargy

Answer 140

1. Ascites
2. Bruising
3. Itching
4. Lethargy

Question 141

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

1. Encourage client to eat bulk-forming foods such as whole grain bread
2. Encourage rest, fluids, and acetaminophen for the fever
3. Make an appointment for the client with the health care provider today
4. Take 2 tablets of loperamide followed by 1 tablet after each loose stool

Answer 141

3. Make an appointment for the client with the health care provider today

Question 142

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

1. Abdominal pain has progressed to the left upper quadrant
2. Hemoglobin of 11.2 g/dL (112 g/L)
3. Lying on side with knees drawn up to abdomen and trunk flexed
4. White blood cell count of 12,000/mm° (12.0 x 10%/L)

Answer 142

1. Abdominal pain has progressed to the left upper quadrant

Question 143

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

1. Abdominal pain has progressed to the left upper quadrant
2. Hemoglobin of 11.2 g/dL (112 g/L)
3. Lying on side with knees drawn up to abdomen and trunk flexed
4. White blood cell count of 12,000/mm° (12.0 x 10%/L)

Answer 143

1. Abdominal pain has progressed to the left upper quadrant

Question 144

The nurse cares for a client with intractable nausea and vomiting after a total colectomy who has a new prescription for total parenteral nutrition (TPN). Which of the following nursing interventions are appropriate? Select all that apply.

1. Administer TN through a central venous access device
2. Ensure that dextrose 10% in water IV solution is available
3. Obtain a prescription for blood glucose checks every 4-6 hours
4. Provide a loading dose so the client receives the necessary nutrients
5. Weigh daily with strict documentation of intake and output

Answer 144

1. Administer TN through a central venous access device
2. Ensure that dextrose 10% in water IV solution is available
3. Obtain a prescription for blood glucose checks every 4-6 hours
4. Weigh daily with strict documentation of intake and output

Question 145

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention?

1. Client experiencing abdominal cramps 2 hours after colonoscopy
2. Client reporting white stools 8 hours after barium swallow study
3. Client with epigastric pain after endoscopic retrograde cholangiopancreatography
4. Client with small bowel obstruction with copious, greenish-brown drainage from the nasogastric tube

Answer 145

3. Client with epigastric pain after endoscopic retrograde cholangiopancreatography

Question 146

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

1. Altered mental status
2. Easy bruising
3. Loss of body hair
4. Pitting edema

Answer 146

4. Pitting edema

Question 147

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse’s priority?

1. Contact the health care provider
2. Cut the tube with scissors
3. Increase gastric suction level
4. Place the client in high Fowler position

Answer 147

2. Cut the tube with scissors

Question 148

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction?
1. “I can expect chalky white stool after the procedure.”
2. “I cannot eat or drink 8 hours before the procedure.”
3. “I may have abdominal cramping during the procedure.
4”I will avoid laxatives after the procedure.”

Answer 148

4”I will avoid laxatives after the procedure.”

Question 149

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client?

1. The client will contact the United Ostomy Association of America
2. The client will look at and touch the stoma
3. The client will read the materials provided on ostomy care
4. The client will verbalize methods to control gas and odor

Answer 149

2. The client will look at and touch the stoma

Question 150

Exhibit
The nurse is caring for a client who underwent an endoscopic sleeve gastrectomy
this morning for the treatment of morbid obesity. Based on the client’s clinical
data, which action by the nurse is appropriate at this time? Click the exhibit
button for more information.

1. Assist the client to ambulate in the hall to dispel retained carbon
   dioxide
2. Give a PRN bolus of fentanyl from the client’s PCA pump
3. Notify the health care provider or surgeon immediately
4. Reposition the client’s nasogastric tube to ensure patency

Answer 150

3. Notify the health care provider or surgeon immediately

Question 151

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required?

1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
2. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
3. Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma
4. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

Answer 151

1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place

Question 152

The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse?

1. Abdominal cramping
2. Frequent, watery stools
3. Positive rebound tenderness
4. Recurring flatus

Answer 152

3. Positive rebound tenderness

Question 153

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question?

1. Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain
2. Increase continuous IV normal saline rate from 75 to 100 mL/hr
3. Insert nasogastric tube and attach to wall suction
4. Ondansetron 4 mg IP every 4 hours PRN for nausea

Answer 153

1. Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain

Question 154

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first?

1. Administer 0.25 mg hydromorphone IV push for pain
2. Draw blood for complete blood count and electrolyte levels
3. Initiate IV access and infuse normal saline 100 mL/hr
4. Obtain brine specimen for urinalysis

Answer 154

3. Initiate IV access and infuse normal saline 100 mL/hr

Question 155

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound?

1. Low Fowler’s position with knees bent
2. Prone to prevent further evisceration
3. Side-lying lateral position
4. Supine with head of the bed

Answer 155

1. Low Fowler’s position with knees bent

Question 156

A client is admitted with severe acute pancreatitis. While obtaining the client’s blood pressure, the nurse notices a carpal spasm.What laboratory result would the nurse assess in response to this symptom?

1. Decreased albumin
2. Elevated troponin
3. Hyperkalemia
4. Hypocalcemia

Answer 156

4. Hypocalcemia

Question 157

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? Select all that apply.

1. Avoid small, frequent meals
2. Can have a cup of coffee with each meal
3. Eat a low-residue, high-protein, high-calorie diet
4. Increase fluid intake to at least 2000 mL/day
5. Medication should be continued even after the resolution of symptoms
6. Take daily vitamin and mineral supplements

Answer 157

3. Eat a low-residue, high-protein, high-calorie diet
4. Increase fluid intake to at least 2000 mL/day
5. Medication should be continued even after the resolution of symptoms
6. Take daily vitamin and mineral supplements

Question 158

The post-anesthesia care unit nurse receives a report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel?

1. Absent bowel sounds
2. Borborygmi sounds
3. High-pitched and gurgling sounds
4. Swishing or buzzing

Answer 158

1. Absent bowel sounds

Question 159

Progress notes
Surgical wound is clean, dry & well approximated. Indwelling urinary catheter is draining clear, yellow urine. Diminished lung sounds auscultated in bilateral bases. Bowel sounds are absent in all four quadrants. Client denies the passage of flatus since surgery.

The nurse is caring for a client who had an open appendectomy 24 hours ago. Based on the client’s clinical data, which of the health care provider’s new prescriptions should the nurse clarify? Click the exhibit button for additional information.

1. Advance client to regular diet
2. Ambulate 3 times daily postoperative day 1
3. Increase IV normal saline rate from 20 mL/hr to 100 mL/hr
4. Remove indwelling urinary catheter

Answer 159

1. Advance client to regular diet

Question 160

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention?

1. Insert a Foley catheter into the existing tract and inflate the balloon
2. Insert a small-bore nasointestinal tube to administer feedings and medications
3. Notify the health care provider who inserted the PEG tube
4. Reinsert the PEG tube into the existing tract immediately

Answer 160

3. Notify the health care provider who inserted the PEG tube

Question 161

The nurse is assessing 4 clients in the emergency department. Which client should the nurse prioritize for care?

1. Client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis
2. Client with new-onset ascites from a suspected ovarian mass who needs paracentesis for diagnostic studies
3. Client with ulcerative colitis who has fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray
4. Nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction

Answer 161

3. Client with ulcerative colitis who has fever, bloody diarrhea, and abdominal distension and needs an abdominal x-ray

Question 162

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client’s morning laboratory results? Select all that apply.

1. Albumin
2. Ammonia
3. Bilirubin
4. Prothrombin time
5. Sodium

Answer 162

2. Ammonia
3. Bilirubin
4. Prothrombin time

Question 163

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client’s care plan? Select all that apply.

1. Acute pain
2. Dysfunctional gastric motility
3. Imbalanced nutrition, less than body requirements
4. Ineffective self[health management
5. Risk for infection

Answer 163

1. Acute pain
2. Dysfunctional gastric motility
3. Imbalanced nutrition, less than body requirements
4. Risk for infection

Question 164

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first?

1. Check the vital signs
2. Draw blood for hemoglobin and hematocrit
3. Lower the head of the bed
4. Maintain an IV line with normal saline

Answer 164

3. Lower the head of the bed

Question 165

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management?

1. Beans, yogurt, and a fruit cup
2. Beef, broccoli, and a glass of wine
3. Eggs, a bagel, and black coffee
4. Steak, tomato basil soup, and cornbread

Answer 165

4. Steak, tomato basil soup, and cornbread

Question 166

• *The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply.
• *The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply.
  1. Blood
  2. Feces
  3. Semen
  4. Urine
  5. Vaginal secretions

Answer 166

1. Blood
2. Semen
3. Vaginal secretions

Question 167

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse’s response is based on an understanding of which of the
following?
1. Fasting for 7 days is not likely to cause health problems
2. Fasting spares protein in favor of fat metabolism
3. Fasting will help control hunger pangs in the long term
4. Initial weight loss during fasting is primarily from fluid loss

Answer 167

4. Initial weight loss during fasting is primarily from fluid loss

Question 168

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?

1. Administer the prescribed as-needed milk of magnesia
2. Ask dietary services to add more fruits and vegetables to the client’s tray
3. Notify the health care provider (HCP)
4. Perform a focused abdominal assessment

Answer 168

4. Perform a focused abdominal assessment

Question 169

The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test?

1. “After the test, you may notice your stools are tarry black for a few days.
2. “During the test, a series of x-rays will be taken to assess the function of the small bowel.
3. “The HCP will use an endoscope to visualize your small bowel.”
4. “Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycol by midnight.”

Answer 169

2. “During the test, a series of x-rays will be taken to assess the function of the small bowel.

Question 170

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites and esophageal varices. Which statement by the client indicates that the teaching was effective?

1. “I may have one alcoholic drink a day, but no more.”
2. “I may take aspirin instead of acetaminophen for fever or pain.”
3. “I should avoid straining while having a bowel movement.”
4. “I should eat a protein and sodium restricted diet.”

Answer 170

3. “I should avoid straining while having a bowel movement.”

Question 171

A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply.
1. “Fruit juice is a good substitute for soda.”
2.”I will aim to lose 1-2 lb (0.45-0.91 kg) per week.”
3”I will keep healthy snacks on hand in case I get hungry.”
4. “I will skip breakfast to save calories for later in the day.”
5.”I will take the stairs instead of the elevator.”

Answer 171

2.”I will aim to lose 1-2 lb (0.45-0.91 kg) per week.”
3”I will keep healthy snacks on hand in case I get hungry.”
5.”I will take the stairs instead of the elevator.”

Question 172

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning?

1. Blood glucose levels for the past 24 hours are 2250 mg/dL (13.9 mmolL)
2. Client is lying with knees drawn up to the abdomen to alleviate pain
3. Five large, liquid stools that are yellow and foul-smeling
4. Temperature of 102.2 F (39 C) with increasing abdominal pain

Answer 172

4. Temperature of 102.2 F (39 C) with increasing abdominal pain

Question 173

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.

1. “I need to avoid taking medicines like ibuprofen without a prescription.”
2. “I should avoid drinking excess coffee or cola.”
3. “I should enroll in a smoking cessation program.”
4. “I should reduce or eliminate my intake of alcoholic beverages.”
5. “I will eliminate whole wheat foods, like breads and cereals, from my diet.”

Answer 173

1. “I need to avoid taking medicines like ibuprofen without a prescription.”
2. “I should avoid drinking excess coffee or cola.”
3. “I should enroll in a smoking cessation program.”
4. “I should reduce or eliminate my intake of alcoholic beverages.”

Question 174

Which nursing interventions would the nurse implement when caring for a client
newly diagnosed with acute, viral hepatitis B? Select all that apply.
1. Offer small, frequent meals to prevent nausea
2. Promote rest periods between periods of activity
3. Provide a diet high in fat and low in carbohydrates
4. Teach the client not to share razors or toothbrushes with others
5. Teach the client to abstain from drinking alcohol

Answer 174

1. Offer small, frequent meals to prevent nausea
2. Promote rest periods between periods of activity
3. Teach the client not to share razors or toothbrushes with others
4. Teach the client to abstain from drinking alcohol

Question 175

The nurse cares for a client with ulcerative colitis who is having abdominal pain and 210 bloody stools per day. Which of the following interventions should be included in the client’s plan of care? Select all that apply.

1. Administer prescribed analgesic medications as needed
2. Encourage the client to discuss feelings about illness
3. Initiate strict, hourly intake and output monitoring
4. Investigate the client’s compliance with the medication regimen
5. Offer the client high-protein foods during meals and snacks

Answer 175

1. Administer prescribed analgesic medications as needed
2. Encourage the client to discuss feelings about illness
3. Initiate strict, hourly intake and output monitoring
4. Investigate the client’s compliance with the medication regimen
5. Offer the client high-protein foods during meals and snacks

Question 176

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply.

1. Checks for residual every 4 hours
2. Places client in semi-Fowler’s position
3. Plugs the air vent if gastric content refluxes
4. Provides mouth care every 4 hours
5. Turns off suction when auscultating bowel sounds

Answer 176

1. Checks for residual every 4 hours

3. Plugs the air vent if gastric content refluxes

Question 177

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

1. Avoid social gatherings that occur in restaurants or around meals
2. Create multiple small goals with rewards for achievement
3. Identify a list of desired outcomes not directly related to weight loss
4. Perform anxiety-reducing activities rather than using food to cope with stress
5. Utilize visual cues such as motivational quotes to encourage positive behavior

Answer 177

2. Create multiple small goals with rewards for achievement
3. Identify a list of desired outcomes not directly related to weight loss
4. Perform anxiety-reducing activities rather than using food to cope with stress
5. Utilize visual cues such as motivational quotes to encourage positive behavior

Question 178

A 78-year-old client recovering from a hip fracture tells the home health nurse, “I haven’t had much of an appetite lately and have been really tired. I’m worried I’m not eating enough.” Which question is the priority for the nurse to ask?

1. “Are you able to prepare your own meals?”
2. “Are you feeling lonely or depressed?”
3. “Have you lost any weight unintentionally?”
4. “How many meals do you eat each day?”

Answer 178

3.”Have you lost any weight unintentionally?”

Question 179

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform?
1. Administer docusate and teach the client to avoid straining during defecation
2. Give pain medications and instructions related to pain control
3. Remove the rectal dressing and check the client for bleeding
4, Teach the client how to self administer a sitz bath 2-3 times daily

Answer 179

2. Give pain medications and instructions related to pain control

Question 180

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately?

1. Brick red with slight moisture noted
2. Dusky with moderate edema present
3. Pink with slight oozing of blood
4. Rosy with no stool produced

Answer 180

2. Dusky with moderate edema present

Question 181

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment?

1. Client consuming 90% of each meal
2. Serum albumin of 3.6 g/dL (36 g/L)
3. Weight gain of 2 lb (0.9 kg) in 2 weeks
4. White blood cell count of 15,000/mm 3 (15.0 × 109L)

Answer 181

3. Weight gain of 2 lb (0.9 kg) in 2 weeks

Question 182

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis?

1. Metronidazole 500 mg IV every 8 hours
2. Nasogastric (NG) tube to suction
3. Nothing by mouth (NPO)
4. Prepare for barium enema in AM

Answer 182

4. Prepare for barium enema in AM

Question 183

• *The nurse assessing a client’s pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?
  1. “My pain is a burning sensation in my upper abdomen.”
  2. “My pain is an 8 out of 10 and on my left side below my belly button.”
  3. “My pain is excruciating in my lower abdomen above my right hip.”
  4. “My pain is intermittent in my abdomen and right shoulder.”

Answer 183

3. “My pain is excruciating in my lower abdomen above my right hip.”

Question 184

The nurse assessing a client with an upper gastrointestinal bleed would expect the client’s stool to have which appearance?

1. Black tarry
2. Bright red bloody
3. Light gray “clay-colored”
4. Small, dry, rocky-hard masses

Answer 184

1. Black tarry

Question 185

• *Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.
  1. “Avoid foods that may cause epigastric distress such as spicy or acidic foods.”
  2. “It is best if you refrain from consuming alcohol products.”
  3. “Report black tarry stools to your health care provider immediately.”
  4. “Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days.”
  5. “You may take over-the-counter drugs such as aspirin if you have mild epigastric

Answer 185

1. “Avoid foods that may cause epigastric distress such as spicy or acidic foods.”
2. “It is best if you refrain from consuming alcohol products.”
3. “Report black tarry stools to your health care provider immediately.”
4. “Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days.”

Question 186

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

1. “I will refer you to the dietitian.”
2. “It should take about 6-8 weeks before you see improvement in your symptoms.”
3. “Tell me what you had to eat yesterday.”
4. “You must not be following your diet.”

Answer 186

3. “Tell me what you had to eat yesterday.”

Question 187

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

1. “I will clarify with my health care provider before taking enteric-coated medications.”
2. “I will irrigate the colostomy to promote regular bowel movements.”
3. “I will limit eating foods such as broccoli and cauliflower to reduce odor.”
4. “I will restrict my fluid intake to 2,000 milliliters of fluid a day.”
5. “I will wait for the pouch to become completely full before emptying the contents.”

Answer 187

1. “I will clarify with my health care provider before taking enteric-coated medications.”
2. “I will limit eating foods such as broccoli and cauliflower to reduce odor.”

Question 188

Which group of food selections would be the best choice for a client advancing to a full liquid
diet 3 days after bariatric surgery?
1. Apple juice, mashed potatoes, chocolate pudding
2. Chicken broth, low-fat cheese omelet, strawberry ice cream
3. Creamy wheat cereal, blended cream of chicken soup, protein shake
4. Low-fat vanilla yogurt, smooth peanut butter, vegetable juice

Answer 188

3. Creamy wheat cereal, blended cream of chicken soup, protein shake

Question 189

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?

1. “I need to raise the head of my bed on blocks by at least 6 inches.”
2. “I will remain sitting up for several hours after I eat any food.”
3. “If my reflux and abdominal pain don’t improve, I might need surgery.”
4. “Losing weight may reduce my reflux, so I plan to take a weight-lifting class.”

Answer 189

4. “Losing weight may reduce my reflux, so I plan to take a weight-lifting class.”

Question 190

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client’s abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client’s most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is the priority action by the nurse?

1. Collect peritoneal fluid for culture and sensitivity
2. Heat the remaining dialysate fluid and increase the dwell time
3. Place the client in high Fowler’s position
4. Prepare to administer regular insulin intravenously

Answer 190

1. Collect peritoneal fluid for culture and sensitivity

Question 191

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

1. Apply anti-embolism stockings
2. Assist with early ambulation
3. Offer stool softeners
4. Provide low-fat

Answer 191

2. Assist with early ambulation

Question 192

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.

1. Add high-protein foods to diet
2. Consume high-carbohydrate meals
3. Eat small, frequent meals
4. Increase intake of fluids with meals
5. Lie down after eating

Answer 192

1. Add high-protein foods to diet
2. Eat small, frequent meals
3. Lie down after eating

Question 193

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply.

1. Abdominal pain
2. Blood in the stools
3. Change in bowel habits
4. Low hemoglobin level
5. Unexplained weight loss

Answer 193

1. Abdominal pain
2. Blood in the stools
3. Change in bowel habits
4. Low hemoglobin level
5. Unexplained weight loss

Question 194

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply.

1. Applying bilateral sequential compression devices
2. Encouraging splinting of the incision with a pillow when coughing
3. Keeping the client NPO until bowel sounds return
4. Maintaining supine positioning at all times
5. Repositioning and irrigating a clogged nasogastric tube PRN

Answer 194

1. Applying bilateral sequential compression devices
2. Encouraging splinting of the incision with a pillow when coughing
3. Keeping the client NPO until bowel sounds return

Question 195

A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene?

1. Administers morphine IV PRN for pain
2. Initiates continuous normal saline IV
3. Provides a heating pad for abdominal discomfort
4. Teaches client about prescribed strict NPO status

Answer 195

3. Provides a heating pad for abdominal discomfort

Question 196

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence. All options must be used.

1. Obtain supplies, wash hands and apply nonsterile gloves.
2. Open the slide’s flap and apply 2 separate stool samples to the boxes on the slide
3. Open the back of the slide and apply 2 drops of developing solution to each box.
4. Wait 30-60 seconds.
5. Document the results in the electronic medical record.

Answer 196

1. Obtain supplies, wash hands and apply nonsterile gloves.
2. Open the slide’s flap and apply 2 separate stool samples to the boxes on the slide
3. Open the back of the slide and apply 2 drops of developing solution to each box.
4. Wait 30-60 seconds.
5. Document the results in the electronic medical record.

Question 197

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? SATA

1. Assess the clients hand movements with the arms extended
2. Compare current mental status findings with those from previous shifts
3. Contact the health care provider to request a blood draw for ammonia levels
4. Encourage the client to ambulate in the hallway
5. Hold the clients morning dose of lactulose

Answer 197

1. Assess the clients hand movements with the arms extended
2. Compare current mental status findings with those from previous shifts
3. Contact the health care provider to request a blood draw for ammonia levels

Question 198

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client’s condition has progressed to hepatic encephalopathy? Select all that apply.

1. Ask if the client knows what day it is
2. Ask the client to extend the arms
3. Assess for telangiectasia (spider nevi)
4. Determine if the conjunctiva is jaundiced
5. Note amylase and lipase serum levels

Answer 198

1. Ask if the client knows what day it is

2. Ask the client to extend the arms

Question 199

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client’s comfort? Select all that apply.

1. Encourage adequate sodium intake
2. Place client in semi-Fowler position
3. Place client in Trendelenburg position
4. Provide alternating air pressure mattress
5. Use music to provide a distraction

Answer 199

2. Place client in semi-Fowler position
3. Provide alternating air pressure mattress
4. Use music to provide a distraction

Question 200

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse?

1. “Enteral feedings have no complications.”
2. “Enteral feedings maintain gut integrity and help prevent stress ulcers.”
3. “Enteral feedings provide higher calorie content.”
4. “Risk of hyperglycemia is lower with enteral feedings than with TPN.”

Answer 200

2. “Enteral feedings maintain gut integrity and help prevent stress ulcers.”

Question 201

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? Select all that apply. Click the exhibit button for additional information.

1. Administer morphine sulfate as prescribed for pain control
2. Insert a rectal tube to protect the client’s skin from diarrhea
3. Instruct the client to avoid straining
4. Maintain NPO status
5. Start IV infusion of normal

Answer 201

1. Administer morphine sulfate as prescribed for pain control
2. Instruct the client to avoid straining
3. Maintain NPO status
4. Start IV infusion of normal

Question 202

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?

1. Assess the client’s vital signs
2. Check the client’s blood glucose
3. Report the findings to the health care provider
4. Slow down the rate of infusion

Answer 202

2. Check the client’s blood glucose

Question 203

The nurse is teaching a client with newly diagnosed lactase deficiency about dietary manage ent. Which statements by the client indicate a correct understanding of this condition? Select all that apply.
1. “I can still eat cheese and yogurt as long as they don’t make me feel sick.”
2. “I should take a daily calcium and vitamin D supplement.”
3. “Most dairy products should be eliminated from my diet, but ice cream is okay.”
4”My lactase enzyme supplement should be taken with meals containing dairy.”
5. “This means that I have developed an allergy to milk.”

Answer 203

1. “I can still eat cheese and yogurt as long as they don’t make me feel sick.”
2. “I should take a daily calcium and vitamin D supplement.”
   4”My lactase enzyme supplement should be taken with meals containing dairy.”

Question 204

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction?

1. “Il empty the JP bulb when it is totally full so that I don’t have to unplug it so many times.”
2. “I’ll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup.”
3. “I’Il squeeze the JP bulb from side-to-side as I hold it in my hand.”
4. “While the JP bulb is totally compressed, I’ll clean the spout with alcohol and replace the plug.”

Answer 204

1. “Il empty the JP bulb when it is totally full so that I don’t have to unplug it so many times.”

Question 205

• *The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective?
  1. Abdominal circumference reduced from admission recording
  2. Flapping tremor no longer visible with arm extension
  3. Shortness of breath no longer experienced in supine position
  4. Vital signs remain within the client’s normal parameters

Answer 205

4. Vital signs remain within the client’s normal parameters

Question 206

A client with a 10-year history of unipolar major depression has relapsed and is now hospital zed. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client?

1. Crackers and cheddar cheese
2. Hard-boiled egg with tomatoes
3. Steamed fish and potatoes
4. Tortilla chips with avocado dip

Answer 206

3. Steamed fish and potatoes

Question 207

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome?

1. Meals should be small and low in carbohydrate content
2. Fluids should be encouraged with each meal
3. Take a multivitamin with iron and calcium supplements daily
4. You will need to take your cobalamin injection monthly

Answer 207

1. Meals should be small and low in carbohydrate content

Question 208

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.

1. Flank pain radiating to the groin
2. High-protein food ingestion before the onset of pain
3. Low-grade fever with chills
4. Pain at the umbilicus
5. Right upper-quadrant (RUQ) pain radiating to the right shoulder

Answer 208

3. Low-grade fever with chills

5. Right upper-quadrant (RUQ) pain radiating to the right shoulder

Question 209

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply.

1. “I need to eat a diet high in calories and protein so that I avoid losing weight.”
2. “I need to take multivitamins containing calcium daily.”
3. “I should avoid consuming alcoholic beverages.”
4. “I should drink at least 2 liters of water daily and more when I have diarrhea.”
5. “I will keep a symptom journal to note what I eat and drink during the day.”

Answer 209

1. “I need to eat a diet high in calories and protein so that I avoid losing weight.”
2. “I need to take multivitamins containing calcium daily.”
3. “I should avoid consuming alcoholic beverages.”
4. “I should drink at least 2 liters of water daily and more when I have diarrhea.”
5. “I will keep a symptom journal to note what I eat and drink during the day.”

Question 210

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed
from suspected gastroesophageal varies. Which new prescription should the
nurse question?
1. Administer pantoprazole IV piggyback every 12 hours
2. Initiate continuous octreotide IV infusion
3. Insert and maintain a nasogastric tube
4. Maintain NPO status except for PO medications

Answer 210

3. Insert and maintain a nasogastric tube

Question 211

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

1. Apply cool, moist washcloths to the affected areas
2. Keep the fingernails trimmed short to minimize skin scratching
3. Take a hot bath or shower to alleviate itching sensations
4. Use skin protectant or moisturizing cream over unbroken skin
5. Wear cotton gloves or long-sleeved clothing to avoid scratching

Answer 211

1. Apply cool, moist washcloths to the affected areas
2. Keep the fingernails trimmed short to minimize skin scratching
3. Use skin protectant or moisturizing cream over unbroken skin
4. Wear cotton gloves or long-sleeved clothing to avoid scratching

Question 212

The nurse assesses cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.

1. “A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.”
2. “I am proud that I was able to lose 10 lb, but I’m still considered obese for my height.”
3. “I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.”
4. “I have struggled with daily episodes of acid reflux for years, especially at nighttime.”
5. “I snack on a lot of salted foods like popcorn and peanuts.”

Answer 212

1. “A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.”
2. “I am proud that I was able to lose 10 lb, but I’m still considered obese for my height.”
3. “I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.”
4. “I have struggled with daily episodes of acid reflux for years, especially at nighttime.”

Question 213

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply.

1. Educate client about the procedure and obtain informed consent
2. Initiate NPO status 6 hours prior to the procedure
3. Obtain baseline vital signs, abdominal circumference, and weight
4. Place client in high Fowler position or as upright as possible
5. Request that the client empty the bladder

Answer 213

3. Obtain baseline vital signs, abdominal circumference, and weight
4. Place client in high Fowler position or as upright as possible
5. Request that the client empty the bladder

Question 214

The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? Select all that apply.

1. Commercial fruit juice
2. Flavored club soda
3. Fresh vegetable juice
4. Sports beverages
5. Unsweetened

Answer 214

2. Flavored club soda
3. Fresh vegetable juice
4. Unsweetened

Question 215

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply.、

1. Elevate the head of the hospital bed
2. Instruct the client to avoid tobacco and caffeine
3. Offer small, frequent, low-fat meals
4. Provide a girdle to reduce the hernia
5. Teach the client to avoid lifting or straining

Answer 215

1. Elevate the head of the hospital bed
2. Instruct the client to avoid tobacco and caffeine
3. Offer small, frequent, low-fat meals
4. Teach the client to avoid lifting or straining

Question 216

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy. Which statement by the client indicates that further teaching is required?

1. “I can resume a regular diet but will avoid fatty foods for several weeks after surgery.”
2. “I can return to work within a week of surgery.”
3. “I will report to the health care provider if my temperature is higher than 101 F (38.3 C).
4. “Tomorrow I can remove the puncture site bandages and take a bath.”

Answer 216

4. “Tomorrow I can remove the puncture site bandages and take a bath.”

Question 217

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client’s IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action?

1. Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour
2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr
3. Hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr
4. Hang lactated Ringer’s until the new bag arrives, then resume TPN at 75 mL/hr

Answer 217

2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr

Question 218

• *The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client’s labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider?
  1. Albumin 2.5 g/dL (25 g/L)
  2. INR 14
  3. Potassium 3.0 mEq/L (3.0 mmol/L)
  4. Sodium 131 mEg/L (131 mmol/L)

Answer 218

3. Potassium 3.0 mEq/L (3.0 mmol/L)

Question 219

The nurse assesses a client who has followed a vegan diet for several years.
Which client statement indicates a potential nutritional deficiency?
1. “I have had some visual disturbances while driving at night.”
2. “I have had trouble falling asleep over the past few months.”
3.”Scaly patches of skin are developing on my elbows and knees.”
4.”Sometimes my hands and feet get a tingling sensation.”

Answer 219

4. “Sometimes my hands and feet get a tingling sensation.”

Question 220

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus
(HIV) about actions to prevent complications. Which of the following statements indicate that
teaching was effective? Select all that apply.
1. “I should ask for my steak to be cooked thoroughly with no pink.”
2. “I should receive the influenza vaccine every year.”
3. “I will ask my roommate to change the cat litter box for me.”
4. “If I travel to a developing country, I will use bottled water when brushing my teeth.
5. “If my HIV viral load is undetectable, I do not need to wear condoms.”

Answer 220

1. “I should ask for my steak to be cooked thoroughly with no pink.”
2. “I should receive the influenza vaccine every year.”
3. “I will ask my roommate to change the cat litter box for me.”
4. “If I travel to a developing country, I will use bottled water when brushing my teeth.

Question 221

**The nurse is reinforcing education about home and lifestyle alterations to a client recently
diagnosed with HIV. Which of the following statements by the client indicates a need for further
education? Select all that apply.
1. “I don’t have to use protection if my sexual partner is also HIV positive.”
2. “I have to make sure my family knows not to borrow my razors.”
3. “I need to avoid eating raw or undercooked meats and eggs.”
4. “I started to use lambskin condoms during sex, as I have a latex allergy.”
5. “I won’t reuse or share any needles or syringes that I use to inject heroin.

Answer 221

1. “I don’t have to use protection if my sexual partner is also HIV positive.”
2. “I started to use lambskin condoms during sex, as I have a latex allergy.”

Question 222

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply.

1. Apply a tick repellent spray before outdoor activities
2. Avoid hiking through areas of tall grass and thick underbrush
3. Cover ticks found on skin with petroleum jelly
4. Report bull’s-eye rash or flu like symptoms to a healthcare provider
5. Wear a long-sleeved shirt tucked into pants and closed-toe shoes while hiking

Answer 222

1. Apply a tick repellent spray before outdoor activities
2. Avoid hiking through areas of tall grass and thick underbrush
3. Report bull’s-eye rash or flu like symptoms to a healthcare provider
4. Wear a long-sleeved shirt tucked into pants and closed-toe shoes while hiking

Question 223

The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing
actions should be included in the client’s plan of care? Select all that apply.
1. Assign client to a private room
2. Don mask before entering room
3. Elevate head of bed 10-30 degrees
4. Keep padded tongue blade at bedside
5. Maintain dimmed room lighting

Answer 223

1. Assign client to a private room
2. Don mask before entering room
3. Elevate head of bed 10-30 degrees
4. Maintain dimmed room lighting

Question 224

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test
(TST). Which prescription from the health care provider does the nurse anticipate will confirm the
diagnosis in this client?
1. Collect 2 blood cultures from different intravenous sites after cleansing with a
chlorhexidine swab
2. Collect 2 early morning nose specimens (swabs) from each nare using sterile
culturettes
3. Collect an early morning sterile sputum specimen on 3 consecutive days
4. Collect blood for the QuantiFERON-TB test after cleansing the site with a
chlorhexidine swab

Answer 224

3. Collect an early morning sterile sputum specimen on 3 consecutive days

Question 225

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches,
headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply.
1. Clarify the prescription for oseltamivir with the health care provider
2. Instruct the client to cover the mouth and nose while coughing or sneezing
3. Place a mask on the client when transporting the client through the halls
4. Plan discharge teaching about the importance of annual influenza vaccination
5. Use contact precautions when providing care for the client

Answer 225

2. Instruct the client to cover the mouth and nose while coughing or sneezing
3. Place a mask on the client when transporting the client through the halls
4. Plan discharge teaching about the importance of annual influenza vaccination

Question 226

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the
infection from spreading. What is the nurse’s most appropriate response?
1. “Avoid close contact for about a week.”
2. “It’s impossible to avoid contact with the client. Just wash your hands often.”
3. “You are sick already, and so you are not contagious anymore.
4. “You don’t have to worry as long as the client has received the influenza vaccination.”

Answer 226

1. “Avoid close contact for about a week.”

Question 227

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The
nurse assesses for which characteristic presenting signs and symptoms associated with TB
disease? Select all that apply.
1. Dysuria
2. Jaundice
3. Low back pain
4. Night sweats
5. Purulent or blood-tinged sputum
6. Weight loss

Answer 227

4. Night sweats
5. Purulent or blood-tinged sputum
6. Weight loss

Question 228

The public health nurse provides care for a client on a directly observed therapy (DOT) program
to treat tuberculosis (TB). Which option best describes the care the nurse provides on this
program?
1. Follows the client until 3 sputum cultures are normal
2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits
3. Provides and watches the client swallow every prescribed medication
4. Screens all of the client’s close contacts

Answer 228

3. Provides and watches the client swallow every prescribed medication

Question 229

The nurse is preparing educational materials about histoplasmosis for a group of nursing students
Which teaching point is appropriate for the nurse to include?
1. Histoplasmosis infection causes pink or purple spots to develop all over the client’s skin
2. Histoplasmosis infection usually causes serious illness and often requires hospitalization
3. Histoplasmosis is a bacterial infection that is spread through the air from an infected
person
4. Histoplasmosis is an opportunistic infection that occurs in clients who are immunocompromised

Answer 229

4. Histoplasmosis is an opportunistic infection that occurs in clients who are immunocompromised

Question 230

A nurse is discharging a client who has been hospitalized with streptococcal infective
endocarditis (IE). Which statement by the client would indicate a need for further teaching?
1. “I may need prophylactic antibiotics before dental work from now on.”
2. “I should call my health care provider (HCP) or 911 right away if I notice my speech is
slurred.”
3. “I shouldn’t be concerned if I continue to have a fever at home.”
4. “I will expect a home health nurse to give me IV antibiotics for several more weeks.”

Answer 230

3. “I shouldn’t be concerned if I continue to have a fever at home.”

Question 231

The nurse is caring for a 76-year-old client newly admitted with pneumonia and Clostridium difficile
infection. Which of the following would be priority to report to the health care provider?
1. Blood gas results of PO, 80 mm Hg (10.6 kPa), pCO, 35 mm Hg (4.7 kPa), pH 7.38
2. Blood urea nitrogen of 29 mg/dL (10.4 mmol/L), potassium of 3.3 mEq/L (3.3 mmol/L),
sodium of 132 mEq/L (132 mmol/L)
3. Coarse crackles in lung bases with moderate sputum production
4. Fever of 100.6 F (38.1 C) and reports of chills and fatigue

Answer 231

2. Blood urea nitrogen of 29 mg/dL (10.4 mmol/L), potassium of 3.3 mEq/L (3.3 mmol/L),
   sodium of 132 mEq/L (132 mmol/L)

Question 232

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant
Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply.
1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L)
2. Creatinine is 2.1 mg/dL (185.6 umol/L)
3. Glucose is 140 mg/dL (7.7 mmol/L)
4. Hemoglobin is 15 g/dL (150 g/L)
5. Magnesium is 1.5 mEq/L (0.75 mmol/L)
6. White blood cell count is 14.000/mm3 (14.0 x 109/L)

Answer 232

1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L)

2. Creatinine is 2.1 mg/dL (185.6 umol/L)

Question 233

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after
beginning medication therapy. The client states, “I’ve had really bad nausea and fatigue, but
because my cough has already improved, I knew it would be alright to stop taking the medications. The nurse identifies which priority nursing diagnosis (ND) in this client’s care plan?
1. Activity intolerance
2. Imbalanced nutrition, less than body requirements
3. knowledge deficit of prescribed therapeutic regimen
4. Nausea

Answer 233

3. knowledge deficit of prescribed therapeutic regimen

Question 234

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent. Which assessment findings indicate that the client may be in septic shock? Select all that apply.

1. Blood pressure of 80/50 mm Hg
2. Capillary refill of 5 seconds
3. Temperature of 96.4 F (35.8 C)
4. Urine output of 125 mL/hr
5. WBC count of 26,000/mm3 (26 x 10%/L)

Answer 234

1. Blood pressure of 80/50 mm Hg
2. Capillary refill of 5 seconds
3. Temperature of 96.4 F (35.8 C)
4. WBC count of 26,000/mm3 (26 x 10%/L)

Question 235

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB)
disease to a group of home health aides. Which statement made by a home health aide
indicates an understanding about the mode of transmission of pulmonary TB?
1.”It is spread by contact with the client’s blood or urine.”
2.’It is spread by contact with the client’s soiled clothing and bed linens.”
3. “It is spread by contact with the client’s soiled eating utensils.”
4. “It is spread by small droplets that the client coughs or sneezes into the air.”

Answer 235

4. “It is spread by small droplets that the client coughs or sneezes into the air.”

Question 236

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the
teaching plan?
1. Adhesive bandaging should remain on the lesions to prevent virus shedding
2. Blood tests will be drawn to ensure the virus is eradicated
3. Condoms should be used during intercourse until the lesions are healed
4. Gloves should be used to apply the medication to the lesions

Answer 236

4. Gloves should be used to apply the medication to the lesions

Question 237

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no

symptoms. Which action will the nurse take next?
1. Document the negative response in the client’s medical record
2. Have the client return in a week to receive a second injection
3. Obtain a prescription for the client to have a chest x-ray
4. Place the client in an airborne-infection isolation room

Answer 237

3. Obtain a prescription for the client to have a chest x-ray

Question 238

**The nurse teaches a group of homeless community clients preventive measures related to transmission of hepatitis A. Which of these measures would the nurse teach as the priority
precaution to prevent transmission?
1. Do not share needles when injecting drugs
2. Practice safe sox by using condoms
3. Receive the hepatitis A vaccine
4. Wash hands after bowel movements and before eating

Answer 238

4. Wash hands after bowel movements and before eating

Question 239

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply.

1. Avoid raw, unpeeled fruits or vegetables
2. Limit contact with infected pets
3. Use insect (mosquito) repellent
4. Wash all bedding in hot water
5. Wear long-sleeved, light-colored clothes

Answer 239

3. Use insect (mosquito) repellent

5. Wear long-sleeved, light-colored clothes

Question 240

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client’s WBC count has increased from 11,200/mm? (11.2 x 109/L) to 14,600/mm° (14.6 × 109/L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection? Select all that apply.

1. Client rating left shoulder pain as 4 on a scale of 0-10
2. Greenish-gray drainage noted on surgical dressing
3. Productive cough with thick, green sputum
4. Stiff abdomen with rebound tenderness on palpation
5. Warm, reddened area around the incision site

Answer 240

2. Greenish-gray drainage noted on surgical dressing
3. Productive cough with thick, green sputum
4. Stiff abdomen with rebound tenderness on palpation
5. Warm, reddened area around the incision site

Question 241

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF) Which question is most important for the nurse to ask to establish a diagnosis?
1. “Do you typically take all your antibiotics when they are prescribed?”
2 “Has anyone in your family had thematic fever?”
3. ‘Have you recently had a streptococcal throat infection?”
4. What has your temperature been over the past several days?”

Answer 241

3. ‘Have you recently had a streptococcal throat infection?”

Question 242

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis
confirms a diagnosis of cystitis. Which symptoms reported by the client would be most consistent with this condition? Select all that apply.
1. Chills and vomiting
2. Flank pain
3. Painful urination
4. Urinary frequency
5. Urinary urgency

Answer 242

3. Painful urination
4. Urinary frequency
5. Urinary urgency

Question 243

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client
reports itching and pain around the rash. What is the priority question for the nurse to ask the
client?
1. “Did the rash start after taking a new medication?”
2. “Have you been keeping the rash covered?”
3. “Have you ever had chickenpox?”
4 “What have you tried to help the pain?”

Answer 243

3. “Have you ever had chickenpox?”

Question 244

**The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on
antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for
further instruction?
1. “I can stop taking these HIV drugs once my viral levels are undetectable.”
2. “I need to get tested regularly for sexually transmitted infections because I’m sexually
active.
3. “I should use latex condoms and barriers when having anal, vaginal, or oral sex.”
4. “I won’t stop injecting drugs, but I will use a needle exchange program.

Answer 244

1. “I can stop taking these HIV drugs once my viral levels are undetectable.”

Question 245

• *An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate?
  1. The client has a false-positive reaction due to advanced age
  2. The client has a tuberculosis (TB) infection
  3. The client has active TB disease
  4. The client must be isolated immediately

Answer 245

2. The client has a tuberculosis (TB) infection

Question 246

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis?

1. A client with asthma who uses an albuterol nebulizer once a day
2. A septic client receiving intravenous broad-spectrum antibiotics daily
3. A teenage client with braces who drinks several sugary drinks daily
4. An elderly client with poor oral hygiene and inadequate nutrition

Answer 246

2. A septic client receiving intravenous broad-spectrum antibiotics daily

Question 247

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration?

1. Serum albumin level and body weight
2. Serum potassium and phosphate
3. Symptoms of dumping syndrome
4. White blood cell count and neutrophils

Answer 247

2. Serum potassium and phosphate

Question 248

A client with end-stage liver disease is admitted for a transplant workup. The client’s spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement?

1. Ask the transplant team to place a palliative care referral so the client can learn about the option of hospice instead of transplant
2. Assess the client’s motivation to make the necessary self- care changes before and after the transplant
3. Schedule a meeting to enlist the help of family members in encouraging the client to stay sober until the transplant
4. Tell the nurse manager that the client may not be an appropriate transplant candidate

Answer 248

2. Assess the client’s motivation to make the necessary self- care changes before and after the transplant

Question 249

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who
underwent paracentesis 4 hours ago. The UP reports to the nurse that the client
was lightheaded and unsteady while ambulating to the chair. Which action should
the nurse implement first?

1. Ask the UAP to take a set of vital signs
2. Assess the symptoms reported by the UAP
3. Hold the prescribed diuretic medications
4. Instruct the UAP to assist the client to bed

Answer 249

2. Assess the symptoms reported by the UAP

Question 250

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply.

1. Administer hydromorphone IV PRN for pain
2. Administer intravenous fluids
3. Insert a nasogastric tube for nasogastric suction
4. Maintain client in a supine position, with head of bed flat
5. Provide small, frequent, high-carbohydrate, high-calorie meals

Answer 250

1. Administer hydromorphone IV PRN for pain
2. Administer intravenous fluids
3. Insert a nasogastric tube for nasogastric suction

Question 251

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse
whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mol/L). Which
assessment finding does the nurse anticipate?
1. Constipation and polyuria
2. Increased thirst and dry mucous membranes
3. Leg weakness and soft, flabby muscles
4. Tremors and brisk deep-tendon reflexes

Answer 251

4. Tremors and brisk deep-tendon reflexes

Question 252

A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure
is 170/100 mm Hg. How should the nurse respond initially?
1. Administer PRN analgesic medication
2. Administer PRN antihypertensive medication
3. Lower the head of the bed
4. Palpate the client’s bladder

Answer 252

4. Palpate the client’s bladder

Question 253

The nurse completes a neurological examination on a client who has suffered a stroke to
determine if damage has occurred to any of the cranial nerves. The nurse understands that
damage has occurred to cranial nerve IX based on which assessment finding?
1. A tongue blade is used to touch the client’s pharynx; gag reflex is absent
2. Only one side of the mouth moves when the client is asked to smile and frown
3. The absence of light touch and pain sensation on the left side of the client’s face
4. When the client shrugs against resistance, the left shoulder is weaker than the right

Answer 253

1. A tongue blade is used to touch the client’s pharynx; gag reflex is absent

Question 254

The nurse receives the assigned clients for today on a neurology unit. The nurse should
check on which client first?
1. Client with history of head injury whose Glasgow Coma Scale (GCS) changes
frôm 13 to 14
2. Client with history of myasthenia gravis who had ptosis in the evening
3. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and
hypertension
4. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle
strength

Answer 254

3. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and
   hypertension