RN Adult Care Nursing Online Practice 2023 B

Question 1

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?

Wear a mask.
Wear a gown.
Keep the client’s room well.
Maintain the head of the bed at 45° elevation.

Answer 1

“Wear a mask.”
CORRECT
Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hours after the client has begun receiving antibiotic therapy.

“Wear a gown.”
INCORRECT
A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis does not spread via direct contact.

“Keep the client’s room well-lit.”
INCORRECT
Staff caring for this client should keep the illumination in the room dim and avoid bright light from windows to promote comfort and rest and avoid photophobia.

“Maintain the head of the bed at a 45° elevation.”
INCORRECT
Staff caring for this client should keep the head of the bed at a 30° elevation.

Question 2

A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching?

“I will avoid eating raw fruits and vegetables.”
“I can ask a friend to change my cat’s litter box.”
“I will use a mild soap when washing my genital area.”
“I can sip on a glass of juice for at least 2 hours before I should discard it.”

Answer 2

“I will avoid eating raw fruits and vegetables.”
INCORRECT
The nurse should instruct the client to wash raw fruits and vegetables thoroughly prior to eating them because uncleaned fruits and vegetables can contain microorganisms and place the client at risk for infection.

“I can ask a friend to change my cat’s litter box.”
CORRECT
Changing a pet’s litter box increases the client’s risk of being exposed to toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet’s litter box.

“I will use a mild soap when washing my genital area.”
INCORRECT
The nurse should instruct the client to wash the genital area twice a day with antimicrobial soap to prevent bacterial and fungal infections.

“I can’t sip on a glass of juice for at least 2 hours before I should discard it.”
INCORRECT
The nurse should instruct the client to avoid drinking any liquids that have been out for more than 1 hour. Beverages left out for extended periods of time could expose the client to microorganisms and place them at risk for infection.

Question 3

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Restlessness
T3 level 215 ng/dL (40 to 180 ng/dL)
Blood pressure 170/80 mm Hg
Decreased weight

Answer 3

Restlessness
INCORRECT
Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.

T3 level 215 ng/dL (40 to 180 ng/dL)
INCORRECT
An elevated T3 level is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.

Blood pressure 170/80 mm Hg
CORRECT
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

Decreased weight
INCORRECT
Decreased weight is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.

Question 4

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?

Bounding pedal pulse
Capillary refill less than 2 seconds
Pain that increases with passive movement
Areas of warmth on the cast

Answer 4

Bounding pedal pulse
INCORRECT
The nurse should expect a client who has compartment syndrome to have a diminished pulse or pulselessness in the affected extremity due to lack of distal perfusion caused by a decrease in the muscle compartment size.

Capillary refill less than 2 seconds
INCORRECT
The nurse should expect a client who has compartment syndrome to have capillary refill greater than 2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a decrease in the muscle compartment size.

Pain that increases with passive movement
CORRECT
The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

Areas of warmth on the cast
INCORRECT
A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an infection of the underlying tissue, not compartment syndrome.

Question 5

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

Answer 5

Glossitis, a smooth red tongue, is also a manifestation of deficiencies in Vit B6 or folic acid

Question 6

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?

Try to walk at least three times per week for exercise.
To increase stamina, walk for 5 min after fatigue begins.
Take over-the-counter cough medicine for persistent cough.
Use a salt substitute to reduce sodium intake.

Answer 6

Try to walk at least three times per week for exercise.
CORRECT
The development of a regular exercise routine can improve outcomes in clients who have heart failure.

To increase stamina, walk for 5 min after fatigue begins.
INCORRECT
Walking for 5 min after the onset of fatigue will not increase stamina and can exacerbate the client’s heart failure.

Take over-the-counter cough medicine for persistent cough.
INCORRECT
The provider should approve the use of over-the-counter cough medication for a persistent cough prior to use. A persistent cough can exacerbate the client’s heart failure.

Use a salt substitute to reduce sodium intake.
INCORRECT
Salt substitutes contain an increased amount of potassium, which can place the client at an increased risk for hyperkalemia.

Question 7

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Painless ulcerations on the ankles
Hair loss on the lower legs
No extremity pain when resting
Rubor with elevation of the extremity

Answer 7

Painless ulcerations on the ankles
INCORRECT
The nurse should expect a client who has peripheral arterial disease to have painful ulcerations on the ends of the toes and between the toes due to impaired arterial circulation.

Hair loss on the lower legs
CORRECT
The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs due to impaired arterial circulation affecting follicular growth.

No extremity pain when resting
INCORRECT
The nurse should expect a client who has peripheral arterial disease to have pain when resting due to decreased blood flow in the lower extremities. This pain is often relieved by dangling the lower extremities off the bed.

Rubor with elevation of the extremity
INCORRECT
The nurse should expect a client who has peripheral arterial disease to have dependent rubor, which is redness resulting from dangling or ambulation.

Question 8

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?

Encourage the client to eat raw fruits and vegetables.
Avoid placing plants or flowers in the client’s room.
Limit visitors to members of the client’s immediate family.
Wear an N95 respirator mask when providing care to the client.

Answer 8

Encourage the client to eat raw fruits and vegetables.
INCORRECT
The nurse should identify that P. aeruginosa can be found in raw fruits and vegetables.

Void placing plants or flowers in the client’s room.
CORRECT
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client’s room.

Limit visitors to members of the client’s immediate family.
INCORRECT
The nurse does not need to limit visits to family members. However, the nurse should prohibit visits from those at risk for P. aeruginosa infection, such as anyone who is ill, other hospitalized clients, and small children.

Wear an N95 respirator mask when providing care to the client.
INCORRECT
P. aeruginosa spreads by contact, either on health care workers’ hands or contaminated equipment. It is not airborne, so respirator masks are unnecessary.

Question 9

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?

“It is just easier to let my partner administer my insulin.”
“I used to never worry about my feet. Now, I inspect my feet every day with a mirror.”
“I’m concerned I won’t be able to read my blood sugar level because the screen is so small.”
“I know a lot of people who have diabetes and do not take insulin. I wish I didn’t have to.”

Answer 9

“It is just easier to let my partner administer my insulin.”
INCORRECT
This statement does not indicate that the client is successfully coping with the change.

“I used to never worry about my feet. Now, I inspect my feet every day with a mirror.”
CORRECT
This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.

“I’m concerned I won’t be able to read my blood sugar level because the screen is so small.”
INCORRECT
This statement does not indicate that the client is successfully coping with the change. The nurse should provide the client with a monitor that has a larger screen.

“I know a lot of people who have diabetes and do not take insulin. I wish I didn’t have to.”
INCORRECT
This statement does not indicate that the client is successfully coping with the change.

Question 10

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.
Assist the client to start arm exercises 48 hr after surgery.
Maintain the right arm in an extended position at the client’s side when in bed.
Place the client in a supine position for the first 24 hr after surgery.

Answer 10

“Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.”
CORRECT
The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

“Assist the client to start arm exercises 48 hr after surgery.”
INCORRECT
The nurse should instruct the client to start exercising the right arm 24 hr after surgery.

“Maintain the right arm in an extended position at the client’s side when in bed.”
INCORRECT
The nurse should elevate the client’s right arm on a pillow to promote lymphatic fluid return.

“Place the client in a supine position for the first 24 hr after surgery.”
INCORRECT
The nurse should elevate the head of the client’s bed to at least 30° to promote drainage from the surgical site and facilitate breathing.

Question 11

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

240 mL (8 oz) of orange juice
1 ampule of 50% dextrose IV bolus
NPH insulin 60 units subcutaneous
Regular insulin 20 units IV bolus

Answer 11

“240 mL (8 oz) of orange juice”
INCORRECT
DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Orange juice would increase the client’s blood glucose levels.

“Ampule of 50% dextrose IV bolus”
INCORRECT
DKA management requires hydration and lowering blood glucose levels. An ampule of 50% dextrose would increase the client’s blood glucose levels.

“NPH insulin 60 units subcutaneous”
INCORRECT
NPH insulin is a long-acting insulin with an onset of 1.5 to 4 hours. The treatment goal for a client with DKA is to reduce blood glucose levels by 50 to 75 mg/dL every hour, which requires the use of faster-acting insulin.

“Regular insulin 20 units IV bolus”
CORRECT
Regular insulin is a fast-acting insulin that can be effective within 10 minutes when administered intravenously, making it suitable for managing DKA.

Question 12

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following results is an indication of an adverse effect of the medication?

Increased potassium
Increased magnesium
Increased BUN
Increased hematocrit

Answer 12

“Increased potassium”
INCORRECT
Amphotericin B can cause damage to the kidneys and lead to hypokalemia, not increased potassium levels.

“Increased magnesium”
INCORRECT
Amphotericin B can cause several metabolic imbalances, including hyponatremia, hypokalemia, and hypomagnesemia, rather than increased magnesium levels.

“Increased BUN”
CORRECT
Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

“Increased hematocrit”
INCORRECT
Amphotericin B can cause bone marrow suppression, resulting in decreased hematocrit rather than increased levels.

Question 13

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad?

Hypotension
Tachypnea
Nuchal rigidity
Bradycardia

Answer 13

Hypotension
INCORRECT
A client who has increased intracranial pressure from a traumatic brain injury can develop hypertension, which is one component of Cushing’s triad.

Tachypnea
INCORRECT
A client who has a traumatic brain injury can develop decreased cerebral blood flow, resulting in increased arterial pressure. However, respirations are not affected.

Nuchal rigidity
INCORRECT
Nuchal rigidity, or neck stiffness, is an indication of meningitis.

Bradycardia
CORRECT
A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing’s triad. The other components of Cushing’s triad are severe hypertension and a widened pulse pressure.

Question 14

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?

INR 1 (0.8 TO 1.1)
INR 2.5 (0.8 TO 1.1)
aPTT 45 seconds (30 to 40 seconds)
aPTT 90 seconds (30 to 40 seconds)

Answer 14

INR 1.0 (0.8-1.1)
INCORRECT
INR, along with PT, is obtained to measure the clotting abilities of the blood in a client who is taking warfarin. This INR value is below the target reference range for a client who has atrial fibrillation.

INR 2.5 (2.0-3.0)
CORRECT
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

aPTT 45 seconds (30 to 40 seconds)
INCORRECT
Clients who are receiving heparin should have aPTT levels monitored to ensure appropriate anticoagulation is achieved. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds.

aPTT 20 seconds (30 to 40 seconds)
INCORRECT
PTT is obtained to measure the clotting abilities of the blood. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds.

Question 15

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

Document that depolarization has occurred.
Increase the pacemaker’s voltage.
Decrease the pacemaker’s sensitivity.
Check the placement of the ECG leads.

Answer 15

Document that depolarization has occurred
CORRECT
When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

Increase the pacemaker’s voltage
INCORRECT
The presence of a QRS complex after the spike indicates that the pacemaker has adequate voltage to stimulate the heart.

Decrease the pacemaker’s sensitivity
INCORRECT
Sensitivity should be decreased if the pacemaker fires at a regular rate in the presence of an adequate intrinsic rhythm, which is not the case for this client.

Check the placement of the ECG leads
INCORRECT
A pacing stimulus followed by a QRS complex indicates the pacemaker is firing correctly. The ECG leads are detecting this activity and do not need to be checked.

Question 16

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

Change the dressing every 72 hr.
Immobilize the hand with a pressure dressing.
Take pain medication 30 min after changing the dressing.
Wrap fingers with individual dressings.

Answer 16

Change the dressing every 72 h
INCORRECT
The nurse should instruct the client to change the dressing every 12 to 24 hours to allow for wound inspection. The client should observe the wound closely for manifestations of increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection.

Immobilize the hand with a pressure dressing
INCORRECT
A client who undergoes surgery to receive skin grafts for full-thickness burns should elevate and immobilize the graft site with cotton pressure dressings for 3 to 5 days following the procedure. This action prevents the graft from dislodging and allows for revascularization of the wound.

Take pain medication 30 min after changing the dressing
INCORRECT
The nurse should instruct the client to take pain medication 30 minutes before a dressing change to decrease the level of pain during the procedure.

Wrap fingers with individual dressings
CORRECT
The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.

Question 17

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?

Decreased cells
Increased creatinine clearance
Increased eosinophils
Decreased viral load

Answer 17

Decreased T cells
INCORRECT
T cells are responsible for cellular immunity. The T cell count indicates the body’s ability to fight opportunistic infections and cancer. A decreased T cell count indicates the progression of HIV. Once the T cells counts falls below 200 cells/mm3, the client receives a diagnosis of AIDS

Increased creatinine clearance
INCORRECT
Creatinine clearance measures the ability of the kidneys to filter the blood. An increased creatinine clearance level indicates compromised renal function, which is a common occurrence in client who have HIV.

Increased eosinophils
INCORRECT
Eosinophils are a type of leukocyte that are responsive to parasitic infections and allergic reactions. An increase in eosinophils indicates the presence of infection.

Decrease viral load
CORRECT
Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.

Question 18

The PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client’s initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min
Blood pressure 160/70 mm Hg
Respiratory rate 18/min
Temperature 38.4° C (101.1° F)

Answer 18

Heart Rate 110/min
CORRECT: One of the first signs of hemorrhage is an increase in the heart rate from the client’s baseline, which occurs to compensate for blood loss.

Blood Pressure 160/70 mm Hg
INCORRECT: An early sign of hemorrhage is a slight increase in diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An increase in blood pressure postoperatively can indicate that the client is in pain.

Respiratory Rate 14/min
INCORRECT: An increase in the respiratory rate from the client’s baseline is an indication of hemorrhage.

Temperature 38.4° C (101.1° F)
INCORRECT: An increase in temperature from the client’s baseline is an indication of infection, not hemorrhage.

Question 19

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity
Hypertension
Bounding peripheral pulses
Hyperglycemia

Answer 19

Low Urine Specific Gravity
CORRECT: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys’ responsiveness to the hormone.

Hypertension
INCORRECT: The nurse should expect a client who has diabetes insipidus to have hypotension due to dehydration caused by excessive excretion of urine.

Bounding Peripheral Pulses
INCORRECT: The nurse should expect a client who has diabetes insipidus to have weak peripheral pulses due to dehydration caused by excessive excretion of urine.

Hyperglycemia
INCORRECT: Hyperglycemia is a manifestation of diabetes mellitus. Manifestations of diabetes insipidus include polydipsia and polyuria.

Question 20

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

The chest tube is draining serosanguineous fluid at 65 mL/hr.
The client tolerates gentle milking of the tubing.
Bubbling in the water seal chamber has ceased.
There is tidaling in the water seal chamber.

Answer 20

The chest tube is draining serosanguineous fluid at 65 mL/h
INCORRECT: Serosanguineous drainage of 65 mL/hr is an expected finding for the client but does not indicate lung re-expansion.

The client tolerates gentle milking of the tubing
INCORRECT: The nurse can gently milk the chest tube to release clots, but the client’s ability to tolerate this action does not indicate lung re-expansion.

Bubbling in the water seal chamber has ceased
CORRECT: Bubbling in the water seal chamber ceases when the lung re-expands.

There is tidaling in the water seal chamber
INCORRECT: The presence of tidaling in the water seal chamber results from the client’s inhalation and exhalation and is not indicative of lung re-expansion.

Question 21

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hours ago. Which of the following actions should the nurse take?

Inspect the cast for drainage once every 24 hours.
Check that one finger fits between the cast and the leg.
Perform neurovascular checks every 2 to 3 hours.
Make sure the client has a warm blanket covering the cast.

Answer 21

Inspect the cast for drainage once every 24 hr.
INCORRECT
The nurse should inspect the cast for drainage and alignment at least once every 8 to 12 hr.

Check that one finger fits between the cast and the leg.
CORRECT
To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

Perform neurovascular checks every 2 to 3 hr.
INCORRECT
For the first 24 hr after cast application, the nurse should check the neurovascular status of the client’s leg every hour. The nurse does this by assessing sensation, motion, and circulation.

Make sure the client has a warm blanket covering the cast.
INCORRECT
The nurse should make sure the cast is uncovered to allow for thorough air drying of the plaster. Also, the heat that is generated by the drying process has to escape.

Question 22

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted.” Which of the following actions should the nurse take?

Administer a placebo to the client without their knowledge.
Instruct the client on alternative therapies for pain reduction.
Tell the client not to worry about addiction to prescribed narcotics.
Suggest the client receive a different opioid for pain reduction.

Answer 22

Administer a placebo to the client without their knowledge
INCORRECT: The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights.

Instruct the client on alternative therapies for pain reduction
CORRECT: The nurse should respect the client’s concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.

Tell the client not to worry about addiction to prescribed narcotics
INCORRECT: This response by the nurse is nontherapeutic because it dismisses the client’s concerns.

Suggest the client receive a different opioid for pain reduction
INCORRECT: By suggesting the client receive a different opioid for pain reduction, the nurse is disregarding the client’s concerns about opioid use disorder.

Question 23

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.
The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy.
Family members should follow airborne precautions at home.
A follow-up tuberculosis skin test is necessary in 2 months.

Answer 23

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures
CORRECT: After three negative sputum cultures, the client is no longer considered infectious.

The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy
INCORRECT: The client’s infection is usually no longer contagious after taking TB medications for 2 to 3 weeks.

Family members should follow airborne precautions at home
INCORRECT: Family members do not need to follow airborne precautions because they have already been exposed to TB.

A follow-up tuberculosis skin test is necessary in 2 months
INCORRECT: A follow-up evaluation of the client’s TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive.

Question 24

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?

Use pillows to support the client’s head and neck.
Offer opioid medication.
Place a tracheostomy tray at the bedside.
Place the client in semi-Fowler’s position.

Answer 24

Use pillows to support the client’s head and neck
INCORRECT: The nurse should use pillows to support the client’s head and neck to prevent stress on the suture line, but this action is not the priority.

Offer opioid medication
INCORRECT: The nurse should offer opioid medication for pain relief, but this action is not the priority.

Place a tracheostomy tray at the bedside
CORRECT: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client’s bedside in case of airway obstruction.

Place the client in semi-Fowler’s position
INCORRECT: The nurse should place the client in semi-Fowler’s position to avoid neck extension, but this action is not the priority.

Question 25

Here’s the text with corrected formatting and emphasis on the appropriate oxygen delivery system for a client with viral pneumonia:

A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Nonrebreather mask
Venturi mask
Simple face mask
Partial rebreather mask

Answer 25

Nonrebreather mask
CORRECT: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

Venturi mask
INCORRECT: The nurse should initiate a Venturi mask for a client who requires an exact oxygen flow. A Venturi mask can only deliver an oxygen concentration between 24% and 50%.

Simple face mask
INCORRECT: The nurse should initiate a simple face mask for a client who requires short-term supplemental oxygen. A simple face mask can only deliver an oxygen concentration between 40% and 60%. A simple face mask does not usually fit well and can lead to skin breakdown.

Partial rebreather mask
INCORRECT: The nurse should initiate a partial rebreather mask for a client who can sustain adequate oxygen saturation levels with a mixture of room air and oxygen. A partial rebreather allows a portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to a range between 60% and 75%.

Question 26

Which of the following information should the nurse include in the teaching?

Drink 240 mL (8 oz) of water after administration.
Expect results in 1 to 3 days.
Take this medication before meals to increase appetite.
Reduce dietary fiber intake to improve medication absorption.

Answer 26

Drink 240 mL (8 oz) of water after administration
CORRECT: The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

Expect results in 4 to 6 hours
INCORRECT: The client should expect results in 12 to 24 hours and bowel regularity in 2 to 3 days.

Take this medication before meals to increase appetite
INCORRECT: The client should take the medication after meals to prevent appetite suppression.

Reduce dietary fiber intake to improve medication absorption
INCORRECT: Reducing dietary fiber intake does not affect medication absorption. However, the client should increase dietary fiber intake for management of chronic constipation.

Question 27

Appendicitis vs Crohn’s Disease

Pain location RLQ, client reports gastrointestinal concerns, small amount of blood in stool, and temp of 101.4°F

Answer 27

When analyzing cues, the nurse should identify that the client’s assessment findings of right lower quadrant pain, fever, and client report of anorexia indicate appendicitis.

When analyzing cues, the nurse should identify that the client’s assessment findings of blood in stool, right lower quadrant pain, fever, and client report of anorexia indicate Crohn’s disease.

Question 28

A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching?

Take an antacid before meals and at bedtime.
Increase fiber intake to at least 30 g per day.
Drink ginger tea daily.
Consume no more than 1 L of water per day.

Answer 28

Take an antacid before meals and at bedtime
INCORRECT: Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and pain associated with diarrhea and constipation. Anticholinergic or antispasmodic agents can be prescribed to control cramping.

Increase fiber intake to at least 30 g per day
CORRECT: Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

Drink ginger tea daily
INCORRECT: Ginger tea is useful for treating nausea, not cramping. Additionally, a client who has IBS should avoid dairy products, raw fruits, and grains that can cause bloating.

Consume no more than 1 L of water per day
INCORRECT: The client should consume at least 2 L of water daily to promote regular bowel function.

Question 29

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client’s chart, which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

Potassium 4.1 mEq/L
Heart rate 55/min
SpO2 92%
Weight 67.1 kg (148 lb)

Answer 29

Potassium 4.1 mEq/L
INCORRECT: The client’s potassium level of 4.1 mEq/L is within the expected reference range (3.5 to 5 mEq/L).

Heart rate 55/min
CORRECT: The client’s heart rate of 55/min is a decrease from the client’s baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

Oxygen saturation level
INCORRECT: The nurse should ensure that the client’s oxygen saturation level remains at or above 90%. This finding is within the expected reference range.

Weight gain
INCORRECT: The nurse should report a client’s weight gain of 1.4 kg (3 lb) in a day or 2.3 kg (5 lb) or more in a week.

Question 30

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Secure the straps firmly around the boot.
Remove the device before showering.
Use crutches with rubber tips.
Adjust the screws to maintain alignment.

Answer 30

Secure the straps firmly around the boot
INCORRECT: The surgeon applies the external fixation device directly to the client’s bone to form a rigid structure around the affected extremity. Casts, boots, or splints are applied to the leg for internal fixation.

Remove the device before showering
INCORRECT: The client should wear external fixation devices continuously for a period of 4 to 6 weeks. The nurse should teach the client to perform care of the wound and pin sites at home.

Use crutches with rubber tips
CORRECT: Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

Adjust the screws to maintain alignment
INCORRECT: Only the provider should adjust the client’s external fixation device to maintain bone alignment.

Question 31

A nurse is caring for a client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should the nurse take to avoid restraining the client?

Check on the client every 2 hours.
Provide a quiet environment with no distractions.
Turn on the television in the client’s room.
Keep the client occupied with a manual activity.

Answer 31

Check on the client every 2 hr
INCORRECT: The nurse should check on the client at least once every hour.

Provide a quiet environment with no distractions
INCORRECT: The nurse should provide soft music to calm the client. If possible, the nurse should allow the client to choose the type of music they prefer.

Turn on the television in the client’s room
INCORRECT: If the client is agitated, the nurse should turn off the television in the client’s room.

Keep the client occupied with a manual activity
CORRECT: The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

Question 32

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client’s bedside?

Suction machine
Wire cutters
Padded clamp
Communication board

Answer 32

Suction machine
CORRECT: The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client’s airway as needed and reduce the risk for aspiration.

Wire cutters
INCORRECT: The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary fixation to cut the wires in case the client vomits. This enables the client to clear their airway and reduce the risk for aspiration.

Padded clamp
INCORRECT: The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to clamp the tube and prevent air from entering the client’s chest if there is an interruption in the sealed drainage system.

Communication board
INCORRECT: The nurse should ensure a communication board is at the bedside of a client who has aphasia to assist the client with communicating.

Question 33

A nurse in an emergency department is reviewing the provider’s prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect?

Apply ice to the client’s puncture wounds.
Initiate corticosteroid therapy for the client.
Keep the client’s leg above heart level.
Administer an opioid analgesic to the client.

Answer 33

Apply ice to the client’s puncture wounds
INCORRECT: The nurse should apply ice for a bite from a black widow spider to reduce the action of the neurotoxin from the spider.

Initiate corticosteroid therapy for the client
INCORRECT: The nurse should expect a prescription for antihistamines and corticosteroids for stings from bees and wasps.

Keep the client’s leg above heart level
INCORRECT: The nurse should keep the affected extremity at heart level, not above or below it.

Administer an opioid analgesic to the client
CORRECT: The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

Question 34

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)

Expressive aphasia
Visual spatial deficits
Left hemianopsia
Right hemiplegia
One-sided neglect

Answer 34

Expressive aphasia
INCORRECT: Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke.

Visual spatial deficits
CORRECT: Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke.

Left hemianopsia
CORRECT: Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke.

Right hemiplegia
INCORRECT: Right hemiplegia occurs secondary to a left-hemispheric stroke.

One-sided neglect
CORRECT: One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

Question 35

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?

Defibrillate the client’s heart.
Perform synchronized cardioversion.
Begin cardiopulmonary resuscitation.
Administer lidocaine IV bolus.

Answer 35

Defibrillate the client’s heart
INCORRECT: The nurse should defibrillate the client’s heart for ventricular tachycardia or ventricular fibrillation.

Perform synchronized cardioversion
CORRECT: The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

Begin cardiopulmonary resuscitation
INCORRECT: The nurse should initiate CPR for a client who is pulseless or not breathing.

Administer lidocaine IV bolus
INCORRECT: The nurse should administer lidocaine IV bolus for a client who has a ventricular dysrhythmia.

Question 36

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 min of the infusion.
Prime the blood administration IV tubing with lactated Ringer’s solution.
Verify the client’s identity by using the client’s room number prior to starting the transfusion.
Infuse the unit of packed RBCs within 6 hr.

Answer 36

Remain with the client for the first 15 min of the infusion
CORRECT: The nurse should remain with the client for the first 15 to 30 minutes of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

Prime the blood administration IV tubing with lactated Ringer’s solution
INCORRECT: The nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or hemolysis of the RBCs.

Verify the client’s identity by using the client’s room number prior to starting the transfusion
INCORRECT: The client’s room number is not an acceptable client identifier. The nurse should ensure that the name and number on the client’s identification band matches the name and identification number on the blood label. The client’s identification, the blood compatibility, and the expiration date of the blood should be verified by two nurses.

Infuse the unit of packed RBCs within 8 hr
INCORRECT: The nurse should transfuse the packed RBCs within 2 to 4 hours based upon the client’s age and cardiovascular status. Longer infusion times increase the risk for bacterial contamination of the blood product.

Question 37

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing?

Weight loss of 1 kg in 1 week
BMI 24
Urine output 25 mL/hr
Report of 3/10 pain on a 0 to 10 pain scale

Answer 37

Weight loss of 1 kg in 1 week
INCORRECT: A decrease in weight of 4.54 kg (10 lb) in a short time period is a sign of a nutritional problem, which can delay wound healing.

BMI readings
INCORRECT: BMI readings provide a means of determining a client’s nutritional status. Clients who have a BMI less than 18.5 are considered at risk for complications, such as poor wound healing.

Urine output 25 mL/h
CORRECT: Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

Report of 3/10 pain on a 0 to 10 pain scale
INCORRECT: A well-managed pain level enhances a client’s willingness to increase mobility.

Question 38

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneously. Which of the following actions should the nurse take?

Monitor the client’s INR daily.
Expel air bubbles when using a prefilled syringe.
Inject the medication into the anterolateral abdominal wall.
Massage the injection site after administration.

Answer 38

Monitor the client’s INR daily
INCORRECT: A client who is taking enoxaparin does not require a daily INR. The nurse should periodically compare the client’s CBC with a baseline CBC.

Expel air bubbles when using a prefilled syringe
INCORRECT: The nurse should plan to follow the injection of the medication with the air bubble located at the site of the plunger in the prefilled syringe. The air bubble ensures that the client receives the whole dose of the medication.

Inject the medication into the anterolateral abdominal wall
CORRECT: The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

Massage the injection site after administration
INCORRECT: The nurse should avoid massaging the client’s injection site after administration to minimize bruising.

Question 39

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Blood sodium level 132 mEq/L (136 to 145 mEq/L)
Forearm skin tents when pinched
Respiratory rate decreased
Urine specific gravity 1.045 (1.005 to 1.030)

Answer 39

Blood sodium level 132 mEq/L (136 to 145 mEq/L)
INCORRECT: A client who has hypertonic dehydration may experience a blood sodium level above the expected reference range because the kidneys respond to the loss of free body water by attempting to conserve it, which increases the blood concentration of sodium. A finding of 132 mEq/L is below the expected reference range and indicates an excess of free body water.

Forearm skin tents when pinched
INCORRECT: Skin turgor can be an unreliable indication of dehydration in older adult clients due to age-related changes in skin elasticity. The nurse should check an older adult client’s skin turgor on the sternum for a more reliable indicator.

Respiratory rate decreased
INCORRECT: The nurse should expect the client’s respiratory rate to increase if dehydration occurs because the decreased vascular fluid volume associated with dehydration reduces oxygenation and organ perfusion, requiring a compensatory increase in the respiratory rate.

Urine specific gravity greater than 1.030
CORRECT: A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

Question 40

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

“This measures how much blood my heart is pumping.”
“This identifies if I have a defective heart valve.”
“This identifies if the pacemaker cells of my heart are working properly.”
“This measures the blood circulating to my heart muscle.”

Answer 40

This measures how much blood my heart is pumping.
INCORRECT: Cardiac output, calculated by multiplying heart rate and stroke volume, measures the amount of blood ejected by the heart over one minute.

“This identifies if I have a defective heart valve.”
INCORRECT: An echocardiogram, a noninvasive ultrasound procedure, evaluates heart valve function and structure.

“This identifies if the pacemaker cells of my heart are working properly.”
CORRECT: Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

“This measures the blood circulating to my heart muscle.”
INCORRECT: Cardiac catheterization allows for the measurement of coronary artery blood flow.

Question 41

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?

“You will still have the urge to void.”
“You can apply an aspirin tablet to the pouch to reduce odor.”
“You should cut the opening of the skin barrier one-eighth inch wider than the stoma.”
“You should use a moisturizing soap when washing the skin around the stoma.”

Answer 41

“You will still have the urge to void.”
INCORRECT: During the procedure, the client’s bladder is removed, and the ureters are brought to the skin surface of the abdomen to form a stoma, from which urine will flow into an external ostomy bag. Therefore, the client will not have an urge to void.

“You can apply an aspirin tablet to the pouch to reduce odor.”
INCORRECT: The client should not add an aspirin tablet to the pouch because it can ulcerate the stoma.

“You should cut the opening of the skin barrier one-eighth inch wider than the stoma.”
CORRECT: The client should cut the opening of the skin barrier 0.3 cm (1/8 inch) wider than the stoma to minimize irritation of the skin from exposure to urine.

“You should use a moisturizing soap when washing the skin around the stoma.”
INCORRECT: The client should avoid using moisturizing soaps to clean the skin around the stoma because it will prevent the pouch from adhering to the skin.

Question 42

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?

Keep the client’s personal care items in the bathroom.
Keep the overhead lights on in the client’s bedroom while the client is sleeping.
Remind the client to scan their complete range of vision during ambulation.
Secure the client’s extension cords under carpeting.

Answer 42

Keep the client’s personal care items in the bathroom.
INCORRECT: The nurse should instruct the client’s family to keep the client’s personal care items within the client’s reach to reduce the risk for falls.

Keep the overhead lights on in the client’s bedroom while the client is sleeping.
INCORRECT: The nurse should instruct the family to use nightlights in the client’s bedroom and bathroom to reduce the risk for falls. Keeping the overhead lights on while the client is sleeping can disrupt the client’s circadian rhythm.

Remind the client to scan their complete range of vision during ambulation.
CORRECT: The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

Secure the client’s extension cords under carpeting.
INCORRECT: The nurse should instruct the client’s family to secure extension cords to the client’s baseboards using electrical tape, rather than placing them under carpeting. This practice can help to reduce the risk for falls.

Question 43

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Obtain a sputum specimen to determine if there is colonization.
Bathe the client using chlorhexidine solution.
Place the client in droplet isolation.
Restrict visits from the client’s friends and family.

Answer 43

Obtain a sputum specimen to determine if there is colonization.
INCORRECT: The nurse should obtain a nasal specimen to determine if there is colonization of MRSA.

Bathe the client using chlorhexidine solution.
CORRECT: The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

Place the client in droplet isolation.
INCORRECT: The nurse should place the client in contact isolation to decrease the risk of the spread of MRSA.

Restrict visits from the client’s friends and family.
INCORRECT: The nurse does not need to restrict the client’s visitors. The nurse should instruct the client’s friends and family to wear gowns and gloves when visiting the client to decrease the risk of the spread of MRSA.

Question 44

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Ginkgo biloba
Glucosamine
Calcium
Vitamin C

Answer 44

Ginkgo biloba
INCORRECT: Ginkgo biloba reduces the pain associated with peripheral vascular disease by promoting vasodilation. It can interact with medications that have anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine.

Glucosamine
INCORRECT: Glucosamine treats osteoarthritis by decreasing inflammation and stimulating the body’s production of synovial fluid and cartilage. It can interact with medications that have antiplatelet or anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine.

Calcium
CORRECT: Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hours of levothyroxine administration.

Vitamin C
INCORRECT: Vitamin C promotes wound healing. It can cause a false negative in fecal occult blood tests, but it is not known to interfere with the absorption of levothyroxine.

Question 45

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

“I should take calcium supplements so the medication will work better in my system.”
“I am taking this medication to increase my energy level.”
“This medication can cause my blood pressure to drop.”
“I will not need to restrict protein in my diet while taking this medication.”

Answer 45

“Should take calcium supplements so the medication will work better in my system.”
INCORRECT: A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal.

“I am taking this medication to increase my energy level.”
CORRECT: The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

“This medication can cause my blood pressure to drop.”
INCORRECT: Therapy with erythropoietin increases RBC production, which can result in hypertension, not hypotension.

“I will not need to restrict protein in my diet while taking this medication.”
INCORRECT: Erythropoietin does not affect the client’s protein requirements, but the client should continue to restrict protein as prescribed by the provider to manage kidney disease.

Question 46

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

“I should avoid walking as much as possible.”
“I should sit down and read for several hours a day.”
“I will wear clean graduated compression stockings every day.”
“I will keep my legs level with my body when I sleep at night.”

Answer 46

“I should avoid walking as much as possible.”
INCORRECT: A client who has venous insufficiency should maintain an exercise regimen, such as routine walking, to decrease venous stasis.

“I should sit down and read for several hours a day.”
INCORRECT: A client who has venous insufficiency should avoid sitting or standing for prolonged periods of time due to the risk of developing deep-vein thrombosis or skin breakdown.

“I will wear clean graduated compression stockings every day.”
CORRECT: The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

“I will keep my legs level with my body when I sleep at night.”
INCORRECT: A client who has venous insufficiency should elevate the legs above heart level while in bed to facilitate venous return and avoid venous stasis.

Question 47

A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?

Metoprolol
Bupropion
Atorvastatin
Naproxen

Answer 47

Metoprolol
INCORRECT: Metoprolol does not interact with feverfew.

Bupropion
INCORRECT: Bupropion does not interact with feverfew.

Atorvastatin
INCORRECT: The nurse should recognize that the effect of atorvastatin is decreased by St. John’s wort.

Naproxen
CORRECT: Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

Question 48

Here’s the text with corrected formatting and emphasis on the appropriate complication associated with long-term mechanical ventilation:

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?

Elevated blood pressure
Dehydration
Stress ulcers
Hypernatremia

Answer 48

Elevated blood pressure
INCORRECT: Positive pressure from mechanical ventilation inhibits blood return to the heart, leading to decreased cardiac output and hypotension.

Dehydration
INCORRECT: Decreased cardiac output associated with mechanical ventilation places the client at risk for fluid retention.

Stress ulcers
CORRECT: Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

Hypernatremia
INCORRECT: Hyponatremia can occur secondary to fluid retention that results from long-term mechanical ventilation.

Question 49

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

Avoid foods that are high in ascorbic acid
Add oatmeal to the water when taking a tub bath
Urinate every 6 hr.
Take daily cranberry supplements.

Answer 49

(Avoid foods that are high in ascorbic acid.

INCORRECT
Adlient who is at risk for developing UTIs should increase intake of ascorbic acid to acidify the urine.

© Add oatmeal to the water when taking a tub bath.

INCORRECT
Adlient who is at risk for developing UTIs should take showers rather than tub baths because bacteria in the bath water can enter
the urethra.

© Urinate every 6 hr

INCORRECT
Aclient who is at risk for developing UTIs should urinate every 2 to 4 hr.

&Y Take daily cranberry supplements.

O Tike daily pp!

> comer
The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to
the urinary tract wall, decreasing the risk for developing a UTI.

Question 50

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Hyporeflexia
Increased blood pressure
Respiratory paralysis
Tachycardia

Answer 50

Hyperreflexia
INCORRECT: Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of magnesium sulfate.

Increased blood pressure
INCORRECT: Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension.

Respiratory paralysis
CORRECT: The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely, as the adverse effects can impact the CNS, cardiovascular system, and respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

Tachycardia
INCORRECT: Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate.

Question 51

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer’s disease. Which of the following information should the nurse include in the teaching?

Position tabletop clocks with multi-colored backgrounds throughout the home.
Explain how to complete a task while having the client do the task.
Place a calendar on the wall with days and weeks included.
Create complete outfits and allow the client to select one each day.

Answer 51

Position tabletop clocks with multi-colored backgrounds throughout the home.
INCORRECT: The family should use easy-to-read clocks with a plain background to minimize confusion and allow the client to find and read them easily.

Explain how to complete a task while having the client do the task.
INCORRECT: The family should explain how to complete a task before there is a need to complete the task to minimize confusion and frustration.

Place a calendar on the wall with days and weeks included.
INCORRECT: The family should place a calendar on the wall with the present day available to view to minimize confusion and assist in orientation.

Create complete outfits and allow the client to select one each day.
CORRECT: The family should place completed outfits on hangers and allow the client to select which one to wear each day.

Question 52

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Explain procedures as they occur to the client.
Place personal items, such as pictures, at the client’s bedside.
Orient the client to their location once a shift.
Encourage the family members to remain home until the client has adjusted.

Answer 52

Explain procedures as they occur to the client.
INCORRECT: The nurse should plan to explain all procedures and routines to the client before they occur to decrease confusion and anxiety.

Place personal items, such as pictures, at the client’s bedside.
CORRECT: The nurse should plan to have the family bring personal items such as pictures to place at the client’s bedside for cognitive support.

Orient the client to their location once a shift.
INCORRECT: The nurse should plan to orient the client to person, place, and time frequently during a shift to decrease confusion and anxiety.

Encourage the family members to remain home until the client has adjusted.
INCORRECT: The nurse should plan for family members and friends to visit often to decrease confusion and anxiety and to reinforce cognitive support.

Question 53

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet?

12 Almonds

One small banana

1 tbsp peanut butter

½ cup tomato juice

Answer 53

12 almonds
CORRECT: The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

One small banana
INCORRECT: The nurse should recommend a different food because there is another choice that contains more calcium. One small banana contains 5 mg of calcium.

1 tbsp peanut butter
INCORRECT: The nurse should recommend a different food because there is another choice that contains more calcium. One tablespoon of peanut butter contains 8 mg of calcium.

2 cups tomato juice
INCORRECT: The nurse should recommend a different food because there is another choice that contains more calcium. A half cup of tomato juice contains 12 mg of calcium.

Question 54

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

History of asthma

appendectomy 1 year ago

penicillin allergy

Total knee arthroplasty 6 months ago

Answer 54

History of asthma
CORRECT: A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

Appendectomy 1 year ago
INCORRECT: A history of an appendectomy does not have an effect on a CT scan. However, clients who have a history of diabetes mellitus, renal impairment, or heart failure have an increased risk for renal failure when contrast media is used and require further screening.

Penicillin allergy
INCORRECT: A penicillin allergy does not have an effect on a CT scan. However, a client who is taking certain medications, such as aminoglycosides, NSAIDs, and the biguanide metformin, is at increased risk for renal damage and requires further screening.

Total knee arthroplasty 6 months ago
INCORRECT: A total knee arthroplasty does not have an effect on a CT scan.

Question 55

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects?

Tingling sensation replacing the pain

Electrically generated feelings of heat

cryotherapy for painful areas

Realignment of energy flow through meridians

Answer 55

Electrically generated feelings of heat
INCORRECT: A TENS unit does not create heat when applied to a painful area. Warm compresses, heating pads, and paraffin dips are examples of modalities that apply heat to painful areas.

Cryotherapy for painful areas
INCORRECT: Many over-the-counter gels and creams work by creating a sense of cold to help relieve muscle aches and pain. A TENS unit does not work by cryotherapy, or cold treatment.

Realignment of energy flow through meridians
INCORRECT: Acupuncture is a therapy that works via the insertion of fine needles to help unblock any obstructed flow of energy in other parts of the body. A TENS unit does not clear obstructions in energy flow.

Tingling sensation replacing the pain
CORRECT: A TENS unit applies small electric currents to the painful area, with the client increasing the current until the “pins and needles” sensation overrides the pain.

Question 56

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Disconnect the machine and manually ventilate the client.

Administer Propofol to the client

Obtain ABGs.

Instruct the client to allow the machine to breathe for them.

Answer 56

Obtain ABGs.
INCORRECT: The nurse should monitor ABG results to determine the effectiveness of mechanical ventilation, but this is not the first action the nurse should take.

Administer propofol to the client.
INCORRECT: The nurse might need to administer propofol to provide sedation and increase the client’s tolerance of mechanical ventilation, but this is not the first action the nurse should take.

Instruct the client to allow the machine to breathe for them.
CORRECT: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to “fight the ventilator.”

Disconnect the machine and manually ventilate the client.
INCORRECT: Many factors can cause a high-pressure alarm to sound. The nurse might have to disconnect the machine and manually ventilate the client if the ventilator fails or the client experiences respiratory distress, but this is not the first action the nurse should take.

Question 57

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?

A client who is receiving preoperative teaching for a right knee arthroplasty.

A client who states they will have difficulty obtaining a walker for home use.

A client who reports an increase in pain following a left hip arthroplasty.

A client who is having emotional difficulty accepting that they have a prosthetic leg.

Answer 57

A client who is receiving preoperative teaching for a right knee arthroplasty.
CORRECT: The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

A client who states they will have difficulty obtaining a walker for home use.
INCORRECT: The nurse should make a referral to a social worker for a client who reports difficulty obtaining a walker for home use.

A client who reports an increase in pain following a left hip arthroplasty.
INCORRECT: The nurse should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty.

A client who is having emotional difficulty accepting that they have a prosthetic leg.
INCORRECT: The nurse should refer the client to a counselor to assist with coping with the adjustment to the need for a prosthetic leg.

Question 58

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Document the client’s intake and output.

Scan the bladder with a portable ultrasound.

Pour warm water over the client’s perineum.

Perform a straight catheterization.

Answer 58

Document the client’s intake and output.
INCORRECT: The nurse should document the client’s intake and output to ensure adequate fluid balance. However, there is another action that the nurse should take first.

Scan the bladder with a portable ultrasound.
CORRECT: The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

Pour warm water over the client’s perineum.
INCORRECT: Pouring warm water over the client’s perineum is a method for stimulating micturition. However, there is another action that the nurse should take first.

Perform a straight catheterization.
INCORRECT: Performing a straight catheterization might prove necessary. However, there is another action that the nurse should take first.

Question 59

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

“I will need to take antibiotics for 1 year.”

My partner will need to take an antiviral medication.

“My joints ache because I have Lyme disease.”

“I bruise easily because I have Lyme disease.”

Answer 59

I will need to take antibiotics for 1 year.
INCORRECT: A client who has severe stage II Lyme disease will be prescribed a 30-day course of antibiotics. The nurse should emphasize to the client that, like with other types of infection, the full course of antibiotics should be completed.

My partner will need to take an antiviral medication.
INCORRECT: Lyme disease is a vector-borne illness that is treated with antibiotics. Other vector-borne illnesses, such as West Nile Virus, are treated with antiviral medications. Lyme disease is not transmitted to others via human contact.

My joints ache because I have Lyme disease.
CORRECT: Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages, beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

I bruise easily because I have Lyme disease.
INCORRECT: Lyme disease is an infectious disease that affects the body systemically, involving the neurologic, musculoskeletal, and cardiac systems. Cardiac manifestations include carditis and dysrhythmias. However, a client who has stage II Lyme disease does not typically experience bruising.

Question 60

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching?

“I will take my temperature once a day.”

“I should clean my toothbrush in the dishwasher once a month.”

“I should eat more fresh fruit and vegetables.”

“I will avoid drinking a glass of cold liquid that has been standing for 30 minutes.”

Answer 60

I should clean my toothbrush in the dishwasher once a month.
INCORRECT: A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should clean their toothbrush weekly in the dishwasher or in a bleach solution to destroy microorganisms.

I should eat more fresh fruit and vegetables.
INCORRECT: A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid eating raw fruits and vegetables that can contain bacteria and cause infection. The nurse should advise the client to eat a low-bacteria diet.

I will avoid drinking a glass of cold liquid that has been standing for 30 minutes.
INCORRECT: A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid drinking a glass of liquid that stands for 60 minutes or more to reduce the risk of drinking contaminated liquids.

I will take my temperature once a day.
CORRECT: A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8°C (100°F), which is an early manifestation of an infection.

Question 61

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

“I will take my iron with a glass of milk.”

“I will take an antacid with my iron.”

“I will limit my intake of red meat.”

“I will eat more high-fiber foods.”

Answer 61

I will take my iron with a glass of milk.
INCORRECT: Although oral iron supplements can cause gastrointestinal disturbances, the client should not consume dairy products at the same time as taking iron because dairy products inhibit the absorption of iron.

I take an antacid with my iron.
INCORRECT: Although oral iron supplements can cause gastrointestinal disturbances, the client should not take antacids at the same time as taking iron because antacids inhibit the absorption of iron.

I limit my intake of red meat.
INCORRECT: The client should increase intake of red meat because red meat is high in iron and will supplement this medication.

I will eat more high-fiber foods.
CORRECT: The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

Question 62

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Hydrocodone

Bupropion

Lactulose

Warfarin

Answer 62

Hydrocodone
INCORRECT: Hydrocodone is an opioid analgesic and is not contraindicated for a client scheduled for eye surgery. However, long-term opioid use can alter the client’s response to analgesic agents.

Bupropion
INCORRECT: Bupropion is an antidepressant and is not contraindicated for a client scheduled for eye surgery.

Lactulose
INCORRECT: Lactulose is a laxative used to treat constipation and is not contraindicated for a client scheduled for eye surgery.

Warfarin
CORRECT: Warfarin is an anticoagulant, which increases the client’s risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

Question 63

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client’s indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

Remove the client’s indwelling urinary catheter.

Irrigate the indwelling urinary catheter.

Clamp the indwelling urinary catheter.

Apply traction to the indwelling urinary catheter.

Answer 63

Remove the client’s indwelling urinary catheter
INCORRECT: The nurse should not remove the client’s indwelling urinary catheter as it ensures adequate urine flow.

Irrigate the indwelling urinary catheter
CORRECT: The nurse should irrigate the client’s catheter per facility protocol to remove clots obstructing the urine flow.

Clamp the indwelling urinary catheter
INCORRECT: Clamping the urinary catheter can increase pressure inside the client’s bladder and cause internal bleeding.

Apply traction to the indwelling urinary catheter
INCORRECT: The nurse should apply traction to the catheter to reduce the risk for bleeding, but this action will not clear the tubing of an obstruction.

Question 64

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

Shellfish

Peanuts

Eggs

Avocados

Answer 64

Shellfish
INCORRECT: Clients who have a shellfish allergy might have an allergic reaction to povidone-iodine.

Peanuts
INCORRECT: Clients who have a peanut allergy might have an allergic reaction to propofol.

Eggs
INCORRECT: Clients who have an egg allergy might have an allergic reaction to propofol.

Avocados
CORRECT: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.

Question 65

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?

Total cortisol 0.9 mcg/dL (5 to 23 mcg/dL)

Amylase 440 units/L (30 to 220 unit/L)

Calcium 7.5 mg/dL (9 to 10.5 mg/dL)

Troponin 18 ng/mL (less than 0.03 ng/mL)

Answer 65

Total cortisol 0.9 mcg/dL (5 to 23 mcg/dL)
INCORRECT: A total cortisol level of 0.9 mcg/dL is less than the expected range. However, a decreased level of cortisol indicates a deficiency of the adrenal, pituitary, or thyroid glands, not an MI.

Amylase 240 units/L (30 to 220 units/L)
INCORRECT: An amylase level of 240 units/L is above the expected range. However, an increased amylase level indicates pancreatitis, not an MI.

Calcium 7.5 mg/dL (9 to 10.5 mg/dL)
INCORRECT: A calcium level of 7.5 mg/dL is below the expected range. However, a decreased calcium level indicates a condition such as renal failure, hypoparathyroidism, or vitamin D deficiency, not an MI.

Troponin 8 ng/mL (less than 0.03 ng/mL)
CORRECT: Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client’s laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.

Question 66

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse’s priority?

Anorexia

Abdominal pain radiating to the right shoulder

Rebound abdominal tenderness

Tachycardia

Answer 66

Anorexia
INCORRECT
Anorexia is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse’s priority.

Abdominal pain radiating to the right shoulder
INCORRECT
Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse’s priority.

Rebound abdominal tenderness
INCORRECT
Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse’s priority.

Tachycardia
CORRECT
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client’s bed flat and report this finding immediately to the provider.

Question 67

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

“I will wash the ink markings off the radiation area after each treatment.”

“I will use my hands rather than a washcloth to clean the radiation area.”

“I will be able to be out in the sun 1 month after my radiation treatments are over.”

“I will use a heating pad on my neck if it becomes sore during the radiation therapy.”

Answer 67

“I will wash the ink markings off the radiation area after each treatment.”
INCORRECT
The ink markings designate the exact radiation area. The client should not remove these markings until they complete the entire radiation treatment.

“I will use my hands rather than a washcloth to clean the radiation area.”
CORRECT
The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

“I will be able to be out in the sun 1 month after my radiation treatments are over.”
INCORRECT
Radiation therapy causes skin to become sensitive to the effects of sun exposure and increases the risk for developing skin cancer. The client should avoid direct sunlight during the radiation treatments and for at least 1 year following the conclusion of the therapy.

“I will use a heating pad on my neck if it becomes sore during the radiation therapy.”
INCORRECT
The client should avoid exposing the treatment area to heat as this can cause further irritation to the skin.

Question 68

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client’s room.

Limit each visitor to 1 hr per day.

Place a dosimeter badge on the client.

Remove soiled linens from the client’s room each day.

Answer 68

“Keep a lead-lined container in the client’s room.”
CORRECT
The nurse should keep a lead-lined container and forceps in the client’s room in case of accidental dislodgement of the implant.

“Limit each visitor to 1 hr per day.”
INCORRECT
The nurse should restrict each visitor to 30 min per day to limit exposure to radiation.

“Place a dosimeter badge on the client.”
INCORRECT
The nurse and other facility staff should wear a dosimeter badge when in the client’s room to monitor their exposure to radiation.

“Remove soiled linens from the client’s room each day.”
INCORRECT
The nurse should keep all soiled linens in the client’s room until the client has had the radiation implant removed.

Question 69

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?

Report of sore throat

Report of memory loss

Alopecia

Mucositis

Answer 69

“Report of sore throat”
CORRECT
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

“Report of memory loss”
INCORRECT
Report of memory loss is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse’s priority. The nurse should provide the client with cognitive training strategies to reduce memory loss.

“Alopecia”
INCORRECT
Alopecia is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse’s priority. The nurse should instruct the client to cover their head to protect from injury due to sunburn or loss of heat.

“Mucositis”
INCORRECT
Mucositis is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse’s priority. The nurse should instruct the client to increase water intake and use a soft toothbrush to reduce mucositis.