NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial Alterations Nursing



1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:

a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed


2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?

a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like


3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

a. Check respiration, circulation, neurological response.
b. Align the spine, check pupils, and check for hemorrhage.
c. Check respirations, stabilize spine, and check circulation.
d. Assess level of consciousness and circulation.


4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

a. Increasing contractility and slowing heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen consumption.
d. Decreasing venous return through vasodilation.


5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.


6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.


7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.


8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.


9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.


10.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to sleep immediately.
d. The client refuses dinner because of anorexia.


11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough


12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia


13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema


14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own


15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity


16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?

a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).


17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.


18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.


19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump


20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses


21. When caring for a female client who is being treated for hyperthyroidism, it is important to:

a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
c. Balance the client’s periods of activity and rest.
d. Encourage the client to be active to prevent constipation.


22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

a. Avoid focusing on his weight.
b. Increase his activity level.
c. Follow a regular diet.
d. Continue leading a high-stress lifestyle.


23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.


24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?

a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel movement or bending at the waist.


25. George should be taught about testicular examinations during:

a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.


26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:

a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.


27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:

a. A progressively deeper breaths followed by shallower breaths with apneic periods.
b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses.
d. Shallow breathing with an increased respiratory rate.


28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs


29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this
change is that:

a. The attack is over.
b. The airways are so swollen that no air cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.


30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

a. Place the client on his back remove dangerous objects, and insert a bite block.
b. Place the client on his side, remove dangerous objects, and insert a bite block.
c. Place the client o his back, remove dangerous objects, and hold down his arms.
d. Place the client on his side, remove dangerous objects, and protect his head.


31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage


32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:

a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.


33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?

a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.


34. When performing oral care on a comatose client, Nurse Krina should:

a. Apply lemon glycerin to the client’s lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed lowered.
d. Clean the client’s mouth with hydrogen peroxide.


35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis


36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?

a. A 16-year-old female high school student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a history of alcoholism
d. A 54-year-old businessman


37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection


38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids


39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema


Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.

40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

a. The patient is under local anesthesia during the procedure
b. The aspirated bone marrow is mixed with heparin.
c. The aspiration site is the posterior or anterior iliac crest.
d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.


41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

a. Call the physician
b. Document the patient’s status in his charts.
c. Prepare oxygen treatment
d. Raise the side rails


42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells.


43. Diagnostic assessment of Francis would probably not reveal:

a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts


44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?

a. Explain the risks of not having the surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the nurses’ notes


45. During the endorsement, which of the following clients should the on-duty nurse assess first?

a. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)


46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines


47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?

a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes


48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name?

a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy


49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
c. Can't assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis


50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma care initially until you get used to the procedure."
d. "Keep the stoma moist."


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

a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer


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

a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
d. hoarseness and dysphagia.


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

a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.


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

a. "Avoid drinking liquids until the gag reflex returns."
b. "Avoid eating milk products for 24 hours."
c. "Notify a nurse if you experience blood in your urine."
d. "Remain supine for the time specified by the physician."


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

a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan


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

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


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

a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)


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

a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.


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

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


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

a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness


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

a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis


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

a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour


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

a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus


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

a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.


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

a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t


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

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


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

a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.


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

a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)


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

a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid


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

a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.


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

a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia


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

a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered


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

a. urine glucose level.
b. fasting blood glucose level.
c. serum fructosamine level.
d. glycosylated hemoglobin level.


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

a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm


75. The adrenal cortex is responsible for producing which substances?

a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine


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

a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia


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

a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level


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

a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice


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

a. The baby can get the virus from my placenta."
b. "I'm planning on starting on birth control pills."
c. "Not everyone who has the virus gives birth to a baby who has the virus."
d. "I'll need to have a C-section if I become pregnant and have a baby."


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

a. "Put on disposable gloves before bathing."
b. "Sterilize all plates and utensils in boiling water."
c. "Avoid sharing such articles as toothbrushes and razors."
d. "Avoid eating foods from serving dishes shared by other family members."


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

a. Pallor, bradycardia, and reduced pulse pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia


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

a. Page an anesthesiologist immediately and prepare to intubate the client.
b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs.
d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.


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

a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.


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

a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte


85. In an individual with Sjögren's syndrome, nursing care should focus on:

a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.


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

a. enzyme-linked immunosuppressant assay (ELISA) test.
b. electrolyte panel and hemogram.
c. stool for Clostridium difficile test.
d. flat plate X-ray of the abdomen.


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

a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.


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

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


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

a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC) count
c. Thrombin time, calcium levels, and potassium levels
d. Fibrinogen level, WBC, and platelet count


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

a. Bread
b. Carrots
c. Orange
d. Strawberries


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

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


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

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


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

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


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

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


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

a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the client on the left side.
d. Insert a Foley catheter


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

a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.


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

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


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

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


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

a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.


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

a. Encourage the client to perform pursed lip breathing.
b. Check the client’s temperature.
c. Assess the client’s potassium level.
d. Increase the client’s oxygen flow rate.



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