NCLEX Review Medical-Surgical Exam - Version A, Exams of Nursing

Download NCLEX Review Medical-Surgical Exam - Version A and more Exams Nursing in PDF only on Docsity! NCLEX Review Medical-Surgical Exam - Version A Your response has been submitted successfully. Points Award ed 26 Points Missed 85 Percentage 23% 1. The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities. Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands (A) which may lead to gangrene. (B, C, and D) are abnormal findings, but do not indicate the development of septic emboli. Points Earned: 0/1 Correct Answer: A Your Response: C 2. A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? A. Xylocaine (Lidocaine). B. Procainami de (Pronestyl). C. Phenytoin (Dilantin). D. Digoxin (Lanoxin). Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, 5. A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement? A. Review the electrocardiogram tracing. B. Obtain blood for coagulation studies. C. Apply a warming blanket. D. Provide heated PO fluids. Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous cardiac monitoring is indicated (A) because hypothermic clients have an increased risk for dysrhythmias. Coagulations studies (A) and re-warming procedures (C and D) can be initiated after a review of the ECG tracing (A). Points Earned: 1/1 Correct Answer: A Your Response: A 6. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? A. Check it again in one month, and if it is still there schedule an appointment. B. Most lumps are benign, but it is always best to come in for an examination. C. Try not to worry too much about it, because usually, most lumps are benign. D. If you are in your menstrual period it is not a good time to check for lumps. (B) provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. (A) postpones treatment if the lump is malignant, and does not relieve the client's anxiety. (C and D) provide false reassurance and do not help relieve anxiety. Points Earned: 0/1 Correct Answer: B Your Response: C 7. A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? A. Determine the client is anxious and allow him to sleep. B. Evaluate his blood pressure, pulse, and respiratory status. C. Review the client's pre-operative history for alcohol abuse. D. Continue to monitor the client for reactivity to anesthesia. Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs (B) will provide information about possible cardiovascular complications, such as stroke. The client's anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated to the client's sudden onset of slurred speech. Points Earned: 1/1 Correct Answer: B Your Response: B 8. A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low- grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea. Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever (A). (B) would be indicative of appendicitis. (C and D) are symptoms exhibited with ulcerative colitis. Points Earned: 1/1 Correct Answer: A Your Response: A 9. A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A. they occur in the lower lobe alveoli which are more sensitive to infection. B. gram-negative organisms are more resistant to antibiotic therapy. C. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. gram-negative pneumonias usually affect infants and small children. The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gram-negative pneumonias affect all lobes of the lung (A). The mean age for contracting this type of pneumonia is 50 years (C and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases. Points Earned: 0/1 Correct Answer: B Your Response: A 10. Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? A. Place HIV positive clients in strict isolation and limit visitors. B. Wear gloves when coming in contact with the blood or body fluids of any client. C. Conduct mandatory HIV testing of those who work with AIDS clients. D. Freeze HIV blood specimens at -70° F to kill the virus. The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from ANY client (B) since HIV is infectious before the client becomes aware of symptoms. (A) is not recommended, nor is it necessary. (C) is very controversial, difficult to enforce, and is not recommended by CDC. (D) does not guarantee to kill the virus. Additionally, the purpose of the blood specimen will determine how it is stored and handled. Points Earned: 0/1 Correct Answer: B Your Response: A compliant with the prescribed diet? A. He visits his diabetic brother who just had surgery to amputate an infected foot. B. He is provided with the most current information about the dangers of untreated diabetes. C. He comments on the community service announcements about preventing complications associated with diabetes. D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. The loss of a limb by a family member (A) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (B, C, and D) may influence his behavior but do not have the personal impact of (A). Points Earned: 0/1 Correct Answer: A Your Response: B 14. The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? A. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. B. Shuffling gait, masklike facial expression, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Numbness of the extremities, loss of balance, and visual disturbances. (B) are common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis. Points Earned: 1/1 Correct Answer: B Your Response: B 15. An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client is most likely to reveal which sign/symptom? A. Leukocytosis and febrile. B. Polycythemia and crackles. C. Pharyngitis and sputum production. D. Confusion and tachycardia. events which result from blood pooling in the fibrillating atria. (A, B, and D) are not indicated. Points Earned: 0/1 Correct Answer: C Your Response: D 18. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? A. Help the client to determine ways to increase his fluid intake. B. Obtain an appointment for the client to see an ear, nose, and throat specialist. C. Schedule an appointment with an allergist to determine if the client is allergic to the cat. D. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen. The nurse should suggest creative methods to increase the intake of fluids (A), such as having disposable fruit juices readily available. Clients with COPD should have at least three liters of fluids a day. These clients often reduce fluid intake because of shortness of breath. (B) is not indicated. These symptoms are not indicative of an allergy (C). Many elderly depend on their pets for socialization and self- esteem. Humidified oxygen will not relieve these symptoms and increased oxygen levels will stifle the COPD client's trigger to breathe (D). Points Earned: 1/1 Correct Answer: A Your Response: A 19. Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma? A. Numbness, tingling, and cramps in the extremities. B. Headache, diaphoresis, and palpitations. C. Cyanosis, fever, and classic signs of shock. D. Nausea, vomiting, and muscular weakness. (B) is the typical triad of symptoms of tumors of the adrenal medulla (symptoms depend on the relative proportions of epinephrine and norepinephrine secretion). (A) lists the signs of latent tetany, exhibited by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism. Points Earned: 0/1 Correct Answer: B Your Response: A 20. The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. She sustained an insect bite to her left arm yesterday. B. She has lost twenty pounds since the surgery. C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not. Points Earned: 1/1 Correct Answer: A Your Response: A 21. After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A. 15 minutes before and 15 minutes after the next dose. B. One hour before and one hour after the next dose. C. 5 minutes before and 30 minutes after the next dose. D. 30 minutes before and 30 minutes after the next dose. Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV. 24. An adult client is admitted to the hospital burn unit with second and third degree burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about third degree burns? A. Regenerative function of the skin is absent because the dermal layer has been destroyed. B. Tissue regeneration will begin several days following return of normal circulation. C. Debridement of eschar will delay the body's ability to regenerate normal tissue. D. Normal tissue formation will be preceded by scar formation for the first year. Third degree burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary (A). (B, C, and D) are simply false. Points Earned: 1/1 Correct Answer: A Your Response: A 25. A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A. Prevention of deformities. B. Avoidance of joint trauma. C. Relief of joint inflammation. D. Improvement in joint strength. Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated. Points Earned: 1/1 Correct Answer: A Your Response: A 26. A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client? A. Avoid high carbohydrate foods. B. Decrease intake of fat soluble D. Chronic use of laxatives. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility. Points Earned: 0/1 Correct Answer: B Your Response: A 31. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to notify the healthcare provider for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside. Calf pain is indicative of thrombophlebitis, a serious, life- threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention (C). (A) are symptoms of oral contraceptive use, but are of less immediacy than (C). (B) may cause an embolism if thrombophlebitis is present. By not seeking immediate attention, (D) is potentially dangerous to the client. Points Earned: 0/1 Correct Answer: C Your Response: A 32. The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's A. serum digoxin level is 1.5. B. blood pressure is 104/68. C. serum potassium level is 3. hours. The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures (B), and treatment options should be provided. In-depth pathophysiology of the symptoms (A) may only confuse the client. There is no indication that the client has tuberculosis and an infection, so (C and D) are not indicated. Points Earned: 0/1 Correct Answer: B Your Response: A 35. An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion? A. Pain in the calf awakening him from a sound sleep. B. Calf pain on exertion which stops when standing in one place. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D. Pain upon arising in the morning which is relieved after some stretching and exercise. Thrombophlebitis pain is relieved by rest and elevation of the extremity (C). It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place (B). (A and D) describe pain that is not common with thrombophlebitis. Points Earned: 0/1 Correct Answer: C Your Response: A 36. A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? A. The vaccine is given annually before the flu season to those over 50 years of age. B. The immunization is administered once to older adults or persons with a history of chronic illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re- vaccination is sometimes required. Points Earned: 0/1 Correct Answer: B Your Response: A 37. Which client should the nurse recognize as most likely to experience sleep apnea? A. Middle-aged female who takes a diuretic nightly. B. Obese older male client with a short, thick neck. C. Adolescent female with a history of tonsillectomy. D. School-aged male with a history of hyperactivity disorder. Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea. Points Earned: 0/1 Correct Answer: B Your Response: D 38. The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) A. Remove the diaphragm immediately after intercourse. male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? A. Ask the client what he means by "heart trouble." B. Call for an ECG to be performed immediately. C. Notify surgery that the ECG is over two years old. D. Notify the client's surgeon immediately. Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (B) should be implemented to ensure that the client's current cardiovascular status is stable. Additional data might be valuable (A), but since time is limited, the priority is to obtain the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (D). Points Earned: 0/1 Correct Answer: B Your Response: A 41. The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound. B. If the family would prefer a private or semi- private room. C. If the client also has a Hemovac® in place. D. If the client's wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most important to place an infected client in a private room (D). A penrose drain does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a dead space and is not important in choosing a room. provide insurance coverage for their employees. In return, the insurance company receives a large pool of clients for their facilities. (A, B, and D) are not accurate representations of the PPO. Points Earned: 0/1 Correct Answer: C Your Response: B 44. In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? A. Genetic counseling. B. Twelve-step recovery program. C. Clinical nutritionist. D. Smoking cessation program. Buerger's disease is strongly related to smoking. The most effective means of controlling symptoms and disease progression is through smoking cessation (D). The cause of Buerger's disease is unknown; a genetic predisposition is possible, but (A) will not be of value. The client with Buerger's disease does not need referral to a 12-step program any more than the general population (B). Diet is not a significant factor in the disease, and general healthy diet guidelines can be provided by the nurse (C). Points Earned: 0/1 Correct Answer: D Your Response: A 45. What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? A. Observe cyst size fluctuations as a sign of malignancy. B. Use estrogen supplements to reduce breast discomfort. C. Notify the healthcare provider if whitish nipple discharge occurs. D. Perform a breast self-exam (BSE) procedure monthly. Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE (D) and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen (B), which is not indicated. Nipple discharge associated with fibrocystic breasts is often milky or watery-milky and is an expected finding (C). Points Earned: 0/1 Correct Answer: D Your Response: A 46. A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? A. Information about smoking cessation. B. Diet instructions for a low-residue diet. C. Instructions on a weight-loss program. D. The importance of increasing milk in the diet. Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management (A). Diet management includes a reduction in high-fiber/high-roughage foods as well as spicy foods. (B) would be indicated for inflammatory bowel disease. Sodium and caloric intake are not the key elements in an ulcer diet. Although this client does need (C), the management of his ulcer is the key factor at this point. (D) would actually increase gastric acid production. Points Earned: 1/1 Correct Answer: A Your Response: A 47. A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer? A. Adenocarcinoma. B. Oat-cell carcinoma. C. Malignant melanoma. D. Squamous- cell carcinoma. Adenocarcinoma is the only lung cancer not related to cigarette smoking (A). It has been found to be directly related (D), is common with diabetics, but when the serum glucose is decreased, new onset numbness can possibly improve. Points Earned: 1/1 Correct Answer: B Your Response: B 50. A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? A. Impaired communication related to paralysis of skeletal muscles. B. High risk for infection related to increased intracranial pressure. C. Potential for injury related to impaired lung expansion. D. Social isolation related to inability to communicate. To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. Impaired communication (A) is a serious outcome because the client cannot communicate his/her needs. Although this client might also experience (D), it is not a priority when compared to (A). Infection is not related to increased intracranial pressure (B). The respirator will ensure that the lungs are expanded (C). Points Earned: 0/1 Correct Answer: A Your Response: B 51. A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse recommend the client return for repeat blood testing? A. 6 to 18 month s. B. 1 to 12 month s. C. 1 to 18 weeks. D. 6 to 12 weeks. Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to repeat the serum screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests positive. (B and C) may provide are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause. Although all of the women described have one of the risk factors for developing breast cancer, (B) has the greater risk over (A, C, and D). Points Earned: 0/1 Correct Answer: B Your Response: A 56. While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? A. Immediately after the exposure. B. Within one week of the exposure. C. Four to six weeks after the exposure. D. Three months after the exposure. A tuberculin skin test is effective 4 to 6 weeks after an exposure (C), so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test. Points Earned: 0/1 Correct Answer: C Your Response: A 57. A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client A. have her own teeth or dentures?" B. take aspirin and if so, how much?" C. take nitroglycerin?" D. take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant. Points Earned: 0/1 Correct Answer: D Your Response: C 58. A client taking furosemide (Lasix), reports difficulty sleeping. femur? A. Failing eyesight resulting in an unsafe environment. B. Renal osteodystrophy resulting from chronic renal failure. C. Osteoporosis resulting from hormonal changes. D. Cardiovascular changes resulting in small strokes which impair mental acuity. The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in later life (C). (A) may or may not have contributed to the accident, but it had nothing to do with the hip being involved. (B) is not a common condition of the elderly; it is common in chronic renal failure. (D) may occur in some people, but does not affect the fragility of the bones as osteoporosis does. Points Earned: 0/1 Correct Answer: C Your Response: A 61. Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color? A. Black. B. White. C. Light green. D. Mediu m yellow. Yellow is the easiest for a person with failing vision to see (D). (A) will be almost impossible to see at night because the shadows of the steps will be too difficult to determine, and would pose a safety hazard. (B) is very hard to see with a glare from the sun and it could hurt the eyes in the daytime to look at them. (C) is a pastel color and is difficult for elderly clients to see. Points Earned: 0/1 Correct Answer: D Your Response: A 62. Which assessment finding by the nurse during a client's clinical breast examination requires follow- up? A. Newly retracted nipple. B. A thickened area where the skin folds under the breast. C. Whitish nipple discharge. D. Tender lumpiness noted bilaterally throughout the breasts. A newly retracted nipple (A), compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up. The inframammary ridge (B) is a normal anatomic finding. Up to 80% of women may experience an intermittent nipple discharge (C), especially related to recent stimulation, and in most cases, nipple discharge is not related to malignancy. (D) is a classic finding for fibrocystic breast disease, a benign condition. Points Earned: 0/1 Correct Answer: A Your Response: B 63. Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A. Breasts feel lumpy when palpated. B. History of white nipple discharge. C. Episodes of vaginal bleeding. D. Excessive diaphoresis occurs at night. Postmenopausal vaginal bleeding (C) may be an indication of endometrial cancer, which should be reported to the healthcare provider. Compared to a new-onset of a single lump, breasts that feel lumpy (A) overall may be a normal variant or a finding consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B), depending on sexual stimulation or hormonal levels, and is no longer recommended as a reportable symptom when discovered during breast self-exam (BSE). The client may need further teaching concerning (D), a disturbing symptom, but it is not as important as (C). Points Earned: 0/1 Correct Answer: C Your Response: A 64. A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? cause of the bradycardia? A. Propanolol (Inderal). B. Captopril (Capoten). C. Furosemide (Lasix). D. Dobutamin e (Dobutrex) . Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate. Points Earned: 1/1 Correct Answer: A Your Response: A 67. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? A. Facial flushing. B. Fever. C. Pounding headach e. D. Feelings of dizziness. Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output (D). (A and C) will not occur as the result of pacemaker failure. (B) may be an indication of infection postoperatively, but is not an indication of pacemaker failure. Points Earned: 0/1 Correct Answer: D Your Response: C 68. What is the correct procedure for performing an ophthalmoscopic examination on a client's right eye? A. Instruct the client to look at examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to begin (creates no correction at the beginning of the exam), and should be held in front of the examiner's left eye when examining the client's right eye. For optimum visualization, the ophthalmoscope should be kept within one inch of the client's eye (C). (A, B, and D) describe incorrect methods for conducting an ophthalmoscopic examination. Points Earned: 0/1 Correct Answer: C Your Response: D 69. Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system? A. Pupil constriction. B. Increased heart rate. C. Bronchial constriction. D. Decreased blood pressure. Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a flight-or- fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system. Points Earned: 0/1 Correct Answer: B Your Response: A 70. The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? A. Prepare the client for transcutaneous pacemaker. B. Shock the client with 200 joules per hospital policy. C. Use a magnet to deactivate the implanted pacemaker. D. Observe the monitor until the onset of associated with reduced hormonal levels. x Points Earned: 0/1 Correct Answer: C Your Response: D 73. Which milestone indicates to the nurse successful achievement of young adulthood? A. Demonstrates a conceptualization of death and dying. B. Completes education and becomes self-supporting. C. Creates a new definition of self and roles with others. D. Develops a strong need for parental support and approval. Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self- supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay. Points Earned: 0/1 Correct Answer: B Your Response: A 74. The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide? A. This recessive disorder is carried only on the X chromosome. B. Occurrences mainly affect males and heterozygous females. C. Both genes of a pair must be abnormal for the disorder to occur. D. One copy of the abnormal gene is required for this disorder. Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A and B) dominant or recessive disorder or an autosomal dominant inheritance disorder. Both genes of a pair, not (D), must be present. Points Earned: 0/1 Correct Answer: C Your Response: A information should the nurse provide? A. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). B. Getting pregnant while using an IUD is common and is not the best contraceptive choice. C. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. D. Selecting a contraceptive device should consider choosing a successful method used in the past. The use of an IUD provides the client with no protection from STDs (A). While pregnancy rates with the use of an IUD are somewhat higher, (B) is not therapeutic, but judgmental. (C) is judgmental and does not provide the client any information about use of an IUD. While talking about contraceptives may include (D), it is does not provide the best information to maintain the client's health. Points Earned: 0/1 Correct Answer: A Your Response: D 78. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy? A. An increase in abdominal girth. B. Hypertension and a bounding pulse. C. Decreased bowel sounds. D. Difficulty in handwriting. A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level which is the primary cause of hepatic encephalopathy. Points Earned: 0/1 Correct Answer: D Your Response: A 79. In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Sodium. B. Antidiureti c hormone. C. Potassium. D. Glucose. Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia)--hypertension is the most prominent and universal sign. (A) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (B) is decreased with diabetes insipidus. (D) is not affected by primary aldosteronism. Points Earned: 0/1 Correct Answer: C Your Response: B 80. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? A. Give 20 mEq of potassium chloride. B. Initiate continuous cardiac monitoring. C. Arrange a consultation with the dietician. D. Teach about the side effects of diuretics. Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring (B) to identify ventricular ectopy or other life- threatening dysrhythmias. Potassium chloride (A) should be given after cardiac monitoring is initiated so that the effects of potassium replacement on the cardiac rhythm can be monitored. (C and D) should be implemented when the client is stable. Points Earned: 1/1 Correct Answer: B Your Response: B 81. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? offer? A. Osteoporosis is a progressive genetic disease with no effective treatment. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. C. Estrogen replacement therapy should be started to prevent the progression osteoporosis. D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can prevent further bone loss (B). Osteoporosis can be managed with conservative therapy, such as bone metabolism regulators and estrogen replacement therapy (ERT) to improve bone density, but it is not a genetic disease (A). Although ERT is effective in managing osteoporosis, an increased risk for cancer and heart disease should be considered for individual clients. Corticosteroid therapy promotes bone resorption and is counterproductive in maintaining or increasing bone density (D). Points Earned: 0/1 Correct Answer: B Your Response: D 84. The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? A. Have you ever experienced any paralysis of your arms or legs? B. Have you ever sustained a severe head injury? C. Have you ever been 'frozen' in one spot, unable to move? D. Do you have headaches, especially ones with throbbing pain? Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not cause (A). Parkinson's disease is not usually associated with (B), nor does it typically cause (D). Points Earned: 0/1 Correct Answer: C Your Response: A 85. The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor. Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular destruction. In CRF, an increase in serum nitrogenous waste products, electrolyte imbalances, and demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath related to the accumulation of blood urea nitrogen and is a common complication of CRF, but not as significant as hyperkalemia. Points Earned: 1/1 Correct Answer: A Your Response: A 86. The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement? A. Administer 30 minutes before eating. B. Evaluate the effectiveness 1 hour after administration. C. Instruct the client to swallow the tablet whole. D. Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with renal failure due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse (D). (A, B, and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox). Points Earned: 0/1 Correct Answer: D Your Response: A 87. Which information about mammograms is most important to provide a post-menopausal female Points Earned: 0/1 Correct Answer: D Your Response: B 89. In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) A. Set the infusion pump to infuse the albumin within four hours. B. Compare the client's blood type with the label on the albumin. C. Assign a UAP to monitor blood pressure q15 minutes. D. Administer through a large gauge catheter. E. Monitor hemoglobin and hematocrit levels. F. Assess for increased bleeding after administration. (A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin administration does not require blood typing (B). Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bleeding (F). Points Earned: 0/4 Correct Answer: A, D, E, F Your Response: B 90. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? A. Apply sequential compression devices (SCDs) bilaterally. B. Assess for a positive Homan's sign in each leg. C. Pad all bony prominences on the affected leg. D. Advise the client to remain in bed with the leg elevated. The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care includes bedrest and elevation of the extremity (D). SCDs are used to prevent thrombophlebitis, not for treatment, when a clot might be dislodged (A). Once a client has thrombophlebitis, (B) is contraindicated because of the possibility of dislodging a clot. (C) is indicated to prevent pressure ulcers, but is not a therapeutic action for thrombophlebitis. Points Earned: 0/1 Correct Answer: D Your Response: 91. A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? A. Amount of weight gain or weight loss during the previous year. B. An accurate menstrual cycle diary for the past 6 to 12 months. C. Skin pigmentation and hair texture for evidence of hormonal changes. D. Previous birth-control methods and beliefs about the calendar method. The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and compliancy of a menstrual diary (B) is the basis of the calendar method. (A and C) may be partially related to hormonal fluctuations but are not indicators for using the calendar method. (D) may demonstrate client understanding and compliancy but is not the most important aspect. Points Earned: 0/1 Correct Answer: B Your Response: A 92. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A. White blood count of 10,000 mm3. B. Serum glucose of 115 mg/dl. C. Purulent sputum. D. Excessive hunger. Steroids cause immunosuppression, and a purulent sputum (C) Your Response: A 95. A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A. Fluid and electrolyte balance. B. Prevention of water toxicity. C. Reduced glucose in the urine. D. Adequate cellular nourishment. Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy, so the outcome statement should include stabilization of adequate cellular nutrition (D). (A, B, and C) relate to subsequent osmolar fluid shifts related to glucosuria, polyuria, and polydipsia. Points Earned: 0/1 Correct Answer: D Your Response: A 96. A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A. Stage II. B. Invasive infiltrating ductal carcinoma. C. T1N0M0. D. Inflammatory with peau d'orange. Inflammatory breast cancer, which has a thickened appearance like an orange peel (peau d'orange), is the most aggressive form of breast malignancies (D). Staging classifies cancer by the extension or spread of the disease, and (A) indicates limited local spread. (B) indicates cancer cells have spread from the ducts into the surrounding breast tissue only. TNM classification is used to indicate the extent of the disease process according to tumor size, regional spread lymph nodes involvement, and metastasis, and (C) indicates early cancer with small in situ involvement, no lymph node involvement, and no distant metastases. Points Earned: 0/1 Correct Answer: D Your Response: 97. A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis. Treatment decisions (C) and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well- differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer, not (A). Larger tumors are more likely to indicate poor prognosis, not (B). Stage I indicates the cancer is localized and has not spread systemically (D). Points Earned: 0/1 Correct Answer: C Your Response: A 98. The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? A. Diabetes mellitus. B. Hypothyroidism. C. Parkinson 's disease. D. Recurring pneumoni a. A history of diabetes mellitus poses the greatest risk for developing a CVA (A). (B, C, and D) may place the client at some risk due to immobility, but do not present a risk as great as (A). 101. A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect this client to exhibit? A. Elevated LDH. B. Elevated serum amylase. C. Elevated CK-MB. D. Elevated hematocrit. The cardiac isoenzyme CK-MB (C) is the most sensitive and most reliable indicator of myocardial damage of all the cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac enzyme that peaks around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be expected in a client with a fluid volume deficit, which is not a typical finding in MI. Points Earned: 1/1 Correct Answer: C Your Response: C 102. A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A. The dosage of the diuretic will be decreased. B. The diuretic will be discontinued. C. A potassium supplement will be prescribed. D. The dosage of the diuretic will be increased. This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level (C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level. Points Earned: 0/1 Correct Answer: C Your Response: B 103. A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity Correct Answer: D Your Response: B 107. Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. Hematuria. B. 2 pounds weight gain. C. 3+ bacteria in urine. D. Steady, dull flank pain. Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine (C) is the most significant finding at this time. (A) is an expected finding from the rupture of the cysts. (B) does not provide a time frame to determine if the weight gain is a significant fluid fluctuation, which is determined within a 24- hour time frame. Although kidney pain can also be abrupt, episodic, and colicky related to bleeding into the cysts, (D) is more likely an early symptom in PKD. Points 0/1 Earned: Correct C Answer: Your B Response: