Critical Thinking Nursing Care

Compiled by Zudota
Identify the letter of the choice that best completes the statement or answers
the question.
____ 1. Which action by the nurse demonstrates understanding of a best
practice intervention for client education?
a. Breaking complex skills into small parts
b. Using only visual and oral educational aids
c. Providing standardized educational information
d. Using client goals developed by the nursing staf
1. ANS: A
Best practices for adult learning include the following: breaking complex skills
and information into small parts; assessing willingness to learn, including
family/significant others in the education as appropriate; assessing factors
that may influence learning, such as educational level; using psychomotor
skills in addition to visual aids to enhance learning; and providing the client
with a contact for follow-up questions.
____ 2. How have recent changes in health care delivery afected practice
settings for medical-surgical nurses?
a. Third-party payment systems have restricted the delivery of medicalsurgical nursing services to acute care hospitals.
b. Managed care organizations prefer less expensive care delivered by
unlicensed personnel.
c. Medical-surgical nursing is practiced in community centers and long-term
care facilities.
d. The delivery of medical-surgical nursing practice is now limited to adults
only.
2. ANS: C
Medical-surgical nursing is practiced in a wide variety of settings. Although
hospitals remain the largest employer of nurses, community-based integrated
health care centers and long-term care facilities also require nurses with
medical-surgical nursing experience.
____ 3. Which of the following nursing home facilities ofers the residents a
range of services from independent living to skilled nursing care?
a. Skilled nursing facilities
b. Chronic care facilities
c. Residential facilities
d. Nursing facilities
3. ANS: C

Residential facilities, which include rest homes and assisted living or

continuing care facilities, can provide a continuum of services ranging from
independent living to skilled care. Nursing facilities provide custodial care;
skilled nursing facilities and chronic care facilities provide services requiring
licensed health care professionals.
____ 4. Which client is likely to require transitional subacute care before being
discharged home?
a. The client with stable human immunodeficiency virus infection
b. The client with a progressive neurologic disease
c. The client requiring deep wound management
d. The client who is ventilator dependent
4. Ans. C Although clients requiring subacute care can encompass all these
conditions, transitional care is considered an alternative to prolonged hospital
stay before discharge home or a long term care facility. Transitional subacute
care is provided to continued management before discharge, The stable
client with HIV infection would receive medical/surgical subacute care
whereas the client who is ventilator dependent or who has a progressive
neurologic disorder would require chronic subacute are.
____ 5. A nurse is caring for an older client who has just been admitted to the
hospital. Upon admission the client becomes increasingly confused, agitated,
and combative. What action should the nurse take to minimize relocation
stress syndrome in this client?
a. Reorient the client frequently to his or her location.
b. Obtain a certified sitter to remain with the client.
c. Speak to the client as little as possible to avoid overstimulation.
d. Provide adequate sedation for all procedures to avoid fear-provoking
situations.
5. ANS: A
There are many nursing interventions that can be helpful to older adults who
experience relocation stress syndrome. If the client becomes confused,
agitated, or combative, the nurse should reorient the client to his or her
surroundings. The nurse also can encourage family members to visit often,
keep familiar objects at the clients bedside, and work to establish a trusting
relationship with the client.
____ 6. An older client confides feeling a loss of control over life after having a
mild stroke. What would be the best action the nurse could take to support
this client?
a. Explain to the client that such feelings are normal, but that he or she must
have realistic expectations for rehabilitation.
b. Encourage the client to perform as many tasks as possible and to
participate in decision making.
c. Further assess the clients mental status for other signs of denial.
d. Obtain an order for physical and occupational therapy.
6. ANS: B

Older adults can experience a number of losses that afect their sense of
control over their lives, including a decrease in physical mobility. The nurse
should support the clients self-esteem and increase feelings of competency
by encouraging activities that assist in maintaining some degree of control,
such as participation in decision making and performing tasks they can
manage.
____ 7. Which behavior exhibited by an older adult client should alert the
nurse to the possibility that the client is experiencing delirium?
a. The client becomes confused within 24 hours after hospital admission.
b. The client displays a cheerful attitude despite a poor prognosis.
c. The client becomes depressed and sleeps most of the day.
d. The client begins to use slurred speech.
7. ANS: A
Delirium is characterized by acute confusion that is usually short term.
Delirium can result from placement in unfamiliar surroundings, such as being
hospitalized.
____ 8. Which statement regarding chronic pain is true?
a. Physiologic adaptation occurs so that manifestations of tachycardia and
elevated blood pressure are not present.
b. The person with chronic pain experiences local nerve adaptation so that
the intensity of chronic pain diminishes over time.
c. Chronic pain allows for better psychosocial adaptation over time, and the
client has a reduction in the perception of pain.
d. Morphine and morphine agonists are not efective for chronic pain because
the cells involved in neuromodulation are no longer responsive.
8. ANS: A
The pain manifestations of tachycardia and increased blood pressure occur
with acute pain as a result of activation of the stress response. The stress
response uses much energy and is a relatively short-term response, with
physiologic adaptation occurring over time. The absence of tachycardia or
blood pressure changes in a client with chronic pain do not correlate to a
decreased perception of intensity of pain.
____ 9. The client with cholecystitis also has pain in the right shoulder blade
area. The client expresses concern that a new problem is occurring. What is
the nurses best response to this client situation?
a. Reposition the client on the left side and then check the muscle strength,
capillary refill, and touch sensation in the right hand and arm.
b. Explain to the client that problems in the gallbladder area often are
transmitted by nerves in the area with many branches and can be felt as pain
in the shoulder area.
c. Withhold the next dose of analgesic until the source of the pain is
identified.
d. Notify the physician of the new complaint.
9. ANS: B

Many types of visceral pain can be felt. felt in body areas other than the
originating site; this is known as referred pain. Pain originating in the
gallbladder can be referred to the right posterior shoulder. The client should
be reassured that this is normal and medicated appropriately.
____ 10. An unconscious client who has just been involved in a motor vehicle
accident is brought to the emergency department. Which presenting clinical
manifestation makes the nurse suspicious of an opioid overdose rather than
increased intracranial pressure as a cause of the unconsciousness?
a. Pinpoint pupils
b. Respiratory depression
c. Hyporeflexive deep tendon reflexes
d. Evidence that the client has vomited
10. ANS: A
Morphine and other opioids bind tightly to the mu () opioid receptor, which
causes pupillary constriction. Head injuries resulting in increased intracranial
pressure cause pupillary dilation. A symptom of withdrawal from opioids is
pupillary dilation.
____ 11. Which intervention is compatible with the goals for end-of-life care?
a. Administering a flu shot
b. Preventing the client with COPD from smoking
c. Performing passive range-of-motion exercises to prevent contractures
d. Permitting the client with diabetes mellitus to have a serving of ice cream
11. ANS: D
The goals of end-of-life care are to control distressing symptoms, promote
meaningful interactions between the client and significant others, and
facilitate a peaceful death. Measures that prolong life are discontinued when
they interfere with the client's comfort or pleasure.
____ 12. Which statement regarding disability and chronic illness is true?
a. Disabilities and chronic illnesses occur most often in young adults.
b. Accidents are responsible for more chronic and disabling conditions than
chronic disease.
c. In the United States, one in seven persons experiences activity limitations
because of chronic health problems.
d. Men experience more disability than women, but women experience a
higher incidence of chronic illness than men.
12. ANS: C
In the United States, approximately 50% of the population has one or more
chronic health problems, and about 35 million people (one in seven)
experience some activity limitations because of their chronic health
problems.
____ 13. The client who has been found to have a mutation in the BRCA1 gene
allele and an increased risk for breast and ovarian cancer has asked you to be

present when she discloses this information to her grown daughter. What is
your role in this situation?
a. Primary health care provider
b. Genetic counselor
c. Client advocate
d. Client support
13. ANS: D
You are supporting the client emotionally while she tells her daughter the
information she has learned about the test results. You are not interpreting
the results nor are you counseling the client or her daughter about what
steps to take next.
____ 14. What is the primary survey?
a. Airway, breathing, circulation, head to toe assessment
b. Airway, breathing, circulation, neurologic assessment
c. Airway and cervical spine control, breathing, circulation, disability,
exposure
d. Airway and cervical spine control, breathing, circulation, head to toe
assessment
14. ANS: C
The primary survey for a trauma client organizes the approach to the client
so that life-threatening injuries are rapidly identified and managed. The
primary survey is based on the standard mnemonic ABC, with an added D
and E. A, airway and cervical spine control, B, breathing, C, circulation, D,
disability, E, exposure.
____ 15. What statement best describes the basic concept of mass causality
the basic concept of mass causality triage?
a. The greatest good for the greatest amount of people
b. First come, first served
c. Women and children first
d. First priority to the most critical
15. ANS: A
Triage for a mass causality incident difers from civilian triage in that its
main goal is to provide the most efective care for the greatest number of
people. Clients are classified into one of four categories: emergent, urgent,
nonurgent, or expected to die. Clients who are classified as expected to die
would not be assigned first priority in a mass causality situation.
____ 16. A client has sufered a snakebite (North American pit viper) to a
lower extremity. What would be the most appropriate nursing intervention?
a. Apply ice to the bite site immediately.
b. Attempt to capture the snake for later identification.
c. Immobilize the extremity in a position of function.
d. Incise the bite and suck out the venom.
16. ANS: C
The afected extremity should be immobilized in a position of function to limit
the spread of venom. The extremity should not be elevated but should be
kept below the level of the heart.

____ 17. The primary first aid intervention in the prehospital setting for a
black widow spider bite is the application of ice. Which statement provides
the best rationale for this intervention?
a. Ice inhibits the action of neurotoxin.
b. Ice reduces swelling in the afected extremity.
c. Ice decreases venous return from the afected extremity.
d. Ice decreases the pain associated with spider bites.
17. ANS: A
Ice inhibits the action of neurotoxin and should be the first intervention
provided to a client bitten by a black widow spider.
____ 18. What efect would an infusion of 200 mL of albumin have on a
healthy client's plasma osmotic and hydrostatic pressures?
a. Increased osmotic pressure, increased hydrostatic pressure
b. Increased osmotic pressure, decreased hydrostatic pressure
c. Decreased osmotic pressure, increased hydrostatic pressure
d. Decreased osmotic pressure, increased hydrostatic pressure
18. ANS: A
The addition of albumin to the plasma would add a colloidal substance that
does not move into the interstitial space. Thus, the osmotic pressure would
immediately increase. Not only does the additional 200 mL add to the plasma
hydrostatic pressure, but the increased osmotic pressure would draw water
from the interstitial space, increasing the plasma volume and ultimately
leading to increased hydrostatic pressure in the plasma volume.
____ 19. Which specific condition triggers the "thirst" center in the
hypothalamus?
a. Hyperosmolar extracellular fluid
b. Hypo-osmolar extracellular fluid
c. Elevated serum potassium level
d. Decreased serum potassium level
19. ANS: A
The thirst mechanism is triggered when the osmoreceptors of the
hypothalamus detect that the extracellular fluid is hyperosmolar, especially
when the serum sodium level is elevated. Other conditions that trigger the
thirst centers include hypotension and hypoxemia.
____ 20. Why is sterile pure water not usually ordered as an intravenous fluid?
a. It would suppress the client's natural thirst reflex.
b. It would cause red blood cells to swell and break.
c. It would cause red blood cells to shrink and crenate.
d. It would cause overstimulated ADH secretion.
20. ANS: B
Pure water is hypotonic compared to normal body fluids. Thus if water were
administered intravenously, the plasma would become hypotonic compared

with red blood cells. The red blood cells would take up the hypotonic fluid,
swell, and lyse open.
____ 21. Which intervention is most important for the nurse to teach the client
who has lymphedema in her right arm from a mastectomy 1 year ago?
a. Exercise your arm and use it during tasks that occur at the level of your
chest or higher.
b. Be sure to use sunscreen or protective clothing to reduce the risk of
injuring this arm.
c. Reduce your salt intake to prevent excess water retention.
d. Do not expose the right arm to temperature extremes.
21. ANS: A
Skeletal muscle contractions facilitate flow in lymph channels. Keeping the
arm at chest level or higher prevents stasis of lymph fluid from gravitational
forces.
____ 22. Which is the most important question the nurse should ask the client
who has been diagnosed with isotonic dehydration to identify a possible
cause of the fluid imbalance?
a. Do you take diuretics or 'water pills'?
b. What and how much do you normally eat over a day's time?
c. How many bowel movements do you usually have each day?
d. Have you or any member of your family been diagnosed with diabetes
mellitus?
22. ANS: A
Misuse or overuse of diuretics is a common cause of isotonic dehydration.
____ 23. Which intervention for the client with overhydration-induced
confusion is most likely to relieve the confusion?
a. Measuring intake and output
b. Slowing the IV flow rate to 50 mL/hour
c. Administering diuretic agents as prescribed
d. Placing the client in modified Trendelenburg position (feet and legs
elevated; head and chest flat)
23. ANS: C
Overhydration most frequently leads to poor neuronal function, causing
confusion as a result of electrolyte imbalances (usually sodium dilution).
Eliminating the fluid excess is the best way to reduce confusion.
____ 24. Which nursing intervention would be most efective in preventing
injury in a hospitalized client with hypocalcemia of long duration?
a. Teaching the client to wear shoes when ambulating
b. Applying antiembolic stockings on the client's legs
c. Placing an egg-crate mattress on the clients bed
d. Using a lift sheet when moving the client in bed
24. ANS: D
Prolonged hypocalcemia results in loss of bone calcium, making the bones
brittle and fragile. Using a lift sheet when moving the client rather than
grasping or pulling the client helps prevent fractures.

____ 25. The client with hypophosphatemia who is undergoing intravenous

phosphorus replacement suddenly has a positive Trousseau sign. What is the
correct interpretation of this finding?
a. The client is dehydrated.
b. The hypophosphatemia is worsening.
c. The phosphorus replacement is causing hypocalcemia.
d. Rehydration is too rapid and overhydration is occurring.
25. ANS: C
Calcium and phosphorus exist in the blood in a balanced, reciprocal
relationship. When the blood level of one increases, the other decreases.
Thus, rapid correction of hypophosphatemia can cause hypocalcemia.
____ 26. What adjustment in transfusion therapy needs to be made in order to
deliver packed red blood cells (PRBCs) through a PICC?
a. The transfusion set does not contain a filter.
b. The PRBCs must be delivered with the use of a pump.
c. Ringers lactate rather than normal saline must be the primary infusion
fluid.
d. Each unit of PRBCs must be completely infused within 1 hour of starting
the transfusion.
26. ANS: B
Infusion of packed red blood cells is considerable slower through a PICC. The
blood product is cold and viscous. The length of the PICC adds resistance and
may prevent the blood from infusing within the 4-hour limitation. Therefore, a
pump is needed to ensure adequate flow rates.
____ 27. Which complication should the nurse assess for in a client receiving
epidural therapy with either an opioid or a local anesthetic agent?
a. Numbness and tingling at the insertion site
b. Loss of consciousness
c. Urinary retention
d. Constipation
27. ANS: C
Urination is a complex physiologic action requiring sensory and motor neural
input. Both opioid and local anesthetic agents alter the sensory portion of
innervation to the bladder and urethra
____ 28. Why does a change in blood pH usually result in an abnormality of
one or more blood electrolyte levels?
a. Because an increase in blood pH level stimulates the thirst reflex, the
person then ingests hypotonic fluids to excess, resulting in a dilution of all
other serum electrolytes.
b. A change in the pH is a change in the hydrogen ion concentration, which
causes a corresponding change in the ability of the intestinal mucosa to
absorb ingested electrolytes.
c. Because hydrogen ions carry a positive charge, a change in the pH requires
a corresponding change in the amount of other positive and negative charges
to maintain electroneutrality of the blood.

d. Because hydrogen ions and potassium ions exist in the blood in a

balanced, reciprocal relationship, an increase or decrease in the blood pH
requires a corresponding decrease or increase in potassium ions.
28. ANS: C
The blood pH is a measure of the concentration of the blood hydrogen ion
concentration. Hydrogen ions are cations expressing a positive charge. In
order for body fluids to remain electrically neutral, an increase in hydrogen
ion concentration requires fewer other positive ions and more negative ions
for balance. The reverse is true for decreased hydrogen ion concentration.
____ 29. The hand grasps of the client with acidosis have diminished since the
previous assessment 1 hour ago. What is the nurses best first action?
a. Assess the client's rate, rhythm, and depth of respiration.
b. Measure the client's pulse and blood pressure.
c. Document the findings as the only action.
d. Notify the physician.
29. ANS: A
Progressive skeletal muscle weakness is associated with increasing severity
of the acidosis. Muscle weakness can lead to severe respiratory insufficiency.
Ketamine hydrochloride induces dissociative reactions such as hallucinations,
distorted images, and irrational behavior during emergence from the
anesthesia.
____ 30. Which client is at greatest risk for the development of metabolic
acidosis?
a. 56-year-old man with chronic asthma
b. 36-year-old man hiking in the Canadian Rockies
c. 36-year-old woman on a carbohydrate-free diet
d. 56-year-old woman self-medicating with sodium bicarbonate for
gastroesophageal reflux
30. ANS: C
One cause of acidosis is a strict, low-calorie diet or one that is low in
carbohydrate content. Such a diet increases the rate of fat catabolism and
results in the formation of excessive ketoacids.

____ 31. The client is NPO for surgery scheduled to occur in 4 hours. It is now
9 AM and the client's normal oral medications (consisting of digoxin, 0.125
mg, Colace, 300 mg, and Feostat, 325 mg) are due to be administered. The
physician will not be available until the time of surgery. What is the nurses
best action?
a. Hold all medications.
b. Administer all medications orally.
c. Administer all medications parenterally.
d. Administer digoxin with minimal water and hold the other drugs.
31. ANS: D
Regularly scheduled cardiac medications should be administered on
schedule. If taken with a few small sips of water at least 2 hours before

surgery, this medication should not increase the risk of intraoperative or

postoperative aspiration.
____ 32. The client who has received ketamine hydrochloride during a surgical
procedure has all of the following manifestations and behaviors. Which one
alerts the nurse to a dissociative reaction?
a. Hypoventilation and decreased oxygen saturation
b. Presence of hives on the skin around the IV site
c. Crying because the pain at the surgical site has increased
d. Pulling out the IV because he sees bugs in the solution bag
32. ANS: D Ketamine hydrochloride induces dissociative reactions such a
hallucinations, distorted images and irrational behavior during emergence
from the anesthesia.

____ 33. The client returning to the clinic for a follow-up visit 3 weeks after
abdominal surgery is concerned because she can feel small, uneven lumps
under the suture line of the incision. What is the nurses best response?
a. Avoid touching those areas because you may dislodge the blood clots that
keep your incision from bleeding.
b. What you are feeling is growth of new tissue proceeding at diferent rates
in the incision.
c. Those are the deep stitches the surgeon placed, and they will eventually
be absorbed and disappear.
d. Keep the incision covered for as long as those lumps can be felt.
33. ANS: B
Tissue healing and growth of new cells proceed at diferent rates along the
incision. Small, firm lumps are usually new blood vessels or new collagen
bases. They eventually smooth out without intervention when the scar is
mature.
____ 34. How do immune system cells diferentiate between normal, healthy
body cells and non-self cells within the body?
a. All normal, healthy body cells are considered part of the immune system.
b. Immune system cells recognize normal healthy body cells by the presence
of the nucleus, a structure that is lacking in non-self cells.
c. Non-self cells express surface proteins that are diferent from normal,
healthy body cells and recognized as foreign by immune system cells.
d. Non-self cells are easily identified by the immune system cells, because
non-self cells are much larger than normal, healthy body cells.
34. ANS: C
Normal, healthy body cells all express surface proteins that are unique to the
person, coded by the major histocompatibility genes. Non-self cells express
diferent cell surface proteins. Immune system cells can distinguish between
their own surface proteins and all others.
____ 35. The 28-year-old client has a deep puncture wound on his foot from
stepping on a nail. When the nurse prepares to give him a tetanus toxoid

vaccination, he says he does not need another tetanus shot because he had a
tetanus shot just 1 year ago. What is the nurses best response?
a. You need this vaccination because the strain of tetanus changes every
year.
b. I will check with the doctor. You probably do not need another vaccination
now.
c. Because antibody production slows down as you age, it is better to take
this vaccination as a booster to the one you had a year ago.
d. Tetanus is a more serious disease among younger people because it can
be spread to others by sexual transmission, so it is best to take this
vaccination now.
35. ANS: B
When people have been boosting their tetanus antibodies on a regularly
scheduled basis, they should have sufficient circulating antibodies to mount a
defense against exposure to tetanus. If this clients medical records
substantiate that he did indeed receive a tetanus toxoid booster 1 year ago,
he does not need another one now.
____ 36. The 95-year-old nursing home client has a productive cough and
night sweats. When she is tested for tuberculosis with a PPD, the injection
site does not have a skin response of induration by 48 hours after the
injection. What is the correct interpretation of this finding?
a. The test is negative and airborne precautions are not necessary because
the client does not have tuberculosis.
b. The test is negative; however, airborne precautions are still necessary until
other test results for tuberculosis are also negative.
c. The test is negative and airborne precautions are still necessary because
the client probably has a bacterial pneumonia.
d. The test is negative and airborne precautions are not necessary because
the client has sufficient antibodies against the tuberculosis bacillus.
36. ANS: B
The PPD test for tuberculosis relies on a cell-mediated immune response in
the skin to react with the tuberculosis protein for a positive result. Adults who
are very old may not have enough of a cell-mediated immune response to
demonstrate a positive reaction to a PPD, a condition called anergy. Airborne
precautions are needed when clinical manifestations of tuberculosis are
present and the results of more definitive testing are unknown or such testing
has not yet been performed.
____ 37. The older adult client taking NSAIDs for rheumatoid arthritis now has
pitting edema of both legs. What is the nurses best first action?
a. Assess the clients pulse, blood pressure, and breath sounds.
b. Instruct the client to weigh herself daily and keep a diary.
c. Document the finding as the only action.
d. Notify the physician immediately.
37. ANS: A
NSAIDs increase sodium and water retention. This action can pose a lifethreatening health hazard to clients who are older or who have coexisting
renal or cardiac disease. For some clients, the edema may be the only

problem. For other clients, the extra retained fluid may lead to hypertension,
heart failure, and pulmonary edema. The clients cardiovascular status should
be assessed before any decision is made to keep or discontinue the current
therapy.
____ 38. What is the most important precaution or action the nurse should
teach a client newly diagnosed with systemic lupus erythematosus (SLE)?
a. Monitoring urine output
b. Being immunized yearly against influenza
c. Assessing skin daily for open areas or rashes
d. Avoiding the use of hair dyes and having permanents
38. ANS: A
SLE is a connective tissue disorder that most profoundly afects tissues and
organs that are highly vascular. The leading cause of death in clients with SLE
is kidney disease.

____ 39. The client who has AIDS is admitted with cryptosporidiosis. Which
clinical manifestation should the nurse expect the client to have?
a. Persistent watery diarrhea and abdominal cramping
b. Productive cough with dyspnea and low-grade fever
c. Red, pruritic rash that bleeds easily with light pressure
d. Thick, white coating on the tongue and oral mucous membranes
39. ANS: A
Cryptosporidiosis is a protozoal infection causing gastroenteritis. Clients
experience mild to voluminous diarrhea.
____ 40. Which is the most important precaution for the nurse to take when
administering pentamidine (Pentam) intravenously to a client with
pneumocystis pneumonia?
a. Monitoring intake and output
bChecking the IV site hourly for phlebitis
c. Assessing the client hourly for manifestations of hypoglycemia
d. Assessing deep tendon reflexes and handgrip strength bilaterally
40. ANS: C
This drug can induce a rapid and severe state of hypoglycemia that can be
fatal. Clients receiving IV pentamidine should be monitored no less than
every hour for subjective symptoms of hypoglycemia and blood glucose level.
____ 41. A health care professional has been occupationally exposed to HIV
through a needle stick injury from a client who is HIV-positive and has a low
viral load. What drug regimen should the nurse be prepared to initiate?
a. No regimen is necessary
b. Zidovudine (Retrovir) 100 mg every 4 hours for 24 hours
c. Zidovudine (Retrovir) and lamivudine (Epivir) for 4 weeks
d. Zidovudine (Retrovir) and lamivudine (Epivir) for 1 year
41. ANS: C

This combination of antiretroviral medications is recommended by the CDC

for prophylaxis against occupational exposure to HIV when the source client
is HIV-positive and has a low viral burden. The regimen is recommended for a
duration of at least 4 weeks.
____ 42. The client who has just been diagnosed as HIV-positive asks if he
poses a health hazard to his co-workers in the secretarial pool. What is the
nurses best response?
a. The only time you could make someone else sick is when you have
Pneumocystis pneumonia.
b. As long as you are taking your antiviral medications, you cannot transmit
the virus to your co-workers.
c. Unless your blood or other body fluids comes into contact with your coworkers, you are not a health risk to them.
d. You should inform your co-workers of your HIV status so that they can
take proper precautions to reduce their risk.
42. ANS: C
HIV transmission requires significant contact with contaminated body fluids. If
his co-workers are immunocompetent, even the clients opportunistic
infection will have no physical impact on these people.
____ 43. With which client should the nurse be alert to the possibility of latex
hypersensitivity?
a. 38-year-old man allergic to shellfish
b. 28-year-old woman with spina bifida
c. 68-year-old man with total hip replacement
d. 38-year-old woman taking oral contraceptives
43. ANS B. People who have spina bifida have lifelong exposure to latex
products and frequently develop latex hypersensitivities. Such people are at
an increased risk for an anaphylactic reaction when they have major surgery,
especially abdominal surgery, and the surgeons use latex gloves when
entering the abdominal cavity.
____ 44. How is a type V hypersensitivity reaction diferent from all other
types of known hypersensitivities?
a. It is cell-mediated rather than antibody-mediated.
b. This type of reaction is an immediate response rather than a delayed
response.
c. The result of the reaction is a stimulatory response to normal tissues rather
than an inhibitory response.
d. Type V reactions result in more severe tissue-damaging responses than
does any other type of hypersensitivity reaction.
44. ANS: C
Type V hypersensitivity reactions are known as stimulatory responses.
Currently, the classic example of a type V hypersensitivity is Graves disease,
in which the person makes a large amount of antibody that binds to the
thyroid-stimulating hormone receptor (TSHr-Ab) on thyroid tissue. The binding
of this antibody to the TSH receptor activates the receptor, greatly
stimulating the thyroid gland and causing severe hyperthyroid symptoms

____ 45. Which characteristic of a tumor indicates that it is benign rather than
malignant?
a. It does not cause pain.
b. It is less than 2 cm in size.
c. It is surrounded by a capsule.
d. It causes the sensation of itching.
45. ANS: C
Benign tumors are made up of normal cells growing in the wrong place or
growing at a time when they are not needed. They grow by expansion rather
than invasion and often are encapsulated. The size and the fact that it is
painless does not mean that the tumor is benign. Additionally, the presence
of any sensation (such as itching) does not rule out malignancy.
____ 46. The 36-year-old client who has a suspicious mammogram says that
her mother died of bone cancer when she was 40 years old. Which is the
most important question for the nurse to ask this client next?
a. Have any other members of your family had bone cancer?
b. Did your mother ever have any other type of cancer?
c. How old were you when you started your periods?
d. Did your mother have regular mammograms?
46. ANS: B
Primary bone cancer is extremely uncommon among adults. Breast cancer
often spreads to the bone. Many laypersons do not understand that breast
cancer in the bone is still breast cancer. The client would be very young to
have breast cancer; however, hereditary breast cancer occurs at young ages.
It would be very important to know whether this clients mother had breast
cancer.
____ 47. What cancer screening or prevention activity is most important to
include when examining the client, a 20-year-old man who has Down
syndrome?
a. Encouraging him to eat more fruit and leafy green vegetables
b. Teaching him how to perform self testicular examination
c. Assessing his skin for bruises and petechiae
d. Testing his stool for occult blood
47. ANS: C
All the screening and prevention activities are appropriate; however, people
with Down syndrome have an increased lifetime risk for the development of
leukemia.
____ 48. The client who has developed a wound infection after surgery is
being discharged to home and is prescribed to take a course of antibiotics.
Which statement made by the client indicates correct understanding of the
antibiotic regimen?
a. If my temperature is normal for 3 days in a row, the infection is gone and I
can stop taking my medicine.
b. If my temperature goes above 100 F for 2 days, I should take twice as
much medicine.

c. When my incision stops draining, I will no longer need to take the

antibiotics.
d. Even if I feel completely well, I should take the medication until it is
gone.
48. ANS: D
Antibiotic therapy is most efective when the client takes the prescribed
medication for the entire course and not just when symptoms are present. A
major nursing responsibility is to reinforce to clients the necessity of
completing the antibiotic regimen to ensure that the organism is eradicated.
____ 49. A client has all of the following family and personal factors. Which
one greatly increases the risk for the client to develop respiratory problems?
a. The client has long-standing hypertension.
b. The clients father died of lung cancer at age 82.
c. The clients sister has a child with cystic fibrosis.
d. The client has a deficiency of alpha1-antitrypsin.
49. ANS: D
Alpha1-antitrypsin is an enzyme in the lungs that limits the activity of other
protein- destroying enzymes in the lungs. Without this limitation, those
protein-destroying enzymes break down the collagen and elastin in the lungs,
dramatically increasing the risk for developing emphysema at an early age.
Other types of severe pulmonary problems are also more common among
individuals who are deficient in alpha1-antitrypsin.
____ 50. The client with long-standing pulmonary problems is classified as
having class III dyspnea. Based on this classification, what type of assistance
will you need to provide for ADLs?
a. Dyspnea is minimal and no assistance is required.
b. The client may complete activities of daily living without assistance but
requires rest periods during performance.
c. The client is severely dyspneic with activity and requires assistance for
some but not all tasks.
d. The client is severely dyspneic at rest and cannot participate in any selfcare.
50. ANS: B
Class III dyspnea occurs during usual activities, such as showering, but the
client does not require assistance from others. Dyspnea is not present at rest.
____ 51. Which technique should you teach the caregiver and client with a
tracheostomy to reduce the risk for aspiration during feeding/eating?
a. Encourage the client to swallow as fast as possible to limit the time the
client is at risk for aspiration.
b. Tell the client and family to keep the phone nearby during feedings to
shorten the time it takes to dial 911.
c. Teach the client/caregiver to thicken liquids and avoid foods that generate
thin liquids during chewing.
d. Instruct the client/caregiver to inflate the cuf maximally during and for 1
hour after the feeding.
51. ANS: C

Thin liquids are hard to control and can slip past the epiglottis and into the
trachea. Thicker liquids remain as a bolus that the client can control during
breathing so that he or she does not attempt to swallow during an inhalation.
____ 52. What is the priority teaching focus for the client being discharged
home after a fixed centric occlusion for a mandibular fracture?
a. Keeping wire cutters close at hand
b. Eating at least 6 soft or liquid meals each day
c. Using an irrigating device for oral care 4 times a day
d. Sleeping in a semisitting position for the first week after surgery
52. ANS: A
Aspiration is possible if the client vomits with the wires in place. The vomitus
may not be able to move out of the mouth fast enough through the closed
teeth and could obstruct the upper airway, as well as move into the trachea.
____ 53. Which conditions or factors in a 64-year-old man diagnosed with
head and neck cancer are most likely to have contributed to this health
problem?
a. He quit school at age 16 and has worked in a butcher shop for over 40
years.
b. He uses chewing tobacco and drinks beer daily.
c. His father also had head and neck cancer.
d. His hobby is oil painting.
53. ANS: B
Many environmental risk factors contribute to the development of head and
neck cancer, although the actual cause is unknown. There does not appear to
be a genetic predisposition to this type of cancer. The two most important
risk factors are tobacco and alcohol use, especially in combination. Other risk
factors include chewing tobacco, pipe smoking, marijuana, voice abuse,
chronic laryngitis, exposure to industrial chemicals or hardwood dust, and
poor oral hygiene.
____ 54. Your client with asthma is receiving aminophylline intravenously.
Which manifestation alerts you to the possibility of aminophylline toxicity?
a. Pulse oximetry of 93%
b. Increased restlessness
c. Hourly urine output of 45 mL
d. Heart rate increase from 72 to 84 beats per minute
54. ANS: B
Methylxanthine, including aminophylline, stimulates the sympathetic nervous
system. Manifestations of toxicity include CNS irritability, restlessness,
tachycardia, nausea and vomiting, palpitations, and dizziness.
____ 55. Which clinical manifestation in a client with long-standing COPD
alerts you to the possibility of cor pulmonale?
a. Pursed-lip breathing occurs when the client is at rest.
b. The client's neck muscles are enlarged and prominent.
c. The client's ECG shows tall, peaked T waves and an absent U wave.
d. Jugular venous distention is present when the client is in a sitting position.

55. ANS: D
Neck veins are normally distended (jugular venous distention) only when a
person is supine. Usually, the neck veins flatten when a person sits at a 30degree angle or higher. Jugular venous distention in a full sitting position is
associated with right-sided heart failure, a characteristic of cor pulmonale.
____ 56. The client with lung cancer is scheduled for surgery and is receiving
oxygen for hypoxia. The client tells you that the sensation of air hunger is
worse. What is your best first action?
a. Notify the physician.
b. Increase the oxygen flow rate.
c. Document the observation as the only action.
d. Attempt to calm the client using guided imagery.
56. ANS: B
Depending on the location of the tumor, dyspnea can increase quickly. The
client should be provided with sufficient oxygen to reduce the hypoxia and its
associated symptoms.
____ 57. You are the only licensed health care professional assigned to a small
medical-surgical unit with 12 beds. Two unlicensed assistive personnel are
also working on this unit. Which of these four clients with respiratory
problems should be assigned to you rather than to the unlicensed assistive
personnel?
a. 82-year-old woman receiving steroid therapy for pulmonary fibrosis whose
pulse oximetry is 92%
b. 35-year-old woman receiving intravenous aminophylline for asthma whose
pulse oximetry is 92% and whose FEV1 is 50% of expected
c. 55-year-old man with chronic obstructive lung disease whose pulse
oximetry is 88% and who has the following arterial blood gas values: pH,
7.35; HCO3, 36 mEq/L; PCO2, 65 mm Hg; PO2, 78 mm Hg
d. 50-year-old man 2 days postoperative from a pneumonectomy for lung
cancer whose pulse oximetry is 92% and whose chest tube is draining 200
mL/8-hour shift
57. ANS: B
This client's condition is the least stable and she is receiving a medication
intravenously that has a narrow therapeutic range, with great risk for toxicity.
____ 58. Which intervention should the nurse urge a client with a cold to use
to avoid spreading the infection to other family members?
a. Wash your hands after blowing your nose or sneezing.
b. Use a dishwasher or boiling water to clean all dishes and utensils you
have used.
c. Have the other members of your family wear masks until all cold
manifestations have subsided.
d. Humidify the air in your home with a humidifier or by running hot shower
water to produce steam.
58. ANS: A
Cold viruses are shed in nasal and bronchial secretions. Handwashing after
events that place viruses on the hands reduces the risk that the viruses will
be spread directly or indirectly to others. Dishes need only to be washed in

hot, sudsy water. The mouth has more protective mechanisms to prevent
viral infection than do either the nose or the conjunctiva of the eye. Masks
worn by others have not been proven efective in preventing the spread of
colds and may give family members a false sense of security. Humidifying the
air promotes comfort but does not inhibit viral spread.
____ 59. Which person is a greatest risk for developing nosocomial
pneumonia?
a. The 60-year-old client receiving mechanical ventilation
b. The 40-year-old client receiving antibiotics for a surgical wound infection
c. The 60-year-old client in traction for a fractured femur who also has a cold
d. The 40-year-old client with type 2 diabetes who has a 50 pack-year
smoking history
59. ANS: A
Mechanical ventilation in a hospitalized client is a high risk for the
development of nosocomial pneumonia. The endotracheal tube or the
tracheostomy tube provides direct access of hospital flora to the respiratory
tract. Such pneumonia is termed ventilation-acquired pneumonia (VAP).
____ 60. The client with active tuberculosis has started therapy with isoniazid
and rifampin. He reports that his urine now has an orange color. What is the
nurses best action?
a. Document the report as the only action.
b. Obtain a specimen for culture.
c. Test the urine for occult blood.
d. Notify the physician.
60. ANS: A
Rifampin normally turns urine orange color. No action is needed.
____ 61. Which statement made by a clients spouse indicates the need for
more teaching about prevention of a pulmonary embolism at home after
major abdominal surgery?
a. While he is awake, I will make sure he gets up and walks for at least 5
minutes every 2 hours.
b. He is prone to constipation, so I will increase the amount of fiber in his
meals every day.
c. I will massage his feet and legs twice a day to help blood return.
d. I will check his breathing rate and level twice a day.
61. ANS: C
It is possible that massaging the feet and legs could promote venous return;
however, there is a greater danger of loosening a clot that may have formed
in the deep veins of the legs, which would allow it to move. Thus, after
surgery, the feet and legs of a client should never be massaged.
____ 62. The client with a pulmonary embolism is receiving an intravenous
heparin drip. The nurse should make certain which agent is readily available?
a. Fresh-frozen plasma
b. Protamine sulfate
c. Cryoprecipitate

d. Vitamin K
62. ANS: B
Protamine sulfate is an antidote for heparin.
____ 63. What is the most important intervention for the client with ARDS?
a. Antibiotic therapy
b. Bronchodilators
c. Oxygen therapy
d. Diuretic therapy
63. ANS: C
Although the client with ARDS may not respond to oxygen therapy to the
same degree as clients who have other types of respiratory problems, oxygen
is still the most important intervention. Without oxygen therapy, the client
with ARDS will always die of respiratory failure.
____ 64. A nurse is starting a new shift and assessing the client who has an
oral endotracheal tube in place. Which finding requires immediate
intervention?
a. The client has been intubated for four days.
b. The endotracheal tube is midline in the mouth.
c. The endotracheal tube is taped to the lower jaw.
d. The client has hydrocolloid membrane on the skin of the cheeks.
64. ANS: C
The endotracheal tube can be taped to the upper lip but should never be
taped to the lower jaw because the lower jaw moves too much.
____ 65. The pressure reading on the ventilator of a client receiving
mechanical ventilation is fluctuating widely. What is the correct action to take
for this problem?
a. Determine whether there is an air leak in the clients endotracheal tube
cuf.
b. Increase the tidal volume by at least 100 mL or by the clients weight in kg.
c. Assess the clients oxygen saturation to determine the adequacy of
oxygenation.
d. Disconnect the ventilator from the client and use a manual resuscitation
bag until the machine has been checked.
65. ANS: C
A widely fluctuating pressure reading is one indication of inadequate flow and
oxygenation. The client may be air hungry from hypoxia. Check the clients
oxygen saturation to determine the adequacy of oxygenation and, if the
saturation is less than adequate, increase the flow rate setting on the
ventilator.
____ 66. A client brought to the emergency room following a myocardial
infarction is found to be hypotensive. What efect from baroreceptor
stimulation on this clients heart rate would be expected?
a. The heart rate would increase.
b. The heart rate would decrease.
c. There would be no efect on heart rate.
d. The heart rate would vacillate between accelerations and deceleration.

66. ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch
sense a pressure decrease in the vessels. The parasympathetic system
responds by lessening the inhibitory efect on the SA node, and this results in
an increase in heart rate.
____ 67. Which conditions would lead to an increase in stroke volume?
a. Increased preload, increased afterload
b. Increased preload, decreased afterload
c. Decreased preload, increased afterload
d. Decreased preload, decreased afterload
67. ANS: B
An increased preload increases contractility; decreased afterload reduces the
amount of resistance to ejection of blood from the left ventricle. Both
changes togetheer increase stroke volume of the left ventricle.
____ 68. A clients cardiac status is being observed by telemetry monitoring. A
nurse observes a P wave that changes in shape in lead II. What conclusion
can the nurse make from this?
a. The P wave is originating from an ectopic focus.
b. The P wave is firing twice from the sinoatrial (SA) node.
c. There is no real P wave.
d. The P wave is normal.
68. ANS: A
If the P wave is firing consistently from the SA node, the P wave will have a
consistent shape in a given lead. If the impulse is from an ectopic focus, then
the P wave will vary in shape in that lead.
____ 69. The client is experiencing sinus bradycardia with hypotension and
dizziness. Which of the following drugs/agents should the nurse be prepared
to administer?
a. Atropine
b. Digoxin
c. Lidocaine
d. Metoprolol
69. ANS: A
Atropine is a cholinergic antagonist that inhibits parasympathetic-induced
hyperpolarization of the sinoatrial node. This inhibition results in an increased
heart rate.
____ 70. A client with third-degree heart block is admitted to the telemetry
unit. The nurse observes wide QRS complexes with a heart rate of 35
beats/min on the monitor. What physical assessment parameter would be
important to incorporate for this client?
a. Assess for pulmonary rales.
b. Assess for acute hypertension.
c. Assess for confusion or syncope.
d. Assess for the presence of a gallop rhythm.
70. ANS: C

A heart rate of 40 beats/min or below, with widened QRS complexes, should

alert the nurse to the possibility that the AV block is infranodal and a
ventricular escape focus is pacing the ventricles. This could have
hemodynamic consequences and the client is at risk of inadequate cerebral
perfusion. The nurse should assess for lightheadedness, confusion, syncope,
and seizure activity.
____ 71. The health care provider is planning to treat a client who has
symptomatic, infranodal, third-degree heart block following cardiac surgery
with temporary pacing. Which type of pacing would be most appropriate for
this client?
a. Global pacing
b. Universal pacing
c. Synchronous pacing
d. Asynchronous pacing
71. ANS: D
Asynchronous pacing is most often used for clients who are profoundly
bradycardic because it is found in clients with infranodal blocks or in those
who are asystolic. This type of pacing fires at a fixed rate, regardless of the
clients intrinsic rhythm.
____ 72. A client has been admitted to the acute care unit for an exacerbation
of heart failure. Which of the following nursing actions should be performed
first?
a. Assessment of respiratory and oxygenation status
b. Monitoring of serum electrolyte levels
c. Administration of intravenous fluids
d. Insertion of a Foley catheter
72. ANS: A
Assessment of respiratory and oxygenation status is the priority nursing
intervention for the prevention of complications.
____ 73. The client with hypercholesterolemia and atherosclerosis reports skin
flushing and itching while taking nicotinic acid. What is the nurses best
response?
a. Take this product with meals.
b. Take this product at bedtime.
c. Avoid taking aspirin with this product.
d. Avoid smoking cigarettes while taking this product.
73. ANS: A
Nicotinic acid causes an increased release of prostaglandins, resulting in
vasodilation. Taking the drug with meals minimizes this side efect.
____ 74. What instructions should be given to a client who is about to begin
treatment with an HMG-CoA reductase inhibitor such as simvastatin?
a. This drug can cause constipation.
b. Take this drug on an empty stomach.

c. Report any muscle tenderness to your health care provider.

d. You may experience flushing of the skin with this medication.
74. ANS: C
This class of drugs can cause myopathy. Muscle tenderness should be
reported to the clients health care provider.
____ 75. A client in the hyperdynamic phase of septic shock has been
admitted to the intensive care unit. What complication should the nurse be
alert for as shock progresses from the hyperdynamic to the hypodynamic
phase?
a. Acute respiratory distress syndrome
b. Acute bowel obstruction
c. Ventricular tachycardia
d. Seizure activity
75. ANS: A
As septic shock progresses to the hypodynamic phase, acute respiratory
distress syndrome (ARDS), a potentially fatal complication, can develop.
____ 76. What drug therapy should the nurse prepare to administer to a client
in the hyperdynamic phase of septic shock?
a. Heparin
b. Vitamin K
c. Corticosteroids
d. Clotting factors, platelets, and plasma
76. ANS: A
During the hyperdynamic phase of septic shock, clients are beginning to form
numerous small clots. Heparin is administered to limit clotting and prevent
consumption of clotting factors.
____ 77. The client is being discharged after a percutaneous transluminal
coronary angioplasty (PTCA) and is prescribed to take a calcium channel
blocking agent. Which precaution should the nurse stress when teaching that
is specific for this drug therapy?
a. Change positions slowly.
b. Avoid crossing your legs.
c. Weigh yourself daily.
d. Decrease salt intake.
77. ANS: A
Calcium channel blocking agents cause systemic vasodilation and postural
(orthostatic) hypotension.
____ 78. The 37-year-old male client has a hemoglobin level of 22.1 g/dL.
What is the nurses best action?
a. Document the report as the only action.
b. Institute infection precautions.
c. Institute bleeding precautions.
d. Notify the physician.
78. ANS: D

The normal range for hemoglobin in adult males of this age is 14 to 18 g/dL.
This client's hemoglobin level is elevated, which could indicate possible
chronic hypoxia or polycythemia vera.
____ 79. Which clinical manifestation is common to all types of anemia
regardless of cause or pathologic mechanism?
a. Jaundiced sclera and roof of the mouth
b. Hypertension and peripheral edema
c. Tachycardia at basal activity levels
d. Increased PaCO2
79. ANS: C
The client with anemia has some degree of tissue hypoxia. A compensatory
mechanism to increase tissue oxygenation is to increase cardiac output by
increasing heart rate.
____ 80. The client has anemia and all the following clinical manifestations.
Which manifestation indicates to the nurse that the anemia is a long-standing
problem?
a. Headache
b. Clubbed fingers
c. Circumoral pallor
d. Orthostatic hypotension
80. ANS: B
Clubbing of the fingers requires prolonged hypoxia (many months to years) to
develop.
____ 81. Which problem or condition is most likely to stimulate a crisis in a
person who has sickle cell trait?
a. Becoming pregnant
b. Shoveling snow when the temperature is at 0 degrees
c. Having surgery under general anesthesia for colon cancer
d. Having a cast placed on the wrist after sustaining a simple fracture
81. ANS: C
The person who has sickle cell trait usually has less than 40% of his or her
total hemoglobin as Hgb S. Although these cells could still become sickled,
hypoxic conditions would have to be severe for this to occur to the level of
sickle cell crisis. Such individuals are most vulnerable to crisis during
prolonged surgery under anesthesia.
____ 82. Which clinical manifestation or assessment finding indicates
efectiveness of the therapy for the client with polycythemia vera?
a. Hematocrit of 65%
b. Bilateral darkening of the conjunctiva
c. Blood pressure change from 180/150 to 160/90
d. Unplanned weight loss of 6 lb over a months time
82. ANS: C
Measures that efectively reduce erythrocyte concentration and blood
viscosity also reduce blood pressure.

____ 83. Which precaution should the nurse teach the client who is prescribed
to take thalidomide (Thalomid) as part of her treatment plan for multiple
myeloma?
a. Avoid high-fiber foods to prevent diarrhea.
b. Use multiple forms of birth control to prevent birth defects.
c. Drink plenty of fluids to prevent the development of diabetes mellitus.
d. Avoid crowds and sick people to prevent contraction of contagious
infections.
83. ANS: B
Thalidomide is a potent teratogen and has been known to cause severe birth
defects after even one exposure of the drug. Both women and men who are
taking this drug are urged to use multiple forms of contraception to prevent
exposing a fetus to this drug
____ 84. The client being discharged home after a bone marrow
transplantation for leukemia asks why protection from injury is so important.
What is the nurses best response?
a. The transplanted bone marrow cells are very fragile and trauma could
result in rejection of the transplant.
b. Trauma is likely to result in loss of skin integrity, increasing the risk for
infection when you are already immunosuppressed.
c. Platelet recovery is slower than white blood cell recovery and you remain
at risk longer for bleeding than you do for infection.
d. The medication regimen after transplantation includes drugs that slow
down cell division, making healing after any injury more difficult.
84. ANS: C
Platelets recover more slowly than other blood cells after bone marrow
transplantation. Thus, the client is still thrombocytopenic at home and
remains at risk for excessive bleeding after any trauma of injury.
____ 85. A nurse is assessing a client for pain sensation using a sharp or dull
instrument. What technique should be used to obtain valid results?
a. Test the client first with eyes open, then with eyes closed.
b. Test the client for dull sensation first, followed by sharp.
c. Test the client for sharp sensation first, followed by dull.
d. Test the client for sharp and dull sensation randomly.
85. ANS: D
The proper assessment technique for assessing pain sensation is to test the
client for sharp and dull sensation randomly to prevent the client from
anticipating the type of stimulus that will follow.
____ 86. A client is admitted with a brain attack (stroke). On neurologic
assessment, a nurse notes that the clients arms, wrists, and fingers have
become flexed, and there is internal rotation and plantar flexion of the legs.
What would be the nurses best action?
a. Notify the health care team members.
b. Determine the clients advance directive status.
c. Reposition the client to prevent contractures.
d. Document the finding as the only action.

86. ANS: A
The client is demonstrating decorticate posturing that is seen with
interruption in the corticospinal pathway. This finding is abnormal, and a sign
that the clients condition has deteriorated. The physician, charge nurse, and
other team members should be notified immediately of this change in status.
____ 87. What nursing action addresses the age-related changes of sensory
perception for an older adult client admitted to a general medical floor?
a. Using a call button that requires only minimal pressure to activate
b. Providing a clock and calendar to minimize dementia onset
c. Ensuring that paths are free from equipment
d. Admitting the client to the room closest to the nursing station
87. ANS: C
Dementia and confusion are not common phenomena among older adults.
However, physical impairment related to illness can be expected; providing
opportunity for hazard-free ambulation will maintain strength and mobility.
____ 88. A nurse is preparing a teaching plan for a client with migraine
headaches who is receiving a beta blocker to help manage this disorder. What
instructions would be appropriate to relay to this client?
a. Take this drug only when you have prodromal symptoms indicating the
onset of a migraine headache.
b. Take this drug as ordered, even when feeling well, to prevent vascular
changes associated with migraine headaches.
c. This drug will relieve the pain during the aura phase soon after a
headache has started.
d. This medication will have no efect on your heart rate or blood pressure
because you are taking it for migraines.
88. ANS: B
Beta blockers are prescribed as a prophylactic treatment to prevent the
vascular changes that initiate migraine headaches. Heart rate and blood
pressure will also be afected and the client should monitor these side efects.
____ 89. What statement made by a client with newly diagnosed epilepsy
indicates that further teaching concerning the drug regimen is necessary?
a. I will avoid alcohol.
b. I will wear a medical alert bracelet.
c. I will let my doctor know about this drug when I receive a new prescription
other conditions.
d. I can miss up to two pills if I run out of them or they make me ill.
89. ANS: D
The nurse needs to emphasize that antiepileptic drugs must be taken even if
seizure activity has stopped. Discontinuing the medication can predispose the
client to seizure activity and status epilepticus.
____ 90. Which of the following is the correct rationale for monitoring
peripheral oxygenation saturation in the client with encephalitis?
a. It will prevent increased intracranial pressure.
b. It will prevent permanent neurologic disabilities.

c. It will alert the clinician to hypoxia and possible secondary brain damage.
d. It will prevent inadequate amounts of oxygen in the circulating blood from
causing brain hypoxia.
90.ANS C. Early of inadequate circulating oxygen can allow the clinician to
intervene before hypoxic brain damage occurs.
____ 91. Which statement indicates that the family has a good understanding
of the changes in motor movement associated with Parkinsons disease?
a. I can never tell what hes thinkinghe hides behind a frozen face.
b. She drools all the time just so I cant take her out anywhere.
c. I think this disease makes him nervoushe perspires all the time.
d. I can ofer smaller meals with bite-size portions and a liquid supplement.
91. ANS: D
A masklike face, drooling, and excess perspiration are common to clients with
Parkinsons disease. Changes in facial expression or a masklike facies in a
Parkinsons disease client can be misinterpreted. Because chewing and
swallowing can be problematic, small, frequent meals and a supplement are
better for meeting the clients nutritional needs.
____ 92. Which nursing intervention will assist in preventing respiratory
complications in the client with Parkinsons disease?
a. Keeping an oral airway at the bedside.
b. Ensuring a fluid intake of at least 3 L/day.
c. Teaching the client pursed-lip breathing techniques.
d. Maintaining the backrest elevation at greater than 30 degrees.
90. ANS: C
Early detection of inadequate circulating oxygen can allow the clinician to
intervene before hypoxic brain damage occurs.
92. ANS: D
Elevation of the backrest will help prevent aspiration.
____ 93. A nurse is caring for a client experiencing spinal shock after a spinal
cord injury. What clinical manifestation would indicate the resolution of spinal
shock?
a. The return of reflex activity
b. Normalization of the pupillary reflex
c. Return of bowel and bladder continence
d. Tingling in the extremities below the lesion
93. ANS: A
The resolution of spinal shock is signaled by the return of reflex activity. Note
that spinal shock and neurogenic shock are not interchangeable terms and
describe diferent pathologic phenomena.
____ 94. A nurse is to assess proprioceptive function in the lower extremities
in a client with a suspected spinal cord injury. What assessment technique
should the nurse use?
a. Ask the client to flex and extend the feet and knees.
b. With the clients eyes closed, move the clients toe up or down.

c. Apply resistance while the client plantar flexes the legs and feet.
d. Apply pinprick to the lower extremities and compare bilaterally.
94. ANS: B
The proper technique for testing proprioception is to ask the client to close
his or her eyes. Move the clients toe up or down and ask the client to identify
the position of the digit.
____ 95. Within 4 hours after a cervical spinal injury, the client can
discriminate light touch and position of the arms but cannot perform any
motor function. What is the nurses interpretation of this finding?
a. The client is likely to have a full recovery from this injury.
b. The spinal cord has experienced a complete injury.
c. The spinal cord injury is posterior.
d. The spinal cord injury is anterior.
95. ANS: D
With a spinal cord injury to the anterior portion of the cervical spine, the
client may retain some sensory function (touch, vibration, and position are in
the posterior portion) but may not have motor function and pain and
temperature sensation. Whether the injury is permanent or temporary cannot
be ascertained at this time.
____ 96. A client has multiple sclerosis (MS) of the relapsing-remitting type.
What clinical course of the disease should the nurse expect in this client?
a. An absence of periods of remission
b. Attacks becoming increasingly frequent
c. Absence of active disease manifestations
d. Gradual neurologic symptoms without remission
96. ANS: B
The classic picture of relapsing-remitting MS is characterized by increasingly
frequent attacks.

____ 97. A nurse has instructed the client with myasthenia gravis to take
drugs on time and to eat meals 45 to 60 minutes after taking the
anticholinesterase drugs. The client asks why the timing of meals is so
important. What is the nurses best response?
a. This timing allows the drug to have maximum efect, so it is easier for you
to chew, swallow, and not choke.
b. This timing prevents your blood sugar level from dropping too low and
causing you to be at risk for falling.
c. These drugs are very irritating to your stomach and could cause ulcers if
taken too long before meals.
d. These drugs cause nausea and vomiting. By waiting for a while after you
take the medication, you are less likely to vomit.
97. ANS: A
The skeletal muscle weakness extends to the ability to chew and swallow.
Clients who have myasthenia gravis are at risk for aspiration during meals.
Timing the medication so that the majority of the meal is eaten when the

drugs have produced their peak efect enables the client to chew and swallow
more easily.
____ 98. Which of the following statements made by a client with peripheral
polyneuropathy indicates correct understanding of injury prevention?
a. I will change positions slowly.
b. I will avoid wearing cotton or wool socks.
c. Because I now bleed more easily, I will use an electric razor.
d. Because my feet are always cold, I will use a hot water bottle on them at
night.
98. ANS: A
The autonomic dysfunction associated with peripheral polyneuropathy causes
orthostatic hypotension.
____ 99. What statement by the client indicates her understanding of
treatment for pain related to Guillain-Barr syndrome?
a. I can use the button on the pump as often as I want to get more pain
medication.
b. Aspirin will help me when I have pain from this disease.
c. A combination of morphine and distraction seems to help bring me relief
right now.
d. I should not have any pain as a result of impaired motor movement while
acutely ill.
99. ANS: C
Typical pain from GBS is often not relieved by medication other than opiates
and distraction, repositioning, massage, heat, cold, and guided imagery may
enhance the opiate efects.
____ 100. Which statement or behavior by a client after a stroke indicates to
the nurse that the client is adjusting to the residual limitations from the
stroke?
a. The client uses the unafected side to perform passive range-of-motion
exercises on the afected side.
b. The client states the goal of regaining all sensory and motor function
within 6 months.
c. The client says that she is well and nothing has happened.
d. The client smiles continually while awake.
100. ANS: A
Adjustment to the limitations imposed by a health problem such as a stroke
involves acceptance of the event and active participation in rehabilitative
activities.
____ 101. Which assessment finding alerts the nurse to the possibility that the
client has a paralysis of the medial rectus muscle for the right eye? The client
is unable to
a. Turn the right eye in toward the nose.
b. Lift the right upper eyelid.
c. Move the right eye downward.
d. Move the right eye upward.

101. ANS: A
Contraction of the medial rectus muscle turns the eye toward the nose.
____ 102. Which client is at greatest risk for developing vision problems?
a. 28-year-old woman in the postpartum phase of pregnancy
b. 28-year-old man who has diabetes mellitus
c. 58-year-old man who takes aspirin daily for anticoagulation
d. 58-year-old woman using topical ointments daily for dry skin
102. ANS: B
The hyperglycemia that characterizes diabetes mellitus causes numerous
vascular problems in the eye and damages the nerves. Diabetes mellitus is a
major cause of blindness in Canada and the United States. Although good
control of blood glucose levels delays visual problems, it does not eliminate it
in the diabetic population.
____ 103. The client is using an ophthalmic beta-blocking agent for the
treatment of glaucoma. Which of the following actions should the nurse teach
the client to prevent orthostatic hypotension?
a. Change positions slowly.
b. Take your pulse rate at least four times daily.
c. Apply pressure to the inside corner of your eye when putting the drops
into the eye.
d. Be sure to lie down for at least 10 minutes after putting the drops into
your eyes.
103. ANS: C
Nasal punctal occlusion during eye drop instillation keeps the drug in contact
with the eye structures longer and decreases systemic absorption and side
efects.
____ 104. The client has just returned from having surgery for a scleral
buckling procedure to repair a large retinal detachment in the right eye.
Sulfahexafluoride gas was used intraocularly. What postoperative position
should the nurse use for this client?
a. Completely supine with sandbags to prevent the head from turning to
either side
b. On the nonoperative side in the Trendelenburg position
c. On the operative side in the Trendelenburg position
d. On the abdomen with the afected eye up
104. ANS: D
Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It
will float to the highest position. The client should be positioned so that the
gas will float up and against the newly reattached retina.
____ 105. For which type of foreign object in the ear canal is irrigation
contraindicated?
a. Dried beans
b. Live insect
c. Pencil eraser

d. Cerumen
105. ANS: A
Irrigating the ear canal containing dried beans or any other vegetable matter
is contraindicated because the irrigating fluid can cause the matter to swell
and become more impacted.

____ 106. In assessing the hand function and ROM of a client, the nurse notes
that the client is able to oppose each finger to the thumb when making a fist.
What conclusion can the nurse make from this finding?
a. The clients hand ROM is not seriously restricted.
b. The clients hand ROM is severely limited.
c. The clients hand has nerve entrapment.
d. The clients hand has weakness.
106. ANS: A
In assessing hand ROM, if the client can oppose each finger to the thumb
when making a fist, the clients hand ROM is not seriously restricted.

____ 107. The most serious complication of a pelvic fracture is which of the
following?
a. Infection
b. Delayed union
c. Hypovolemic shock
d. Impaired skin integrity
107. ANS: C
With a pelvic fracture, there can be internal organ damage, resulting in
bleeding and hypovolemic shock. The nurse monitors the clients vital signs,
skin color, and level of consciousness.
____ 108. The nurse notes that the skin around the clients skeletal traction
pin site is swollen, red, and crusty, with dried drainage. What is the nurses
priority action?
a. Decrease the traction weight.
b. Apply a new dressing.
c. Document the finding as the only action.
d. Notify the physician.
108. ANS: D
These clinical manifestations indicate inflammation and possible infection.
Infected pin sites can lead to osteomyelitis and should be treated
immediately.
____ 109. What client instructions would be appropriate after a barium
swallow?
a. Sit in bed with your head elevated to allow the barium to pass through.

b. You may have stools that are darker in appearance for a few days.
c. You may not eat or drink anything for 6 hours after the test.
d. Drink plenty of fluids.
109. ANS: D
The client is encouraged to drink plenty of fluids after a barium swallow to
help eliminate the barium from the colon.
____ 110. Which statement regarding oral candidiasis is true?
a. It is an inflammatory mucocutaneous disease.
b. It is an acute bacterial infection of the gingiva.
c. It is a complication of long-term antibiotic therapy.
d. It is a risk factor for the development of oral cancer.
110. ANS: C
Antibiotic therapy can destroy the normal flora that usually prevents fungal
infections. Long-term treatment with antibiotics predisposes clients to
candidiasis.
____ 111. Which statement made by the client concerning the risk of oral
cancer indicates a need for further teaching?
a. I will brush my teeth and floss regularly.
b. I will begin a smoking cessation program.
c. I will limit my intake of alcoholic beverages.
d. I can still use chewing tobacco since I stopped smoking.
111. ANS: D
Tobacco in any form increases the risk of oral cancer. The client should be
educated to eliminate all tobacco products
____ 112. The most accurate method of diagnosing gastroesophageal reflux
disease (GERD) is which of the following?
a. Endoscopy
b. Schillings test
c. 24-hour ambulatory pH monitoring
d. Stool testing for occult blood
112. ANS: C
The most accurate method of diagnosing gastroesophageal reflux disease is
24-hour ambulatory pH monitoring.
____ 113. In caring for a client with a rolling hernia, the nurse should be alert
for which potential complication?
a. Reflux
b. Vomiting
c. Pneumonia
d. Obstruction
113. ANS: D
A rolling hernia causes the fundus and portions of the stomachs greater
curvature to roll into the thorax next to the esophagus, predisposing the
client to volvulus, obstruction, and strangulation.

____ 114. The nurse is caring for a client who has undergone esophageal
dilation for achalasia. Two hours later, the client develops chest and shoulder
pain. What would be the nurses best action?
a. Administer an analgesic.
b. Document the finding as the only action.
c. Reposition the client.
d. Notify the physician.
114. ANS: D
The client may be experiencing complications of the procedure, such as
bleeding and perforation. These complications require immediate
intervention.
____ 115. On assessment, the nurse notes the presence of bloody nasogastric
tube drainage from a client who underwent an esophagogastrostomy 2 days
ago. What conclusion should the nurse draw from this assessment?
a. The clients nasogastric tube requires irrigation.
b. The drainage is as expected for this time period.
c. The clients nasogastric tube requires repositioning.
d. The client has developed bleeding at the suture line.
115. ANS: D
The initial nasogastric drainage appears bloody, but should turn a yellowgreen color by the end of the first postoperative day. If the bloody color
continues, it may indicate bleeding at the suture line.
____ 116. What complication should the emergency department nurse
anticipate in the client with a chemical injury to the esophagus after ingestion
of an alkaline substance?
a. Infection
b. Stricture
c. Aspiration
d. Perforation
116. ANS: D
Although all these complications are possible, ingestion of alkaline
substances is dangerous because of their potential to penetrate the
esophagus fully, leading to perforation.
____ 117. A client with peptic ulcer disease vomits undigested food after
eating breakfast. The nurse notes abdominal distention. What intervention
should the nurse anticipate will be implemented for this client?
a. Insertion of a nasogastric tube
b. Insertion of a jejunostomy tube
c. Administration of an antiemetic
d. Administration of H2-receptor antagonists
117. ANS: A
Symptoms of abdominal distention and nausea and vomiting of undigested
food signal pyloric obstruction. Treatment is aimed at decompression of the
stomach by an NG tube and restoration of fluid and electrolyte balance.

____ 118. What teaching regarding postoperative care should the nurse
provide for the client undergoing herniorrhaphy?
a. You should avoid solid foods for the first 48 hours after surgery.
b. After surgery, you should take deep breaths, but avoid coughing.
c. You will not be able to ambulate for 2 days after the surgery.
d. Place Steri-Strips over the incision if you note any separation.
118. ANS: B
The client should change positions and take deep breaths to facilitate lung
expansion, but should avoid coughing, which can place stress on the incision
line.
____ 119. A client prescribed polyethylene glycol solution (GoLYTELY) in
preparation for colorectal surgery asks why drinking this solution is
necessary. What is the nurses best response?
a. This solution provides electrolytes directly to the bowel.
b. This solution is given to relax the bowel and facilitate removal of the
tumor.
c. This solution will clear the bowel of feces and reduce the chance of
infection.
d. This solution is optional, but drinking it will make the surgery easier to
tolerate.
119. ANS: C
Polyethylene glycol solution is an isosmotic solution that overwhelms the
absorptive capacity of the small bowel, clearing the bowel of feces and
decreasing the amount of bacteria present, and thereby reducing the risk of
infection.
____ 120. A client with a mechanical bowel obstruction reports that the
abdominal pain that was previously intermittent and colicky is now more
constant. What would be the nurses priority action?
a. Measure the abdominal girth.
b. Notify the health care provider.
c. Place the client in a knee-chest position.
d. Medicate the client with an opioid analgesic.
120. ANS: B
A change in the nature and timing of abdominal pain in a client with a bowel
obstruction can signal peritonitis or perforation. The health care provider
should be notified immediately.
____ 121. The laboratory data reveal a decreased fecal urobilinogen
concentration. What clinical manifestation would accompany this laboratory
finding?
a. Clay-colored stools
b. Petechiae
c. Asterixis
d. Melena
121. ANS: A
When fecal urobilinogen levels are decreased as a result of biliary cirrhosis,
the stools become light- or clay-colored.

____ 122. A client with an esophagogastric tube suddenly experiences acute

respiratory distress. What should be the nurses immediate action?
a. Call the physician.
b. Cut the balloon ports and remove the tube.
c. Place the client in an upright position and apply oxygen.
d. Reduce the balloon pressure slightly using the sphygmomanometer.
122. ANS: B
In case of respiratory compromise in a client with an esophagogastric tube,
the nurse should immediately cut both ports with a pair of scissors that is
kept at the bedside and remove the tube.
____ 123. The physician has ordered vasopressin for a client with bleeding
esophageal varices. What is the action of vasopressin in the control of
bleeding?
a. Constriction of preportal splanchnic arterioles
b. Inducing the release of clotting factors II, VII, IX, and X
c. Increasing portal pressure, thus decreasing portal blood flow
d. Decreasing contraction of smooth muscle in the vascular bed
123. ANS: A
Vasopressin acts to cause contraction of smooth muscle in the vascular bed,
constricting preportal splanchnic arterioles and decreasing blood flow to the
abdominal organs, which in turn reduces portal pressure and portal blood
flow.
____ 124. Which of the following menus would be most appropriate for a client
with cholelithiasis?
a. Two eggs, two slices of toast with margarine, and a glass of whole milk
b. Grilled cheese sandwich, steamed vegetables with butter, and cofee
c. Roast chicken, baked potato, and skim milk
d. Baked fish, steamed broccoli, and tea
124. ANS: C
Clients with cholelithiasis should avoid foods high in cholesterol, such as
whole milk and butter, fried foods, and gas-forming vegetables.
____ 125. What body mass index (BMI) should older adults have?
a. Less than 21
b. Between 20 and 24
c. Between 24 and 27
d. Greater than 30
125. ANS. C Older adults should have a BMI between 24 and 27.
____ 126. The client has a deficiency of all the following pituitary hormones.
Which one should be addressed first?
a. Growth hormone

b. Luteinizing hormone
c. Thyroid-stimulating hormone
d. Follicle-stimulating hormone
126. ANS: C
A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening
deficiency of the hormones listed in this question. TSH is needed to ensure
proper synthesis and secretion of the thyroid hormones, whose functions are
essential for life.
____ 127. The client scheduled for a partial thyroidectomy for hyperthyroidism
asks the nurse why she is being given an iodine preparation before surgery.
What is the nurses best response?
a. To make the surgery as sterile as possible.
b. To stimulate storage of thyroid hormones for use after surgery.
c. To replace the thyroid hormones that will be eliminated as a result of the
surgery.
d. To decrease the blood vessels in the thyroid and prevent excessive
bleeding during surgery.
127. ANS: D
Iodine preparations decrease the size and vascularity of the thyroid gland,
reducing the risk for hemorrhage and the potential for thyroid storm during
surgery.
____ 128. Which clinical manifestation indicates to the nurse that treatment
for the client with hypothyroidism is efective?
a. The client is thirsty.
b. The clients weight has been the same for 3 weeks.
c. The clients total white blood cell count is 6000 cells/mm3.
d. The client has had a bowel movement every day for 1 week.
128. ANS: D
Hypothyroidism decreases gastrointestinal motility significantly. One of the
parameters that clients can use to determine if changes in the dose of thyroid
replacement should be adjusted is the frequency of bowel movements. A
bowel movement every day is a strong indication that the dose of thyroid
replacement hormone is adequate
____ 129. Which client is at greatest risk for hyperparathyroidism?
a. 28-year-old client with pregnancy-induced hypertension
b. 45-year-old client receiving dialysis for end-stage renal disease
c. 55-year-old client with moderate congestive heart failure after myocardial
infarction
d. 60-year-old client on home oxygen therapy for chronic obstructive
pulmonary disease
129. ANS: B

Clients who have chronic renal failure do not completely activate vitamin D
and poorly absorb calcium from the GI tract. They are chronically
hypocalcemic, which triggers overstimulation of the parathyroid glands.
____ 130. Which assessment finding in the client with diabetes mellitus
indicates that the disease is damaging the kidneys?
a. The presence of ketone bodies in the urine during acidosis
b. The presence of glucose in the urine during hyperglycemia
c. The presence of protein in the urine during a random urinalysis
d. The presence of white blood cells in the urine during a random urinalysis
130. ANS: C
Urine should not contain protein, and the presence of proteinuria in a diabetic
marks the beginning of renal problems known as diabetic nephropathy, which
progresses eventually to end-stage renal disease. Chronically elevated blood
glucose levels cause renal hypertension and excess kidney perfusion with
leakage from the renal vasculature. The excess leakiness allows larger
substances, such as proteins, to be filtered into the urine.
____ 131. The client with type 2 diabetes is prescribed to take the antidiabetic
agent nateglinide (Starlix). Which statements made by the client indicates
correct understanding of this therapy?
a. I'll take this medicine with my meals.
b. I'll take this medicine 15 minutes before I eat.
c. I'll take this medicine just before I go to bed.
d. I'll take this medicine as soon as I wake up in the morning.
131. ANS: B
Nateglinide is a D-phenylalanine derivative that causes the beta cells of the
pancreas to undergo depolarization and release a small amount of preformed
insulin. The peak action occurs about 20 minutes after ingestion. To have the
best action and prevent hypoglycemia, clients are instructed to take the drug
about 15 minutes before eating.
____ 132. Which clinical manifestation in a client with uncontrolled diabetes
mellitus should the nurse expect as a result of the presence of ketoacid in the
blood?
a. Increased rate and depth of respiration
b. Extremity tremors followed by seizure activity
c. Oral temperature of 102 F (38.9 C)
d. Severe orthostatic hypotension
132. ANS: A
Ketoacidosis decreases the pH of the blood, stimulating the respiratory
control areas of the brain to bufer the efects of increasing acidosis. The rate
and depth of respiration are increased (Kussmaul respirations) in an attempt
to excrete more acids by exhalation.

133. Which of the following assessments made by the nurse indicates that
clients has a typical sign of a hip fracture? The client right leg is:
a. rotated internally
b. held in a flexed position
c. adducted
d. shorter than the leg on the unafected side
133. ANS. D After hip fracture, the leg on afected side is characteristically
shorter than the unafected le, Typically it is also abducted and rotated
externally. Pain is usually present.
____ 134. What is the priority nursing diagnosis for the older adult client who
has very thin skin on the backs of the hands and arms?
a. Risk for Injury
b. Risk for Infection
c. Risk for Disuse Syndrome
d. Risk for Imbalanced Body Temperature: hyperthermia
134. ANS: A
The thinning skin, with a decreased attachment between the dermis and the
epidermis, is at an increased risk for injury in response to even minimal
trauma or shearing events.
____ 135. What question should the nurse ask to determine a possible trigger
for the worsening of a client's psoriatic lesions?"
a. Have you eaten a large amount of chocolate lately?
b. Have you been under a lot of stress lately?
c. Have you used a public shower recently?
d. Have you been out of the country recently?
135. ANS: B
Systemic factors, hormonal changes, psychological stress, medications, and
general health factors can aggravate psoriasis.
____ 136. A nurse discovers that one of your long-term residents has a fungal
infection (candidiasis) beneath both breasts. What strategy should the nurse
use to prevent spread of this infection?
a. Move the client into a private room.
b. Wash your hands after caring for this client.
c. Wear gloves when providing personal care.
d. Do not allow pregnant staf or visitors into the room.
136. ANS: B
The organism that causes this infection lives on the skin of most adults. Good
handwashing is all that is needed to prevent its spread to other people,
although the client will need medication to clear her active infection and
moisture management to prevent its recurrence.
____ 137. The client is a 35-year-old African American woman who had a
breast biopsy 1 year ago and was diagnosed with benign breast disease.

Now, the incision site is elevated, dark, and protrudes beyond her breast skin.
What is the nurses interpretation of these findings?
a. The client has formed a keloid, consisting of collagen and ground
substance, as a result of surgical injury to the skin.
b. There is a high probability that skin cancer has developed as a result of
surgical injury to the skin (Koebner phenomenon).
c. The benign breast disease has undergone malignant transformation to
breast cancer and become locally invasive.
d. The change in the breast biopsy scar represents chronic inflammatory
changes that accompany deep and persistent infection.
137. ANS: A
A keloid is a benign, noninfectious, overgrowth of a scar from an excessive
accumulation of collagen and ground substance after skin trauma. Although
anyone can form a keloid, the propensity is more common among people with
dark skin.
____ 138. Which clinical manifestation indicates that the burned client is
moving into the fluid remobilization phase of recovery?
a. Increased urine output, decreased urine specific gravity
b. Increased peripheral edema, decreased blood pressure
c. Decreased peripheral pulses, slow capillary refill
d. Decreased serum sodium level, increased hematocrit
138. ANS: A
The fluid remobilization phase improves renal blood flow, increasing
diuresis and restoring fluid and electrolyte levels. The increased water
content of the urine reduces its specific gravity.
____ 139. The burned client relates the following history of previous health
problems. Which one should alert the nurse to the need for alteration of the
fluid resuscitation plan?
a. Seasonal asthma
b. Hepatitis B 10 years ago
c. Myocardial infarction 1 year ago
d. Kidney stones within the last 6 month
139. ANS: C
It is likely the client has a diminished cardiac output as a result of the old MI
and would be at greater risk for the development of congestive heart failure
and pulmonary edema during fluid resuscitation.
____ 140. During the acute phase, the nurse applied gentamicin sulfate
(topical antibiotic) to the burn before dressing the wound. The client has all
the following manifestations. Which manifestation indicates that the client is
having an adverse reaction to this topical agent?
a. Increased wound pain 30 to 40 minutes after drug application
b. Presence of small, pale pink bumps in the wound beds
c. Decreased white blood cell count
d. Increased serum creatinine level

140. ANS: D
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps
in the wound bed are areas of re-epithelialization and not an adverse
reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed
through burn wounds to afect kidney function. Any client receiving
gentamicin by any route should have kidney function monitored.
____ 141. The client is taking a medication for an endocrine problem that
inhibits aldosterone secretion and release. To what complications of this
therapy should the nurse be alert?
a. Dehydration, hypokalemia
b. Dehydration, hyperkalemia
c. Overhydration, hyponatremia
d. Overhydration, hypernatremia
141. ANS: B
Aldosterone is a mineralocorticoid that increases the reabsorption of water
and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or
release increases the client's risk for excessive water loss and potassium
reabsorption
____ 142. Which statement made by the client who has a recurrent urinary
tract infection indicates correct understanding regarding antibiotic therapy?
a. If my urine becomes lighter and clear, the infection is gone and I can stop
taking my medicine.
b. Even if I feel completely well, I should take the medication until it is
gone.
c. When my urine no longer burns, I will no longer need to take the
antibiotics.
d. If my temperature goes above 100 F, I should take twice as much
medicine.
142. ANS. B Antibiotic therapy is most efective especially for recurrent
urinary tract infection when the client takes the prescribed medication for the
entire course and not just when symptoms are present.
____ 143. A client with suspected diminished renal functioning has come to
the outpatient clinic for an appointment. What laboratory test would be most
accurate in assessing this clients renal reserve?
a. 24-hour urine for creatinine clearance
b. Serum blood urea nitrogen level
c. Urine specific gravity
d. Serum sodium level
143. ANS: A
A 24-hour creatinine clearance test is necessary to detect changes in renal
reserve. Creatinine clearance is a measure of the glomerular filtration rate.
The ability of the glomeruli to act as a filter is decreased in renal disease.

____ 144. Which measure would be appropriate for the nurse to take in caring
for a client with chronic renal failure receiving dialysis via a right arm fistula?
a. Take the clients blood pressure in both arms.
b. Take the clients blood pressure in the left arm only.
c. Place the right arm in a sling to protect it from injury.
d. Have the client perform active ROM arm exercises to aid blood flow to the
fistula.
144. ANS: B
The blood pressure should be taken in the left arm only to prevent occlusion
of the dialysis fistula.
____ 145. What instruction should the nurse provide to the client who is
scheduled to have an abdominal ultrasound for evaluation of uterine size and
shape?
a. Do not eat or drink after midnight.
b. Completely evacuate your bowels before this procedure.
c. Do not urinate within an hour of having the test, because a full bladder is
needed for best test results.
d. Have someone drive you to and from the test because you will be sleepy
from the anesthesia.
145. ANS: C
The scan is noninvasive and painless. The abdominal and pelvic organs are
better visualized with the bladder full during the scan.
____ 146. Which statement made by the client preparing to have a cervical
biopsy indicates a need for clarification regarding the follow-up care needed?
a. I will not lift objects weighing more than 10 pounds for about 2 weeks.
b. I will refrain from having intercourse for 48 hours.
c. I will rest for 24 hours after the procedure.
d. I will use napkins rather than tampons.
146. ANS: B
The risk for infection and bleeding requires that the client refrain from vaginal
intercourse for 2 weeks (at least) after this procedure.
____ 147. The client who has just been diagnosed with invasive infiltrating
ductal carcinoma asks what this means. What is the nurses best response?
a. The cancer has spread from the breast ducts into surrounding breast
tissue.
b. The cancer has spread from the breast into local lymph nodes and
channels.
c. The cancer has spread from the breast into surrounding tissues and
organs.
d. The cancer has spread from the breast into distant tissues and organs.
147. ANS: A

The term invasive when applied to infiltrating ductal carcinoma means that
the cancer cells are no longer confined to ductal tissue but have spread into
surrounding breast tissue. This term alone, however, does not indicate that
the disease has spread beyond the breast itself
____ 148. Which pathologic description of a breast cancer would the nurse
interpret as being indicative of a better prognosis for long-term survival?
a. Poorly diferentiated; 20% of cells in S phase; estrogen receptor negative
b. Moderately diferentiated; 50% of cells in S phase; estrogen receptor
negative
c. Undiferentiated; 50% of cells in S phase; estrogen receptor positive
d. Highly diferentiated; 10% of cells in S phase; estrogen receptor positive
148. ANS: D
Lower grade malignancies are less aggressive and have a better chance for
long-term survival. Lower grade malignancies are slower growing (have a
smaller percentage of cells in the S phase) and more closely resemble the
diferentiated breast tissue from which they arose. Estrogen receptorpositive
tumors respond better to adjuvant therapy, and the client usually has a
longer survival rate. In addition, estrogen receptorpositive tumors can be
treated with hormonal manipulation techniques.
____ 149. The client asks how soon after a mastectomy she can engage in
sexual activity. What is the nurses best response?
a. You may engage in sexual activity as soon as you are comfortable.
b. You should wait until 3 months have passed before resuming sexual
activity.
c. You may safely engage in sexual activity as soon as the incision has
healed completely.
d. You should undergo counseling or therapy before you consider having sex
again.
149. ANS: A
Sexual intercourse can be resumed whenever the client is comfortable. Until
the incision is healed, clients should be taught how to protect the incision and
avoid contact with the surgical site during intercourse.
____ 150. Which complication of therapy should the nurse teach to the client
prescribed to receive radiation for vaginal cancer?
a. Perineal hypopigmentation
b. Delay of spontaneous menopause
c. Development of vaginal adhesions or stenosis
d. Relaxation of pelvic floor muscles, causing urinary incontinence
150. ANS: C
Radiation treatment causes local inflammation, leading to the development of
fibrotic tissue changes that cause adhesions and/or stenosis. Without
intervention, these changes can decrease the size and elasticity of vaginal
tissues, limiting or inhibiting vaginal intercourse.

GOODLUCK RN's... GODBLESS