block 5 assessment 2 practice questions

A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client’s aPTT is 96 seconds?
a. Increase the heparin infusion flow rate by 2 mL/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time
d. stop the heparin infusion
d

A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching?
a. “you may no longer be able to feel chest pain.”
b. “your level of activity tolerance will not change.”
c. “after 6 months, you will no longer need to restrict your sodium intake.”
d. “you will be able to stop taking immunosuppressants after 12 months.”
a

A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?
A. confusion
B. friction rub
C. hypertension
D. dry skin
a

A nurse in the emergency department is caring for a client who had an anterior MI. The client’s history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
A. administering IV morphine sulfate
B. administering oxygen at 2 :/min via nasal cannula
C. helping the client to the bedside commode
D. assisting with thrombolytic therapy
d

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
A. ventricular depolarization
B. Guillain-Barre syndrom
C. myelodysplastic syndrome
D. Valvular disease
D

A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
A. obtain blood samples for laboratory testing
B. Tell the client to report vision changes
C. Place the head of the bed at 45 degrees
D. initiate an IV
C

a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for and report which of the following findings to the provider immediately?
a. slurred speech
b. irregular pulse
c. dependent edema
d. persistent fatigue
a

A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?
a. inc abdominal girth
b. weak peripheral pulses
c. jugular vein distention
d. dependent edema
b

a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications?
a. SOB
b. lightheadedness
c. dry cough
d. metallic taste
b

a nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?
a. sternal instability
b. inc WBC count
c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration
d. sinus rhythm with occasional premature atrial contraction and HR 88/min
c

A nurse is preparing a client for coroncary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
a. hemoglobin 14.4 g/dL
b. history of peripheral arterial disease
c. urine output 200 mL/4 hr
d. previous allergic reaction to shellfish
d

A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
a. “I can’t get rid of these hiccups.”
b. “I feel dizzy when i stand.”
c. “My incision site stings.”
d. “I have a headache.”
a

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
a. apply the new patch to the same site as the previous patch
b. place the patch on an area of skin away from skin folds and joints
c. keep the patch on 24 hr per day
d. replace the patch at the onset of angina
b

A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
a. serosanguinous drainage on dressing
b. severe pain with coughing
c. urine output of 20 mL/hr
d. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
c

A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?
a. neck vein distention
b. bowel sounds
c. peripheral edema
d. urine output
d

A nurse is watching a client’s ECG monitor and notes that the client’s rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?
a. delivery of precordial thump
b. vagal stimulation
c. administration of atropine IV
d. defibrillation
b

A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider?
a. weight gain of 2 lb in 24 hr
b. inc of 10 mmHg in systolic BP
c. dyspnea with exertion
d. dizziness when rising quickly
a

A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
a. explore the clients family history of peripheral vascular disease
b. note the presence or absence of pain at the ulcer site
c. inquire about the presence or absence of claudication
d. ask if the client has had a recent infection
c

A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values?
a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
c

a nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
a. a client who has hypothyroidism
b. a client who has DM
c. a client whose daily caloric intake consists of 25% fat
d. a client who consumes two bottles of beer a day
b

a nurse is planning a presentation about hypertension for a community women’s group. which of the following lifestyle modifications should the nurse include (select all that apply)
a. limited alcohol intake
b. regular exercise program
c. dec Mg intake
d. reduced K intake
e. smoking cessation
a, b, e

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft surgery. Which of the following client findings should the nurse report to the provider?
a. mediastinal drainage 100 mL/hr
b. BP 160/80 mmHg
c. Temp 37.1 (98.8)
d. K 3.8 mEq/L
b

A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
a. “I’m still hungry after the bowl of cereal I ate at 7am.”
b. “I didn’t take my heart pills this morning because the doctor told me not to.”
c. “I have had chest pain a couple of times since I saw my doctor in the office last week.”
d. “I smoked a cigarette this morning to calm my nerves about having this procedure.”
d

A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following?
a. left ventricular failure
b. peripheral vasodilation
c. pericardial effusion
d. dec vascular volume
a

A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
a. “My arthritis is really bothering me because I haven’t taken my aspiring in a week.”
b. “My blood pressure shouldn’t be high because I took my BP medication this morning.”
c. “I took my warfarin last night according to my usually schedule.”
d. “I will check my BP because I took a reduced dose of insulin this morning.”
c

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI?
a. myoglobin
b. c-reactive protein
c. creatine kinase- MB
d. Homocysteine
c

a nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?
a. hemoglobin 14 g/dL
b. minimal bruising of extremities
c. reduced circumference of affected extremity
d. INR 2.5
d

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?
a. tendon pain
b. persistent cough
c. frequent urination
d. constipation
b

A client is being evaluated in the ED for a possible brain attack (stroke). Assessment findings consistent with a brain attack include which of the following? (select all that apply)
a. facial droop
b. slurred speech
c. weakness of affected extremity
d. crackles in lungs
e. decreased urine output
a, b, c

A client is admitted with a diagnosis of acute stroke. The provider orders “diet as tolerated.” Before feeding this client, which nursing action is priority?
a. determine client’s food preferences
b. elevate the head of the bed 30 degrees
c. assess client’s swallowing reflex
d. review serum albumin level to determine appropriate diet
c

Which of the following recommendations is best for the nurse to suggest to a client as a way to keep BP under control?
a. follow a regular exercise program
b. attend a stress-reduction support group
c. avoid use of tobacco and limit alcohol intake
d. increase intake of fruits and veggies
a

which of the following assessment findings indicate to the nurse the client is experiencing left-sided HF?
a. fatigue and dyspnea
b. Cheyne-Stokes breathing and orthostatic hypotension
c. liver tenderness and peripheral edema
d. anorexia and dependent edema
a

the nurse is teaching a group of adult clients about risk for coronary artery disease, especially MI. This nurse should instruct this group of clients about which of the following as ways to decrease incidence of CAD and MI? (select all that apply)
a. “if you smoke, quit”
b. “be sure to consume at least 10% of your calories from saturates fats.”
c. “Engage in moderate exercise for 20-30 minutes 3-5 times a week.”
d. “jog at a mild pace for at least one hour a day.”
e. “check BP regularly.”
a, c, e

Which client response requires a focused GI assessment?
a. “I take ibuprofen 600 mg three times a day for arthritis pain.”
b. “I experienced occasional constipation.”
c. “I have had dentures for 3 years.”
d. “spicy foods upset my stomach.”
a

After abdominal surgery, what is the most reliable assessment that suggests return of peristaltic movement?
a. presence of normal bowel sounds
b. client report of passing flatus
c. client report of hunger
d. absence of nausea
b

when administering a new medication to an older client, the nurse understands that:
a. the dose may need to be increased to greater-than-normal levels
b. close monitoring is needed because toxic levels may develop
c. the dose may need to be decreased to lower-than-normal levels
d. nausea and vomiting may develop rapidly and are common side effects in older adults
c

A 59 year old man was admitted to the hospital with dysphagia, stating that he has been having more difficulty swallowing food, even when he has chewed it throroughly and drinks plenty of water. A CT scan shows an area for a possible esophageal tumor. The client unergoes a biopsy and is awaiting results. The client asks, “what am I going to do if this is cancer?” What is the most appropriate nursing response?
a. “You will have surgery to remove it.”
b. “I would choose to get radiation.”
c. “The doctor will go over the options with you.”
d. “You sound as if you are concerned about the biopsy results.”
d

The client with a long history of osteoarthritis is at risk for developing GERD if he or she:
a. weighs 220 pounds
b. frequently takes NSAIDs for pain
c. consumes food with calcium supplementation
d. has limited physical mobility
b

A priority nursing intervention in the care of a client with a hiatal hernia is:
a. providing nutrition education
b. promoting regular exercise
c. providing medication education
d. instructing the client on signs and symptoms of intestinal strangulation
a

Which assessment variable requires immediate intervention post esophagectomy?
a. BP 170/88
b. respiratory rate 28
c. temp 38.1
d. pain 6/10
b

An older client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea, and vomiting, and fatigue for the past 24 hours. The nurse should monitor the client for what priority assessment?
a. dehydration
b. hypokalemia
c. hypernatremia
d. perineal skin breakdown
a

A client has recently been placed on corticosteroids as treatment for ulcerative colitis. the nurse should monitor the client’s laboratory results for evidence of which condition?
a. hypernatremia
b. hypercalcemia
c. hyperglycemia
d. hyperkalemia
c

What priority laboratory analysis should the nurse review when caring for a client with Crohn’s disease?
a. c-reactive protein
b. serum albumin
c. hemoglobin
d. potassium
c

A client is admitted to the acute medical client care unit. The nurse reviews her admission lab results. Which result supports a diagnosis of malnutrition?
a. serum albumin 3.5 g/dL
b. hematocrit 37%
c. Hemoglobin 12g/dL
d. Prealbumin 13 mg/dL
d

Upon assessment the client is noted to have conjunctival xerosis, dry skin, follicular hyperkeratosis and bright magenta (purple) tongue. Which vitamin deficiency does the nurse suspect?
A. Vit A
B. Vit C
C. Vit D
D. Vit K
a

what is a potential outcome when administering total parenteral nutrition (TPN)?
a. infection
b. hyperglycemia
c. electrolyte imbalance
d. dehydration
b

an older adult with anemia requests help with his menu choices. What type of food should the client be encouraged to eat?
a. one-half cup of prunes
b. skim milk
c. wheat bread
d. oranges
b

What percentage of adults in the US are obese (BMI>30)?
a. 14%
b. 21%
c. 34%
d. 47%
c

A client receiving chemotherapy for treatment of cancer is at greatest risk for developing:
a. Stomatitis
b. Xerostoma
c. oral abscess
d. candidiasis
a

A 26-year-old female client informs the nurse that she has had red, raised lesions at the base of the tongue and on the inside of her mouth for the past 2 weeks. What question should the nurse ask the client?
a. “Have you seen a dentist recently?”
b. “Do you smoke cigarettes?”
c. “Do you have a history of HIV?”
d. “What type of work do you do?”
c

An older client with poor oral hygiene was admitted after a fall in which he sustained a fractured hip. What is the priority nursing intervention?
a. initiate oral care every 6 hours
b. implement aspiration precautions
c. use lemon glycerin swabs to moisten the mouth as needed
d. request a consult with a registered dietitian
a

A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider?
a. 0.45% sodium chloride IV
b. Milk of Magnesia
c. Ciprofloxacin
d. Potassium
b

A nurse is caring for a client who has GERD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effects?
a. Thrombocytopenia
b. hearing loss
c. hypotension
d. ataxia
d

A nurse is caring for a client who has colorectal cancer and is recieving chemotherapy. The client asks the nurse why blood is being drawn for a carcinoembryonic antigen (CEA) level. Which of the following responses by the nurse is appropriate?
a. “The CEA determines the current stage of you colon cancer.”
b. “The CEA determines the efficacy of your chemotherapy.”
c. “The CEA determines if the neutrophil count is below the expected reference range.”
d. “The CEA determines if you are experiencing occult bleeding from the GI tract.”
b

A nurse is providing discharge teaching for a client who has chronic cholecystitis. Which of the following food selections by the client indicated the teaching was effective?
a. unsalted nuts
b. bologna
c. cheddar cheese
d. bananas
d

A nurse is providing discharge for a client who has gastritis and a new prescription for famotidine. Which of the following client statements indicated the teaching was effective?
a. “I should make sure the water I drink is filtered.”
b. “I should expect immediate pain relief after starting this therapy.”
c. “I will drink iced tea with my meals and snacks.”
d. “I will monitor by blood glucose level regularly while taking this medication.”
a

What symptom does the nurse expect the client with intussusception to exhibit?
a. decrease in pulse
b. extremely elevated body temperature
c. singultus (hiccups)
d. frequent bloody stools
c

emotional stress is a risk factor for irritable bowel syndrom (IBS)
true false
false

which ethnic group has a higher incidence of colorectal cancer?
a. hispanic
b. asian
c. caucasian
d. african-american
d

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?
a. bloody diarrhea
b. board-like abdomen
c. periumbilical cyanosis
d. increased bowel sounds
b

a nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect?
a. oral temp 38.4
b. WBC 6,000/mm3
c. bloody diarrhea
d. nausea and vomiting
e. right lower quadrant pain
a, d, e

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of acute gastric dilation?
a. hiccups
b. elevated BP
c. bradycardia
d. left lower quadrant pain
a

A nurse is caring for a client who has hepatic encephalopathy. The client asks the nurse if she can have a larger portion of beef for dinner. Which of the following responses by the nurse is appropriate?
a. “Beef is too high in fat, but can i request chicken as a substitute.”
b. “You need to increase your fluid intake. Would you like beef and noodle soup?”
c. “You should limit your animal protein intake. Can I get you a veggie burger instead?”
d. “You need to limit calories. Would you like some sugar-free gelatin?”
c

Immunity that is developed by vaccination or immunization is known as:
a. natural active
b. passive acquired
c. innate/native
d. artificial active
d

A patient with inflammation has a high eosinophil count. The nurse recognizes that this finding most likely indicated that:
a. humoral and cell-mediated immunity is being stimulated
b. the inflammatory response has been stimulated by infection
c. tissue damage has been caused by an allergen-antibody reaction
d. the inflammation has become chronic with persistent tissue damage
c

Which cell types associated with the inflammatory response participate in phagocytosis?
a. neutrophils and eosinophils
b. macrophages and neutrophils
c. macrophages and eosinophils
d. eosinophils and basophils
b

A nurse is providing discharge teaching for a client who has chronic hepatitis C. which of the following statements by the client indicates an understanding of the teaching?
a. “I will avoid alcohol until I’m no longer contagious.”
b. “I will avoid medications containing acetaminophen.”
c. “I will decrease my intake of calories.”
d. “I will need treatment for 3 months.”
b

A nurse is providing discharge teaching for an older adult client who has mild diverticulitis. which of the following client statements indicates an understanding of the teaching?
a. “I may experience right lower quadrant pain.”
b. “I will remain active by working in my garden every day.”
c. “I should eat foods that are low in fiber.”
d. “I will use a mild laxative every day.”
c

A nurse is providing discharge teaching for a client who has GERD. Which of the following client statements indicates the teaching was effective?
a. “I will decrease the amount of carbonated beverages I drink.”
b. “I will avoid drinking liquids for 30 minutes after taking a chew-able antacid tablet.”
c. “I will eat a snack before going to bed.”
d. “I will lie down for at least 30 minutes after eating each meal.”
a

A nurse is reviewing the lab results of a client who has hepatic cirrhosis. Which of the following lab findings should the nurse report to the provider?
a. Albumin 4.0 g/dL
b. INR 1.5
c. Bilirubin 0.2 mg/dL
d. Ammonia 180 mcg/dL
d

A nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the following medications inhibits gastric acid secretion?
a. calcium carbonate
b. famotidine
c. aluminum hydroxide
d. sucralfate
b

A nurse is providing teaching about dietary management to prevent dumping syndrome for a client who is post-op following a gastrectomy. The nurse should encourage the client to include which of the following foods in his diet?
a. lactose-reduced milk
b. eggs
c. grape juice
d. honey
b

A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider?
a. intolerance to high-fiber foods
b. liquid ileostomy output
c. dark purple stoma
d. sensation of burning during bowel elimination
c

A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect?
a. negative fecal occult blood test
b. decreased serum carcinoembryonic antigen (CEA) level
c. hemocrit 43%
d. hemoglobin 9.1 g/dL
d

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
a. blood glucose 110 mg/dL
b. Increased serum amylase
c. WBC 9,000/mm^3
d. Decreased bilirubin
b

A nurse is caring for a client who has duodenal ulcer. which of the following findings should the nurse expect?
a. the client described the pain as spasms in the right lower quadrant of the stomach
b. the client describes the pain as pressure felt in the epigastrium
c. The client states the pain occurs as soon as food enters the stomach
d. the client states the pain occurs 1.5-3 hrs after meals and during the night
d

A nurse is assessing a client who has acute hepatitis B. Which of the following findings should the nurse expect?
a. joint pain
b. obstipation
c. abdominal distention
d. periumbilical discoloration
a

A nurse is assessing a client who has Crohn’s disease. Which of the following findings should the nurse expect?
a. Fatty, diarrheal stools
b. Hyperkalemia
c. weight gain
d. sharp epigastric pain
a

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching?
a. Notify the provider if bloating occurs
b. expect to have two to three soft stools per day
c. restrict carbs in the diet
d. limit oral fluid intake to 1000 mL/day of clear liquids
b

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first?
a. insert an NG tube
b. administer ceftazidime
c. identify the clients current level of pain
d. instruct the client to remain NPO
c

A nurse is teaching a client how to prepare for a colonoscopy. which of the following instructions should the nurse include in the teaching?
a. begin drinking the oral liquid preparation for bowel cleansing on the morning of the procedure
b. drink full liquids for breakfast the day of the procedure, and then take nothing by mouth for 2 hr prior to the procedure
c. drink clear liquids for 24 hr prior to the procedure, and then take NPO by mouth for 6 hr before the procedure
d. Drink oral liquid preparation for bowel cleansing slowly
c

A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include?
a. measure abdominal girth daily
b. administer warfarin at the same time each day
c. provide a daily intake of 4 g of sodium
d. assess breath sounds every 12 hours
a

A nurse is assessing a client who has upper GI bleeding. Which of the following findings should the nurse expect?
a. hypoactive bowel sounds
b. epigastric pain
c. hypotension
d. pernicious anemia
c

A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbation over the past 3 years. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbation (select all that apply)
a. use progressive relaxation techniques
b. increase dietary fiber intake
c. drink two 240 mL (8oz) glasses of milk per day
d. arrange activities to allow for daily rest periods
e. restrict intake of carbonated beverages
a, d, e

A nurse is assessing a client immediately following a paracentesis for the treatment of ascities. Which of the following findings indicates the procedure was effective?
a. presence of a fluid wave
b. increased HR
c. equal pre- and post-procedure weights
d. decreased shortness of breath
d

A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend?
a. eggs
b. fish
c. yogurt
d. broccoli
c

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider?
a. spider angiomas
b. peripheral edema
c. bloody stools
d. jaundice
c

Which clinical manifestation reported by a client suggests to the nurse that anemia is a possibility?
a. difficulty sleeping
b. cold hands and feet
c. chronic headaches
d. shortness of breath
d

A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor for and report which of the following findings immediately to the provider?
a. watery diarrhea
b. vaginitis
c. fever
d. nausea and vomiting
a

A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following is an appropriate action for the nurse to take?
a. sympathize with the clients feelings
b. reassure the client that the surgery will go fine
c. change the topic of discussion
d. provide concise, factual information
d

A nurse is providing preoperative teaching for a client. which of the following prescribed medications should the nurse instruct the client to discontinue 48 hours prior to the surgery?
a. furosemide
b. digoxin
c. prednisone
d. warfarin
d

A nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery. The nurse should report which of the following findings to the provider?
a. K+ level 2.8 mEq/L
b. Na level 140 mEq/L
c. INR 1.5
d. BUN 12mg/dL
a

A nurse is caring for a client who is post-op and has a Jackson-Pratt drain in place. Which of the following interventions should the nurse use to ensure proper functioning of the drain?
a. secure the drain to the client’s bed sheet
b. clamp the drain when the client is ambulating
c. empty and compress the drain reservoir as needed
d. keep the drain higher than the surgical incision
c

A nurse is providing teaching for a client who is scheduled to undergo moderate (conscious) sedation for a bronchoscopy. The nurse should verify that the client understands the procedure when the client states which of the following?
a. “I will need to complete a bowel prep the day before the procedure.”
b. “I will drink plenty of fluids the morning of the procedure.”
c. “I can eat as soon as the procedure is over.”
d. “I can expect to feel sleepy for several hours after the procedure.”
d

A nurse is taking a preoperative medication history on a client who is scheduled for surgery. Which of the following medications should the nurse recognize as placing the client at risk for complications due to interaction with anesthetic agents?
a. captopril
b. atorvastatin
c. ranitidine
d. ciprofloxacin
a

A nurse is caring for a client who is post-op following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications?
a. instruct the client to exhale into incentive spirometer ever 1-2 hr
b. minimize amount of pain med the client receives to prevent sedation
c. advise the client to splint the surgical incision when coughing and deep breathing
d. reposition the client every 8 hours for the first 48 hours
c

A nurse is providing preoperative teaching for a client who is scheduled for a mastestomy. Which of the following statements by the client indicated a need for further teaching?
a. “I should wait 3-4 weeks after surgery to do water aerobics.”
b. “Ill wait until a week after surgery to start hand strengthening exercises.”
c. I should avoid having blood from the arm on the side I had my mastectomy.”
D. “ill be able to shower after the doctor moves the drain.”
b

A nurse is providing teaching for a client who is in the immediate post-op period and has a PCA pump. Which of the following statements should the nurse include in the teaching?
a. “You will receive a dose of medication every time you push the button.”
b. “do not allow your family to push the PCA button if you are sleeping.”
C. ” you cannot receive too much medication by pushing the button.”
d. “Do not push the PCA button until your pain reached a severe level”
b

A nurse is assessing a client in the PACU to determine if he is ready for discharge. Which of the following assessment findings indicated that the client is ready for discharge?
a. the clients pre-op BP was 140/90 mmHg and her post-op BP is 100/65 mmHg
b. the client rates her pain at 4 on a 0-10 scale
c. the client is able to move all four extremities on command
d. the client requires tactile stimulation
c

A nurse is receiving afternoon report on four clients who have returned from the PACU this morning. The nurse should assess which of the following clients first?
a. a client who is post-op following a thoractomy has a chest tube with 150 mL bright-red of blood in the collection chamber from the past hour
b. a client who is post-op following a small bowel resection and has a temporary colostomy has absent bowel sounds in all four quadrants
c. a client who is post-op following a tonsillectomy has had one episode of coffee-ground emesis
d. a client who is post-op following a total knee arthroplasty and has a PCA pump is reporting a knee pain level of 7/10
a

A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client’s vital signs, the nurse finds that the tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first?
a. contact the anesthesiologist
b. assist with endotracheal intubation
c. increase the clients flow of oxygen
d. use the head-tilt, chin-lift method to open the airway
d

A client had an open transverse colectomy 5 days ago. The nurse enters the client’s room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?
a. go to the nurses station to seek assistance
b. reinsert the organs into the abdominal cavity
c. place the client in reverse Trendelenburg position
d. obtain vital signs to assess for shock
d

A nurse is caring for a client who is 2 days post-op following a cholecystectomy. The client has been vomiting for the past 24 hours and reports a pain level of 8/10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first?
a. draw the clients blood for electrolytes
b. insert an NG tube
c. administer pain med
d. initiate I&O
b

A nurse is caring for a client receiving moderate (conscious) sedation with midazolam and fentanyl. The client’s respirations decrease from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following actions should the nurse take first?
a. gather suction equipment
b. obtain equipment necessary for CPR
c. administer reversal agents
d. start an additional IV
c

A nurse is assessing a client who is 2 hr post-op following an appendectomy. Which of the following findings should the nurse report to the provider?
a. urine output 20 mL/hr
b. temperature 36.5C (97.9F)
c. a 2cm x 2cm area of bloody drainage on the dressing
d. Jackson-Pratt drainage 30 mL/hr
a

A nurse is caring for a client who is post-op. To prevent formation of thrombi in the post-op period, the nurse should do which of the following?
a. change the client’s position every 4 hr
b. have the client perform dorsal and plantar flexion of the feet every hour
c. place the client in bed with a pillow under the knees
d. assess pedal and posterior tibial pulses every 2 hr
b

A nurse is caring for a client who has an NG tube set to continuous low suction following a gastrectomy. Which of the following findings should the nurse report to the provider?
a. gastric distention
b. absent bowel sounds
c. incisional pain of 9/10
d. small amount of bloody drainage in the NG tube
a

A nurse is caring for a client during surgery. To help prevent neuromuscular complications during the surgical procedure, the nurse should take which of the following actions?
a. administer an IV bolus of normal saline
b. massage the client’s lower extremities during the procedure
c. support the client’s bony prominence with foam padding
d. extend the clients joints and maintain position with padded straps
c

A nurse is caring for a client who has surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform?
a. cut a slit in a 4 inch square gauze pad to place around the drain
b. use sterile technique when performing dressing changes
c. establish a clamping schedule prior to removal
d. apply negative pressure when emptying the drain
b

A nurse is assessing a client’s recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first?
a. pain
b. cold
c. touch
d. warmth
c

A nurse is completing a pre-op assessment for a client who is a jehovah’s Witness. Which of the following should the nurse recognize as a situation that could pose special care needs for this client?
a. having pre-op blood drawn
b. giving info about sexual history
c. providing informed consent to receive blood products
d. receiving care from a nurse of the opposite gender
c

A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following observations requires an intervention?
a. the scrub tech is wearing a watch under his scrubs
b. the circulating nurse opens dressing packages before applying sterile gloves
c. the surgeon has her hands folded 5 cm above the waist
d. the holding area nurse is performing client education
a

A nurse is monitoring a client receiving succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops malignant hyperthermia?
a. administer dantrolene
b. institute seizure precautions
c. measure blood glucose
d. give IV atropine
a

A nurse is completing an intial PACU assessment of a client who is post-op following a total knee arthroplasty and received spinal anesthesia. Which of the following findings indicated the need to notify the provider?
a. the client states having numbness to the lower extremities bilaterally
b. spinal anesthesia is at T10 level
c. The client rouses to tactile stimuli
d. the client reports chest pain
d

A nurse is preparing a client for surgery. The client appears apprehensive and asks multiple questions about the risks of the procedure. Which of the following actions should the nurse take before witnessing the client’s signing of the informed consent?
a. explain the risks and benefits of the surgery to the client
b. ask the surgeon to speak to the client for clarification
c. reassure the client that the procedure is necessary for recovery
d. document the client’s lack of pre-op teaching
b

A nurse who is working in the surgical suite should check that the rooms are maintained at a cool temp with low humidity to decrease which of the following?
a. risk for malignant hyperthermia
b. amount of anesthetic agents clients need
c. risk of infection
d. amount of oxygen clients need
c

A nurse is providing discharge instructions for a client who is post-op following abdominal surgery. Which of the following client statements indicated a need for further teaching?
a. “I will call my doctor if I have an increase in temp or wound drainage”
b. “I will eat foods high in protein and vitamin C during my recovery”
c. “I will complete the entire course of antibiotics.”
d. “I will remain on bed rest until my follow-up appointment with my doctor.”
d

A nurse is caring for a client who is post-op following a total hip arthroplasty. Which of the following assessment data indicated the client is at an increased risk for infection?
a. use of herbal remedies
b. long-term use of corticosteroids
c. excessive exposure to sunlight
d. diet high in cholesterol
b

A nurse is assessing a client who is 2 days post-op following a total prostatectomy. The nurse notes the client’s right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take?
a. apply an ice pack to the clients right calf
b. elevate the client’s right extremity
c. administer testosterone to the client
d. gently massage the client’s right half
b

Which client response during a genitoreproductive history requires further exploration by the nurse?
a. “I have had one pregnancy and one child”
b. “I began my menses at age 14”
c. “I would rather not answer questions about by sex life with my husband.”
d. “My breasts hurt in the beginning of my menstrual cycle.”
c

Which ethnic group has a higher frequency of developing testicular cancer?
a. caucasian
b. african american
c. hispanic/latino
d. asian american
a

A woman on oral contraceptives reports increasing fatigue and shortness of breath over the past 6 months. The nurse should evaluate the client’s diet for deficiency in what nutrients?
a. protein
b. vit b1 and folic acid
c. vit a and c
d. vit b6 and b12
d

What is the estimated number of deaths in males each year attributed to breast cancer in the US?
a. 100
b. 225
c. 450
d. 600
c

A premenopausal woman reports a mass in her right breast. She also has greenish-brown discharge from the nipple, redness and swelling over the mass, and palpable axillary lymph nodes. The nurse suspects that the client’s condition is:
a. pre cancerous
b. cancerous
c. benign
d. infectious
c

Which age group of woman has the greatest odds of being diagnosed with breast cancer?
a. 30s
b. 40s
c. 50s
d. 60s
d

which ethnic group has the highest incidence of melanoma?
a. asian
b. african american
c. white
d. hispanic/latino
c

evaporation of the water contained in the sweat from eccrine sweat glands can cause the body to lose how much fluid in a single day?
a. 500 mL
b. 1-2 L
c. 5-7 L
d. 10-12 L
d

true/false- Dandruff can cause hair loss.
true

which physical change may be expected by the client who has undergone a total abdominal hysterectomy?
a. the client will no longer have a period
b. vaginal drainage may be bloody for the first month
c. although the ovaries were removed, no menopausal symptoms will be experienced
d. nutrition education to avoid weight gain is necessary
a

A 51-year-old female who is perimenopausal broke her arm after a fall in her home. She also reports progressive fatigue, insomnia, and hot flashes. What question should the nurse ask first to collect more data surrounding the client’s health history?
a. How often do you engage in exercise?
b. can you tell me about your diet?
c. what medications are you currently taking?
d. do you have a history of heart disease?
a

which female reproductive cancer claims the most lives?
a. breast
b. ovarian
c. cervical
d. endometrial
b

A client presents to the ED with urticaria covering his legs and arms after hiking in the woods. In addition to applying a topical antihistamine, interventions for symptom relief may include:
a. taking a warm shower
b. taking a cool shower
c. applying used tea bags over the lesions
d. applying alcohol to the lesions
b

upon removing a dressing from a client’s wound, a pronounced odor is present. What should the nurse do?
a. notify the physician of a possible wound infection
b. clean the wound and reassess for presence of infection
c. culture the wound and anticipate an order for antibiotics
d. no action is necessary at this time
b

An older adult client has been brought to the hospital for generalized weakness after a fall in the nursing home. He is confused, unable to eat independently, and cannot turn himself in bed. Assessment reveals a pressure ulser over his coccyx that is 3 cm wide and 4 cm long, with eschar present. Which technique will be used to remove the necrotic tissue?
a. surgical removal
b. biologic dressing
c. continuous dry gauze dressing
d. dressings along with a topical enzyme prep
d

an older male is being evaluated for hydronephrosis. what priority health history question may provide info about a possible cause of this disorder?
a. “do you have high BP?”
b. “do you have difficulty starting and continuing urination?”
c. “do you have a family history of kidney disease?”
d. “have you had a recent UTI?”
b

The client who has undergone a transurethral resection of the prostate (TURP) is at high risk for developing:
a. perforation
b. hemorrhage
c. infection
d. bladder spasms
b

How many American males are estimated to die of testicular cancer annually?
a. 350
b. 520
c. 725
d. 1050
a

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