Medical Surgical Nursing Review Series

Medical Surgical Nursing Review Series

1. The client in chronic renal failure has a serum potassium level of 5.2 mEq/L. Which of the following would nurse do next?a. Prepare to administer IV potassiumb. Notify the physician immediatelyc. Prepare to administer ion exchange resind. Continue to monitor client

D: The client’s potassium level is normal. Therefore, the nurse would monitor the client. 2. When discussing anticholinesterase agents with the client diagnosed with myasthenia gravis,

the nurse would include which of the following instructions?a. Taking the medication on an empty stomach to increase absorptionb. Ensuring for available bathroom facilities due to increased urinary frequencyc. Obtaining serum drug levels every 3 monthsd. Taking the drug 30 minutes before activities to obtain peak effects

D: Anticholinesterase agents inhibit breakdown of acetylcholine at the neuromuscular junction. Taking the medication 30 minutes before activities allows the drug to reach its peak effect, thereby increasing the client’s muscle strength.

3. Nursing interventions for the client experiencing pruritus would include which of the following?a. Instructing the client to wear extra clothingb. Washing skin with antibacterial soap and waterc. Maintaining a warm room temperatured. Instructing the client to keep rooms humidified

D: Clients with pruritus need moisture in the environment to reduce the drying effects and subsequent itching. Therefore, keeping the rooms humidified helps to reduce the itch.

4. Which of the following laboratory tests would provide the most specific indication that a client has suffered a myocardial infarction?a. Creatine kinase BBb. Lactic dehydrogenasec. Creatine kinase MBd. Myoglobin

C: Creatine kinase MB, a cardiac specific isoenzyme, is found only in cardiac tissue and rises only when cardiac injury has occurred. This isoenzyme starts to increase within 1 hour, peaking 24 hours of MI.

5. Which of the following must the nurse keep in mind when administering oxygen to a client with a chronic obstructive pulmonary disease (COPD)?a. A facemask is necessary for delivery of adequate concentrationsb. The oxygen must be administered at a low ratec. The client is encouraged to remove the oxygen as often as possibled. Oxygen is reserved for use when the client is short of breath.

B: The primary stimulus to breathe for the client with COPD is the elevated carbon dioxide levels. If oxygen were administered at too high a rate, then the client’s respiratory drive would be depressed.

6. The client demonstrates self-management of low blood glucose reactions when stating which of the following?a. “If I take one lifesaver to reverse my low blood sugar, then I will be fine.”b. “I will drink 4 to 6 ounces of fruit juice and then check my blood sugar.”c. “I will need to ask my doctor for a HgA1C test.”d. “I’ll hold my next dose of insulin if my glucose level is >200 mg/dL.”

B: Four to six ounces of fruit juice provides the client with approximately 15 gm of carbohydrate, the amount the needed to correct a low blood sugar.

7. A parent makes all of the following comments about her young child to the nurse. Which comment would indicate to the nurse that the child may have Rocky Mountain spotted fever?a. “The high fever started 3 days ago when we returned from a camping trip and now there

is a rash.”b. “There are creamy, white, curdlike patches in the mouth and on the tongue and I can’t

get them out.”c. “It is so hard to swallow. There must be an obstruction somewhere in the child’s throat.”d. “First there was a dry cough, and then 2 days ago a sore throat started. Now there is

some difficulty breathing.”A: Rocky Mountain spotted fever is a potentially infectious disease marked by fever and skin rash. The clue in the patient’s statement is the recent return from a camping trip. The infection is usually transmitted by dog, wood, or tick.

8. For the client with chronic renal failure (CRF), which of the following dietary modification instructions would be included in the client’s plan of care?a. Protein restricted to 1 g/kg ideal body weight. b. Increase in foods containing potassium and sodiumc. Foods primarily consisting of complete amino acidsd. Measures to maintain a low-calorie diet

A: For the client with CRF, dietary protein should be decreased to limit the accumulation of end products of metabolism in the blood.

9. Which of the following clinical manifestations would the nurse expect to assess in a client diagnosed with a duodenal ulcer?a. Low-grade fever and left lower quadrant painb. Aching or gnawing pain in the right epigastrium, relieved by eatingc. Burning in the upper epigastrium 30 to 60 minutes after mealsd. Severe localized diffuse abdominal pain and rebound tenderness

B: With a duodenal ulcer, the patient typically complaints of aching or gnawing pain in the right epigastrium, relieved by eating. Pain also occurs 2 to 3 hours after meals and may awaken the client at night.

10. Which of the following interventions would be included in the plan of care for a client experiencing heat stroke?a. Avoiding massaging the clientb. Using a hyperthermia blankerc. Immersing the client in ice cold waterd. Sponging the client with cool water

D: For the client with heat stroke, the goal is to reduce the body temperature as quickly as possible. Sponging the client with cool water is one effective method. Additionally, cool sheets or towels also may be used.

11. A preoperative client has doubts about the upcoming surgery and does not want to sign the informed consent. Which of the following should the nurse do next?a. Notify the surgeon of the client’s failure to signb. Have a responsible family member sign the consent formc. Explain to the client that it must be signedd. Have another nurse get the client to sign the form

A: If a client does not want to sign the consent form, the surgeon must be notified. The client cannot be forced to sign the consent or be urged to sign it. If the client has doubts about the surgery, a second opinion can be requested.

12. Which of the following client statements would indicate a possible problem with peripheral vascular function?a. “I often have pain near my upper right rib and back after eating a heavy meal”b. “I stopped smoking last year, but I still have difficulty breathing sometimes.”c. “I can feel my heart beating in my abdomen when I am lying down”d. “I get pain in my legs when I walk down the street more than two blocks.”

D: complaints of pain in the legs with activity are a cardinal sign of arterial insufficiency. 13. Which of the following would the nurse do to help minimize the risk of bacterial growth

during a transfusion?a. Inspect blood for abnormal colorb. Warm blood prior to transfusionc. Begin transfusion slowly and monitor closelyd. Transfuse blood within 4 hours

D: Transfusing blood within 4 hours and changing the blood tubing every 4 hours are appropriate measure to help decrease the risk for bacterial growth. The longer the blood is allowed to hang at room temperature, the greater the risk for microbial growth.

14. When teaching a group of women about Breast Health Awareness (BHA) and Breast Self-Examination (BSE) at a local community center, the nurse follows the American Cancer Society recommendations. Which of the following would the nurse include in the teachinga. Quarterly BSE until the age of 70 after which BHA and BSE are no longer necessaryb. Yearly BSE and follow up clinical examinations every 6 months after onset of mensesc. Monthly BSE, a yearly clinical examination, and yearly mammograms after age 40d. Bi-monthly BSE and yearly mammograms beginning after the woman has had her first

childC: BHA recommends monthly BSE after menses begins, a yearly clinical examination, and yearly mammograms after age 40

15. Which of the following interventions would be most appropriate when caring for the client with osteomyelitis?a. Administering nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicineb. Removing the traction weights every 4 hours and performing range-of-motion exercisesc. Assessing the neurovascular status of the affected limb frequentlyd. Maintaining the affected limb in the dependent position

C: For the client with osteomyelitis, the nurse must assess the neurovascular status of the affected extremity; the 6 P’s to minimize the risk of complications.

16. While caring for a client with deep venous thrombosis (DVT), the client develops a sudden onset of severe leg pain. The limb becomes pale, cold, numb, and pulseless. Which of the following would the nurse suspect? a. Dissecting aneurysmb. Acute arterial occlusionc. Postphlebitic syndromed. Raynaud’s phenomenon

B: The change in color, temperature, sensation, and pulse accompanied by the sudden onset of pain (the classic “P’s” of assessment) all suggest an acute arterial occlusion

17. Which of the following would the nurse expect to assess in a client with emphysema?a. Distant breath soundsb. Cor pulmonalec. Copious sputumd. Cyanosis

A: With emphysema, air trapping and chronic hyperexpansion of the lungs lead to distant breath sounds.

18. For the client with iron deficiency anemia receiving iron therapy, the nurse would encourage the intake of which of the following vitamins?a. Vitamin B12b. Niacinc. Vitamin Cd. Vitamin D

C: iron absorption is increased in an acid environment. Thus, vitamin C (ascorbic acid) enhances iron absorption.

19. When assessing a client who has an abdominal aortic aneurysm, the nurse monitors the client for which of the following?a. Intermittent episodes of high fever with chillsb. Positive Homan’s sign and calf painc. Paresthesias and loss of position sensed. Pulsatile mass and systolic bruit

D: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm20. Which of the following would be included in the plan of care for a client with an immune

system disorder?a. Prevention of the development of immunityb. Prevention of injury to skin and mucous membranes c. Promotion of the histamine (H1) reaction responsed. Promotion of the inflammatory response

B: the person with an immune system disorder would have an increased risk for infection. The body’s first line of defense against infection is intact skin and mucous membranes. Thus, measures would be used to prevent injury to skin and mucous membranes to minimize the risk of infection.

21. When obtaining a history of a client admitted with endocarditis, which of the following would the nurse consider as most significant?

a. History of coronary artery diseaseb. History of marijuana usec. Prolonged use of steroid therapyd. Dental surgery in the recent past

D: Dental surgery is one of the predisposing factors for the development of endocarditis, creating a portal of entry for microorganisms

22. A client with angina is prescribed nitroglycerin tablets sublingually. Which of the following statements indicates that the medication teaching plan has been successful?a. I’ll keep it with me, carrying it in my plastic pill container boxb. I’ll get a new supply every 6 months even if I don’t use them all upc. I should get relief from the chest pain about 15 minutes after I take the drugd. I swallow the tablet with a large glass of water when I have chest pain

B: Nitroglycerin sublingual tables are inactivated by heat, moisture, air, light, and time. The client should renew his or her supply every 6 months to ensure that the current medications are potent

23. Which of the following clinical manifestations would lead the nurse to suspect that the client with a fracture of the left femur is experiencing a fat emboli.a. Diminished capillary refill, cyanotic nailbeds, and Paresthesiasb. Complaints of shortness of breath, restlessness, and petechiae over the chestc. High fever, chills, and purulent drainage from a skin abscessd. Great toe joint swelling, pruritus, and low back pain.

B: A systematic fat embolus is a life-threatening even, most commonly developing within 24-72 hours after fracture. The manifestations are similar to those for a pulmonary embolism, such as shortness of breath and restlessness. Additionally, chest petechiae, personality changes, crackles, on auscultation, and white sputum are noted.

24. When caring for a client with hypoparathyroidism experiencing tetany, which of the following interventions would demonstrate the nurse’s understanding of the potential complications?a. Monitoring for signs and symptoms of transient diabetes insipidusb. Preparing the client for an adrenalectomyc. Padding the siderails for possible seizuresd. Assessing for the development of ketoacidosis

C: Life-threatening tetany may result in seizures. Therefore instituting seizure precautions, including padding the siderails, demonstrates the nurse understands about the potential injury that may occur secondary to the development of seizures.

25. A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary. Which of the following would the nurse’s best response?a. This will relieve your distress and help you be more comfortableb. This is diagnostic surgery done to confirm or rule out malignancyc. The physician removes the precancerous mass to prevent cancer from occurringd. This will provide a more realistic look to the body part.

B: a biopsy is performed to aid in diagnosing whether a mass is benign or malignant. 26. Which of the following would the nurse identify as indicative of a client’s altered peripheral

vascular function?a. Ankle arm index pressure of 0.4

b. Pulses graded as being +4c. Capillary refill time less than 3 secondsd. Diastolic blood pressure of 84 mm Hg

A: The ankle arm index is an objective indicator of arterial disease. Normal value is 1.0. Values less than 0.5 indicate ischemic rest pain

27. The client with uric acid renal calculi is being discharged from the hospital. Discharge teaching would include which of the following?a. Instructing the client to decrease fluid intake at nightb. Explaining the importance of restricting dietary calciumc. Explaining the importance of avoiding foods high in purined. Encouraging the intake of increased amounts of organ meats

C: uric acid stones result from the breakdown of purines. Therefore, the client should avoid foods high in purines, such as shellfish, anchovies, asparagus, and organ meats.

28. Which of the following would the nurse anticipate administering for the client with idiopathic thrombocytopenia (ITP) who experiences an acute bleeding episode?a. Administration of vitamin Kb. Splenectomyc. Administration of cryoprecipitated. Heparin administration

B: A splenectomy would be the treatment of choice because it will help prevent further sequestration of platelets. Other treatment modalities might include administration of steroids and gamma globulin

29. The nurse would expect to assess which of the following clinical manifestations in the client diagnosed with multiple sclerosis (MS)?a. Weakness of muscles after activity, drooping facial muscles, and ptosisb. Resting tremors, muscle rigidity, and mask-like facial expressionsc. Ascending paralysis of the lower extremities and Paresthesiasd. Muscle weakness, diplopia, and nystagmus

D: MS is a progressive demyelinating disease affecting nerve fibers of the brain and spinal cord, resulting in visual problems, motor problems, fatigue, and mental changes.

30. The nurse would assess which of the following clinical manifestation in the client diagnosed with serious otitis media?a. Plugged feeling in ear, reverberation of own voice, and hearing lossb. Itching, pain, and watery dischargec. Sudden episodes of severe whirling vertigo, tinnitus, and nausead. Bright red, bulging tympanic membranes, fever, and throbbing ear pain.

A: plugged feeling in ear, reverberation of own voice and hearing loss are clinical manifestations of serious otitis media

31. Which of the following signs and symptoms would in the nurse expect to find when assessing a client with fluid volume deficit?a. Flat neck veins and decreased urine specific gravityb. Polyuria and increased blood pressurec. Rales and decreased lung soundsd. Fever and elevated white blood cell count

A: Flat neck veins and decreased urine specific gravity are typical assessment findings in client with fluid loss

32. One day after undergoing a right total hip replacement, which of the following would be appropriate?a. Maintaining the right leg in abduction with an abductor pillowb. Avoiding use of sequential compression devices on the right legc. Monitoring the continuous passive motion machine (CPM)d. Elevating the head of the bed (HOB) to 90 degrees

A: Following a right total hip replacement, the right leg should be kept in abduction using abductor pillow. This helps to prevent dislocation of the prosthesis.

33. Which of the following outcomes would best demonstrates client understanding about measures to prevent the spread and transmission of infection?a. Verbalization of the need to cover mouth when coughingb. Regaining skin and mucous membrane integrityc. Demonstration of proper handwashing after using the toiletd. Maintenance of temperature within normal range without complications

C: Demonstration is the best indicator that a client has understood the teaching and is able to incorporate the information into his usual practices. By demonstrating handwashing, the client is complying with the instructions.

34. The client experiencing a contact dermatitis due to poison ivy notes that the rash has spread to his periorbital and groin areas. The client also reports the itching is much worse. Which of the following should the nurse do?a. Notify the physician since the client’s complaints have worsenedb. Hold the steroids and request an order to discontinue medicationc. Instruct the client to continue with the current regimend. Have the client take frequent hot baths

A: these findings represent a deterioration of the client’s condition, which could have profound consequences. The nurse should notify the physician because the client requires additional medical intervention.

35. Which of the following manifestations would the nurse expect to assess in a client diagnosed with compartment syndrome?a. Atrophy of muscles associated with contracturesb. Mild discomfort and deformityc. Absent pulse and excessive redness and warmthd. Pain excessive for visibly injury and tight, shiny skin

D: Compartment syndrome is edema within a muscle compartment. Most commonly, the skin appears taut and shiny and the client’s complaints of pain are out of proportion to the visible injury. Include decreased capillary refill, cyanotic distal tips, absent pulse, paresthesias, and weakness

36. Which of the following nursing intervention would the nurse institute immediately for the newly admitted client diagnosed with a seizure disorder?a. Padding the head and foot of the bedb. Placing the client on seizure precautionsc. Keeping the bed in a high position with side rails downd. Placing a padded tongue blade at the head of the bed

B: Seizure precautions should be instituted for a client with a seizure disorder to minimize the risk of injury should a seizure occur. Seizure precautions include padding side rails, keeping an oral airway at bedside, maintaining the bed in a low position with side rails up, and making sure all staff are aware of the seizure disorder

37. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which of the following would the nurse do next?a. Call the physicianb. Check the CPK-MG levelc. Prepare the client for angioplastyd. Get a 12-lead EKG

D: For the client experiencing chest pain, obtaining a 12-lead EKG is a priority to reveal possible changes occurring during an acute angina attack that will be helpful in treatment

38. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever of 100.6, and is moderately dyspneic. Which of the following would the nurse suspect?a. Aspiration pneumoniab. Pleural effusionc. Chronic obstructive pulmonary diseased. Pneumoconiosis

A: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by the hacking cough, low-grade fever, and moderate dyspnea.

39. After experiencing an allergic reaction to a wasp sting, the client is being prepared for discharge. The nurse knows that teaching has been effective when the client states which of the following?a. I will carry my anti-sting kit whenever I go outsideb. I’ll return to the emergency room if I’m stung again. c. I know which type of wasp stung me, so I will avoid itd. I’ll be sure to take anti-venom when I go outside

A: an anti-sting kit is used immediately to counteract the body’s reaction to allergen. Having the kit with the client whenever outside provides the client with ready access should a sting occur, possibly warding off a severe anaphylactic reaction

40. The nurse is providing discharge teaching for a client with suppurative otitis media. To prevent forcing contaminated material into the inner ear canal, the nurse would instruct the client to do which of the following?a. Tilt the head sideways when using ear dropsb. Use nasal decongestants during coldsc. Wear ear plugs when around loud noisesd. Blow the nose with the mouth and nostrils open.

D: By keeping the mouth and nostrils open when blowing the nose, the client will avoid forcing mucus into his inner ear.

41. After teaching a group of 16-year-old girls about menstrual flow, which of the following terms, if identified by the group as referring to indicate effective teaching?a. Amenorrhea

b. Metrorrhagiac. Menorrhagiad. Dysmenorrhea

C: menorrhagia is a type of abnormal uterine bleeding defines as excessive bleeding at the usual time of menstrual flow.

42. When providing post-operative care after a bowel resection to the client with a pre-existing history of COPD with frequent exacerbations, for which of the following would the nurse be alert?a. Airway obstructionb. Pneumothoraxc. Atelectasisd. Acute respiratory failure

D: the client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubation, the anesthesia used during surgery, and the experience of surgery.

43. A client arrives in the emergency room following a motor vehicle accident with multiple injuries to the head, chest, and extremities with minimal bleeding. Which of the following would the nurse assess first?a. Level of consciousnessb. Quality of peripheral pulsesc. Airway statusd. Blood pressure

C: when dealing with an emergency, the ABCs – airway, breathing, and circulation – are the priorities. Airway management is a basic function and must be established and maintained first.

44. Following a thoracentesis, which of the following assessment findings would warrant immediate interventions by the nurse?a. Symmetrical respirationsb. Auscultation of crackles bilaterallyc. Complaints of pain at the needle insertion sited. Prolonged periods of uncontrolled coughing

D: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention.

45. Which of the following would be included in the plan of care for a patient experiencing an acute exacerbation of chronic inflammatory bowel diseasea. Assessing the client for fluid volume overloadb. Instructing the client to eat cold foods and decrease smokingc. Monitoring the client’s intake and output every 12 hoursd. Administering intravenous fluid therapy

D: For the client with a severe acute exacerbation of chronic inflammatory bowel disease, fluid and electrolyte loss can be great because of the profuse episodes of diarrhea. Thus fluid and electrolyte replacement usually is administered intravenously to reduce the client’s risk for fluid volume deficit and electrolyte imbalances.

46. Which of the following client complaints would lead the nurse to suspect premenstrual syndrome?

a. Painful menstruation and large menstrual flowb. Fatigue and weight gain on the day prior to mensesc. Mood swings and breast tenderness with the onset of mensesd. Headache and mood swings occurring about 10 days prior to menses

D: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle.

47. Which of the following instructions should be included in the teaching plan for a client receiving antibiotic therapy for acute prostatitis?a. Explaining the importance of remaining on bedrestb. Instructing the client to abstain from sexual intercoursec. Teaching the client to cleanse the glans and prepuce after each voidingd. Discussing the care of the Foley catheter needing to be inserted

B: Abstinence is encouraged during antibiotic therapy in acute prostatitis, although in chronic prostatitis, sexual intercourse is encouraged.

48. When assessing a client preoperatively, the nurse would identify which of the following as a major psychological factor affecting a client’s response to surgery?a. Intellectualizationb. Body image concernsc. Regressiond. Anxiety

D: Anxiety is one of the major psychological factors affects a client’s response to surgery. Thus preoperative teaching is performed to help alleviate or minimize this anxiety. Gear is also another major psychological factor.

49. When caring for the client with diabetic ketoacidosis (DKA), which of the following parameters will the nurse monitor closely?a. Plasma osmolarity for urine concentrationb. Serum calcium for hypercalcemiac. Plasma cortisol for elevationd. Arterial blood gases for pH value.

D: as the name implies, acidosis is possible. The major means for monitory acidosis is with arterial blood gases, primarily the pH level.

50. When assessing an elderly client who has been on prolonged bedrest, the nurse observes a break in the skin through the epidermis with a shallow crater on the hip. Based on this assessment, the nurse identifies this wound as a pressure ulcer, documenting that it is at a. Stage Ib. Stage IIc. Stage IIId. Stage IV

B: a stage II pressure ulcer appears as a break in the skin through the epidermis or dermis. An abrasion, blister, or shallow crater may be present.

51. Discharge teaching for the client diagnosed with psoriasis would include discussing which of the following medical treatments?a. Antibiotics and silver nitrate compressesb. Coal tar therapy and cytotoxic therapy

c. Systemic corticosteroids and antibioticsd. Immunosuppressive agents and plasmapheresis.

B: Treatment for psoriasis may include coal tar therapy, photochemotherapy, and cytotoxic therapy.

52. Which of the following would the nurse assess in the client who experienced a full-thickness burn?a. Mottled appearance with waxy white injured areasb. Painful erythematous area without blistersc. White, cherry red, or black in color, without paind. Red to pale ivory with wet, thin-walled blisters

C: A full thickness burn involves destruction of the entire epidermis and dermis. The area appears to be dry and leathery, and ranges in color from white to cherry red to black. Pain is absent because all superficial nerve endings have been destroyed.

53. A client with pulmonary edema is receiving mechanical ventilation with positive end expiratory pressure (PEEP). When explaining to the student about the rationale for using PEEP, the nurse would include which of the following as its major purpose?a. Allows the client to obtain needed restb. Improves area available for gas exchangec. Increases the client’s CO2 leveld. Increases pulmonary capillary pressure.

B: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange, thus improving the client’s oxygenation.

54. A client who has suffered a right-sided cerebrovascular accident (CVA) who has a left-sided paralysis and manifests unilateral neglect. When developing the client’s plan for rehabilitation focusing on the problem of unilateral neglect, which of the following would be most helpful?a. Providing a calendar, clock, and pictures to help with orientationb. Placing objects within the client’s field of visionc. Providing physical therapy and range-of-motion exercisesd. Telling the client repeatedly to use to left side.

B: unilateral neglect is an inability of a client to recognize the existence of one side of the body. Placing objects within the field of vision allows the client to help with self-care activities, thus participating in his or her own care by increasing the use of the neglected side.

55. While caring for a client with a new amputation, the dressing inadvertently comes off the stump. Which of the following should the nurse do?a. Maintain the client in a supine position to improve peripheral blood flowb. Wrap the limb in an elastic compression bandage immediatelyc. Elevate the limb above the level of the heart to promote venous returnd. Apply a large tourniquet at bedside to prevent massive haemorrhage.

B: Because excessive edema will develop in a short time, resulting in delays in rehabilitation, the nurse should wrap the limb with an elastic compression bandage immediately.

56. When caring for the client with Meniere’s disease, which of the following areas would be the primary concern?

a. Sensory and perceptual alterationb. Impaired physical mobilityc. Increased risk for injuryd. Severe pain

C: because of the vertigo associated with Meniere’s, there is a high risk for injury for these clients.

57. When caring for the client with allergic rhinitis, which of the following would be most appropriate to include in the patient’s plan of care?a. Administering gamma globulin after an exposure to the allergenb. Teaching the client to taper oral corticosteroid dosage when discontinuing itc. Advising the client to use a nasal decongestant spray for a least 3 to 4 weeksd. Administering antihistamines and oral decongestants

D: Antihistamines, oral decongestants, and topical steroids such as in nasal sprays, are used to treat allergic rhinitis.

58. When assessing a client with Grave’s disease, which of the following would the nurse expect to find?a. Renal calculi, polyuria, and polydipsiab. Heat intolerance, hyperreflexia, and frequent stoolsc. Hirsutism, edema, and symptoms of hyperglycemiad. Cold intolerance, delayed, muscle contractions, and constipation.

B: Heat intolerance, hyperreflexia, and frequent stools are clinical manifestations of hyperthyroidism, where the body’s metabolism is increased.

59. A client recently treated for Neisseria gonorrhea comes to the clinic complaining of fever and acute labial pain. She exhibits a red, swollen vulva with a visible nodule. Which of the following would the nurse suspect?a. Bartholinitisb. Syphilisc. Pelvic inflammatory diseased. Atrophic vaginitis

A: Bartholinitis is inflammation of the Bartholin glands located near the vaginal opening and at the base of the labia majora. It frequently occurs following an infection and is characterized by unilateral pain and swelling. An abscess can occasionally be seen.

60. The client with a closed head injury is obtunded with a Glasgow Coma Score of 3. The pupils are fixed and dilated, the blood pressure has gone from 140/94 to 170/62, and the heart rate has gone from 84 to 42. The client is exhibiting which of the following?a. Cushing’s triadb. Curling’s syndromec. Impaired cerebral perfusiond. Cerebral edema

A: Cushing’s triad is characterized by increasing systolic blood pressure, decreasing diastolic pressure, and bradycardia. It is indicative of brain stem involvement and impending herniation.

61. The client who has been receiving long-term glucocorticoid therapy begins developing extra weight gain, moon face, and a buffalo hump. The nurse would explain that this is most likely a result of which of the following?

a. Excessive thyroid hormone productionb. Their treatment for Addison’s diseasec. Oversecretion of antidiuretic hormoned. Defective pancreatic beta cell function

B: Long-term glucocorticoid therapy is the treatment for Addison’s disease and may result in Cushing’s syndrome, commonly manifested by weight gain, moon face, and a buffalo hump.

62. The nurse is obtaining a health history from a client with tuberculosis (TB). Which of the following information should the nurse recognize as pertinent to the diagnosis?a. Severe abdominal cramping and stools test positive for orab. Hemoptysis and cough with a positive Candida antibody testc. Mucopurulent sputum and a positive Mantoux testd. Tachypnea and blood cultures positive for Staphylococcus aureus

C: Tuberculosis is an infection caused most commonly by Mycobacterium tuberculosis, characterized by mucopurulent sputum. The Mantoux test, a skin test for tuberculosis, identifies exposure to the mycobacterium

63. The nurse knows the client with COPD understands the discharge teaching when the client sates which of the following?a. I need to drink at least 2 liters of fluid every dayb. I should smoke only when I am not having difficulty breathingc. I should do everything in the morning so I can rest later ond. I need to take a sleeping pill every night so I wake up rested.

A: Secretions are often very thick and difficult to expectorate for clients with COPD. Therefore, drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration.

64. When preparing the discharge teaching plan for a client with stomatitis, which of the following would be included?a. Using a hard bristle toothbrush for mouth careb. Instructing the client to eat a bland dietc. Discussing the importance of eating spicy and acidic foodsd. Instructing the client to gargle with mouthwash

B: to promote adequate food and fluid intake while minimizing the effects of stomatitis, the client should eat a bland diet and avoid spicy and acidic foods.

65. Which of the following assessment findings would lead the nurse to suspect that a client has experienced retinal detachment?a. Pain, decreased accommodation, and tunnel visionb. Cloudy-appearing lens and loss of visionc. Blurred vision, floating spots, and visual field defectsd. Colored halos around lights and red eye with severe pain

C: With retinal detachment, blurred vision, visual floaters, and visual field defects are noted. Additionally, recurrent flashes of light may be seen. Ophthalmoscopic exam reveals a gray, opaque retina with holes and tears.

66. Which of the following actions is most appropriate for a client who is 12 days post-chemotherapy and being admitted with shortness of breath, a dry hacking cough, and a temperature of 101°F?

a. Initiate the prescribed IV antibiotics after checking the WBC countb. Have the dietary department serve the meals as hot as possible c. Reassure the client that fatigue is a common occurrence after chemotherapyd. Limit the protein and calories in the client’s diet

A: The client is probably neutropenic due to a low neutrophil count on the WBC. This occurs as a result of myelosuppressive activity of the chemotherapy. This is further confirmed by the client’s symptoms of infection.

67. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations, which of the following would be included?a. Administration of antibioticsb. Deep breathing and coughing exercisesc. Administration of oxygen as neededd. Eliminating exposure to pulmonary irritants.

D: one aspect of prevention of prevention of exacerbation focuses on eliminating the causes and contributory factors associated with the disease. One of the major causes or contributing factors for COPD is pulmonary irritants, such as smoke, air pollution, occupational irritants, and allergies. Thus prevention would focus on eliminating these irritants.

68. Which of the following would alert the nurse to a problem requiring immediate intervention for the client with a newly applied above-the-knee cast?a. Assessment of a hot spot on the castb. Smooth cast edges with no breaks or ragged edgesc. Use of a soft bristle toothbrush by the client to alleviate an itchd. The ability to insert two fingers under the cast.

A: Hot spots, if noted on a cast, could indicate an infection under the cast. Evidence of a hot spot requires immediate intervention and notification of the physician.

69. Which of the following is the most important aspect to address when completing preoperative teaching for the client undergoing abdominal surgery?a. Incisional careb. Prognosis after surgeryc. Pain control techniquesd. Need for prophylactic antibiotics

C: the client needs to be aware of and understand that pain will occur after surgery and that medications are available to control the pain.

70. The nurse would expect to assess which of the following in the client diagnosed with herpes zoster (shingles)?a. Thin-walled, honeycombed vesicles around the hands and mouthb. Small, red, scaly patches around the groin extending to the thighsc. Inflamed red rash along the soles of the feet and between the toesd. Painful vesicular eruptions along a route of inflamed nerves

D: Herpes zoster is an infection caused by varicella zoster virus manifested by painful vesicular eruptions along the route of inflamed nerves. Usually unilateral, the inflammation appears as a band of typically involving the thoracic, cervical, or cranial nerves. Itching may precede or accompany the eruption.

71. When evaluating a client’s risk for developing cancer, which of the following clients would the nurse identify as having the highest risk?a. Oncology nurse who takes vitamins C and E dailyb. New breast-feeding mother who works in a bankc. Vegetarian who works at a convenience stored. Asphalt road construction worker who eats meats and potatoes

D: exposure to certain chemicals such as tar, soot, asphalt, oils, and sunlight put this occupation at the highest risk. Additionally, meat and potatoes are low fiber, contributing to the risk of cancer. Plus, some processed meats contain chemicals that have been implicated in the development of cancer.

72. The nurse would include which of the following in the plan of care for client with an L5-S1 intervertebral disc herniation?a. Assessing the skeletal traction insertion for sites of infectionb. Positioning with head of bed elevated and kneed slightly flexedc. Encouraging the client to ambulate as much as possibled. Preparing the client for lumbar puncture

B: Positioning the client with the head of the bed elevated and the knees slightly flexed increases the disc space and may help to decrease to client’s pain.

73. When disposing of the plastic bags, tubing, syringes, and gloves used to administer the antineoplastic drugs, the nurse should do which of the following?a. Discard all used equipment in a container marked “isolation”b. Dispose of all used equipment in the regular trash receptaclesc. Dispose of all equipment in a container marked “bio-health hazard”d. Avoid contact with the equipment by allowing housekeeping to remove it.

C: any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment. Placing the items in a container marked “bio-health hazard” is appropriate because these containers can be incinerated at a temperature of 2200 to 2500 F so that there is no residue.

74. The clinical manifestations of a client in end-stage renal disease would include which of the following?a. Polyuria, nocturia, and signs and symptoms of mild anemiab. Altered urine output, which may be oliguria or anuriac. Widespread systemic manifestations including fluid volume overloadd. No symptoms as long as there is no exposure to physiologic stress

C: the client with end-stage renal disease typically exhibits symptoms affecting multiple body systems.

75. When planning the nursing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which of the following would the nurse most likely do?a. Give insulin and monitor serum potassium levelsb. Force fluids and withhold thiazide diureticsc. Administer furosemide (Lasix) and restrict fluidsd. Provide eye protection, such as patches or Artificial Tears

C: the client with SIADH is experiencing excessive water retention and subsequent hyponatremia. Thus diuretics, such as furosemide, are given to promote excretion of the

excess water, and fluids are restricted to prevent additional fluid overload and to aid in regaining sodium balance.