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 staff

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 affected practice settings for
medical-surgical nurses?
a. Third-party payment systems have restricted the delivery of medical-surgical 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 offers 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 client’s 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 client’s 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 affect their sense of control over
their lives, including a decrease in physical mobility. The nurse should support the
client’s 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 effective 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 nurse’s 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 (µ) 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 differs from “civilian” triage in that its main goal is to
provide the most effective 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 suffered 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 affected 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 affected extremity.
c. Ice decreases venous return from the affected 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 effect 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 effective 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 client’s 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. Ringer’s 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 nurse’s 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 nurse’s 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 nurse’s 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 different 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 different 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 differentiate 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 different 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 different 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 nurse’s 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 client’s 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 nurse’s best first action?
a. Assess the client’s 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 life-threatening
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
client’s 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 affects 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 nurse’s 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 co-workers, 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 client’s 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 different 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 client’s 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 effective 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 client’s father died of lung cancer at age 82.
c. The client’s 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 self-care.
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 cuff 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 30-degree 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 effective 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 nurse’s 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 client’s 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 client’s endotracheal tube cuff.
b. Increase the tidal volume by at least 100 mL or by the client’s weight in kg.
c. Assess the client’s 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 client’s 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 effect from baroreceptor stimulation on this client’s heart
rate would be expected?
a. The heart rate would increase.
b. The heart rate would decrease.
c. There would be no effect 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 effect 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 client’s 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 client’s 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 nurse’s 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 effect.

____ 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
client’s 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
nurse’s 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 effectiveness 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 month’s time
82. ANS: C
Measures that effectively 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 nurse’s 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 client’s arms, wrists, and fingers have become flexed, and there is
internal rotation and plantar flexion of the legs. What would be the nurse’s best action?
a. Notify the health care team members.
b. Determine the client’s 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 client’s 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 effect 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
affected and the client should monitor these side effects.
____ 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 Parkinson’s disease?
a. “I can never tell what he’s thinking—he hides behind a frozen face.”
b. “She drools all the time just so I can’t take her out anywhere.”
c. “I think this disease makes him nervous—he perspires all the time.”
d. “I can offer 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
Parkinson’s disease. Changes in facial expression or a masklike facies in a Parkinson’s
disease client can be misinterpreted. Because chewing and swallowing can be
problematic, small, frequent meals and a supplement are better for meeting the client’s
nutritional needs.

____ 92. Which nursing intervention will assist in preventing respiratory complications in
the client with Parkinson’s 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 different
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 client’s eyes closed, move the client’s 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 client’s 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
nurse’s 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 nurse’s best response?
a. “This timing allows the drug to have maximum effect, 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 effect
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-Barré 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 effects.

____ 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 unaffected side to perform passive range-of-motion exercises on
the affected 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 effects.

____ 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 affected 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 client’s hand ROM is not seriously restricted.
b. The client’s hand ROM is severely limited.
c. The client’s hand has nerve entrapment.
d. The client’s 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 client’s 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 client’s vital signs, skin color, and level of
consciousness.

____ 108. The nurse notes that the skin around the client’s skeletal traction pin site is
swollen, red, and crusty, with dried drainage. What is the nurse’s 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. Schilling’s 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 stomach’s 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 nurse’s 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 client’s nasogastric tube requires irrigation.
b. The drainage is as expected for this time period.
c. The client’s 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 yellow-green 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 nurse’s 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
nurse’s 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 nurse’s 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 coffee
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 nurse’s
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 effective?
a. The client is thirsty.
b. The client’s weight has been the same for 3 weeks.
c. The client’s 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 buffer the effects 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 unaffected side

133. ANS. D After hip fracture, the leg on affected side is characteristically shorter than
the unaffected 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 staff 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 nurse’s 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 affect
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 effective 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 client’s 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 client’s blood pressure in both arms.
b. Take the client’s 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 nurse’s 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 differentiated; 20% of cells in S phase; estrogen receptor negative
b. Moderately differentiated; 50% of cells in S phase; estrogen receptor negative
c. Undifferentiated; 50% of cells in S phase; estrogen receptor positive
d. Highly differentiated; 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 differentiated breast tissue from
which they arose. Estrogen receptor–positive tumors respond better to adjuvant
therapy, and the client usually has a longer survival rate. In addition, estrogen receptor–
positive 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 nurse’s 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.

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