The nurse is caring for a 65-year-old male client with a history of ischemic heart disease who has been

admitted to the ICU following a myocardial infarction. The client is currently receiving lidocaine I.V. to
manage his ventricular ectopy, which has been persistent. Which of the following factors would be most
important for the nurse to consider in relation to the administration of this medication?

A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter

B. Increase in systemic blood pressure

C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor

D. Increase in intracranial pressure (ICP)

E. A drop in serum potassium levels as indicated in the latest lab results

F. Observation of a widening QRS complex on the ECG

Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.

In the context of acute myocardial infarction, the priority is to manage life-threatening arrhythmias.
Lidocaine is specifically indicated for the treatment of ventricular arrhythmias, such as PVCs, which can
be indicative of an increased risk for more serious arrhythmias like ventricular tachycardia or ventricular
fibrillation. The presence of PVCs on a cardiac monitor would be the most immediate concern that
lidocaine can address in this scenario. While the other factors listed are important to monitor, they are
not the primary indications for lidocaine administration in the context of arrhythmia management.

A 72-year-old male patient with a history of atrial fibrillation and controlled hypertension has been
initiated on warfarin therapy. Upon assessment of the patient’s history, it was revealed that he has a
history of peptic ulcer. This patient also has a recent history of a peptic ulcer. Given the client’s medical
history and current medication regimen, which of the following instructions should the nurse prioritize
when providing discharge teaching?

A. Report incidents of diarrhea

B. Avoid foods high in vitamin K

C. Use a straight razor when shaving

D. Take aspirin for pain relief

E. Monitor for signs of bleeding, such as bruising or black tarry stools

F. Check blood pressure regularly at home

G. Inform all healthcare providers about the anticoagulant therapy

Correct Answer: B. Avoid foods high in vitamin K

Clients taking warfarin should be educated about maintaining a consistent intake of vitamin K, as it is
necessary for the clotting cascade, and warfarin works by inhibiting the effects of vitamin K, thereby
reducing the blood’s ability to clot. Sudden increases in vitamin K intake can decrease the effectiveness
of warfarin and increase the risk of clot formation. Clients should also be advised to report any incidents
of diarrhea (A) since it can affect the absorption of the medication and potentially lead to unstable
anticoagulation levels. Using a straight razor (C) is not advised due to the increased risk of bleeding; a
safety razor or electric razor would be safer alternatives. Taking aspirin for pain relief (D) is not
recommended without a physician’s approval because aspirin can increase the risk of bleeding when
taken with an anticoagulant. Monitoring for signs of bleeding (E), checking blood pressure regularly (F),
and informing all healthcare providers about anticoagulant therapy (G) are also important instructions
for a patient on warfarin therapy, but avoiding foods high in vitamin K is directly related to the
effectiveness of the anticoagulant medication and is thus the priority teaching point.

In a busy surgical unit, a nurse is preparing to insert an I.V. catheter for a 33-year-old patient who is
scheduled for elective surgery and has a notably hairy forearm where the I.V. is to be placed. The patient
is allergic to a variety of adhesives and has sensitive skin that is prone to irritation. Given these
considerations, how should the nurse manage excess hair at the intended catheter insertion site?

A. Leaving the hair intact

B. Shaving the area

C. Clipping the hair in the area

D. Removing the hair with a depilatory

E. Applying a small amount of water-soluble gel to tame the hair without cutting

F. Use a sterile surgical scalpel to trim the hair as close to the skin as possible without causing abrasions

Correct Answer: C. Clipping the hair in the area

Clipping is preferred over shaving in this scenario because it reduces the potential for creating
microabrasions that can increase infection risk, which is especially important in a patient with sensitive
skin. Chemical depilatories (D) are not recommended due to the patient’s history of allergies and
sensitive skin. Leaving the hair intact (A) could interfere with the securement of the I.V. and increase the
risk of infection. Water-soluble gel (E) is not standard practice for managing hair at an I.V. site and does
not address the infection control issue. A sterile surgical scalpel (F) is not typically recommended for hair
removal in preparation for I.V. insertion due to the risk of cuts and abrasions. Clipping is the safest option
that balances the need to reduce infection risk with the patient’s sensitivity and allergy concerns.

A nurse is tasked with the education of an elderly female patient who has been recently diagnosed with
osteoporosis. The patient leads a sedentary lifestyle, has a diet low in calcium, has undergone
menopause ten years prior, and has a visibly kyphotic posture. In planning the education for this patient,
which of the following complications should the nurse emphasize as the most significant risk associated
with osteoporosis, especially considering the patient’s profile?

A. Increased susceptibility to bone fractures from minimal trauma

B. Consequences of long-term estrogen deficiency post-menopause

C. The impact of sustained negative calcium balance on bone density

D. The progression of spinal deformities such as a kyphotic curvature

E. Potential for height loss over time due to vertebral compression

F. Risk of developing chronic pain associated with skeletal weakness

Correct Answer: A. Increased susceptibility to bone fractures from minimal trauma.

Given the patient’s diagnosis of osteoporosis, a sedentary lifestyle, and poor dietary habits, the most
significant and immediate complication is the risk of bone fractures, particularly hip, wrist, and spine
fractures, which can result from minimal stress. The patient’s visible kyphosis also indicates a history of
spinal bone loss, which compounds this risk. Estrogen deficiency (B) is a contributing factor to the
development of osteoporosis but is not a direct complication. Negative calcium balance (C) is a concern
that should be addressed as it contributes to bone density loss; however, it is not a complication but
rather a contributing factor. Progression of spinal deformities (D), height loss (E), and chronic pain (F) are
all concerns associated with osteoporosis. Still, the priority education should focus on preventing
fractures, which can have immediate and severe consequences on the patient’s mobility and quality of
life.

A community health nurse is conducting a workshop on breast health for a group of women with diverse
backgrounds, ranging from those who have never performed Breast Self-Examination (BSE) to some who
have had benign breast conditions in the past. As part of the educational session, the nurse emphasizes
the importance of BSE for the early detection of potential breast anomalies. What should the nurse
identify as the primary goal for these women in performing regular BSE?

A. To detect any cancerous lumps early in their development

B. To identify areas of thickness or fullness that differ from the rest of the breast tissue

C. To notice any changes in the breast tissue from what is normal for each individual

D. To differentiate between fibrocystic masses and other types of breast lumps

E. To promote self-awareness of breast health and encourage routine health screening

F. To understand the normal texture and appearance of their breast tissue for future comparison

Correct Answer: C. To notice any changes in the breast tissue from what is normal for each individual.

The primary purpose of BSE is for individuals to become familiar with their own breasts so they can
detect any changes early, which could be indicative of breast cancer or other breast conditions.
Detecting cancerous lumps (A) is an important aspect of BSE, but the emphasis is on noticing any
change, not only cancer. Identifying areas of thickness or fullness (B) and differentiating types of masses
(D) are part of noticing changes, but these are not the primary goals. Promoting self-awareness and
encouraging routine screening (E), as well as understanding normal breast tissue (F), are also critical
educational points, but the main goal remains the detection of any new or unusual changes since the
last examination.
A nurse is managing the care of a 32-year-old female client diagnosed with hyperthyroidism. The client
reports experiencing palpitations, unintentional weight loss, and intermittent bouts of excessive
sweating. The treatment plan includes antithyroid medications. In addition to administering medication,
what nursing interventions should be prioritized to manage the client’s condition best?

A. Ensure the client is provided with extra blankets and clothing to maintain a warm environment due to
heightened sensitivity to cold.

B. Closely monitor the client for increased signs of restlessness, sweating, and significant weight loss.

C. Create a balance between the client's periods of activity and rest to manage fatigue without
exacerbating symptoms.

D. Encourage increased physical activity to counteract the sedative effects of the medication and
prevent constipation.

E. Regularly check the client’s temperature as they are prone to developing fevers.

F. Offer a low-iodine diet and coordinate with a dietitian to manage dietary influences on thyroid
function.

Correct Answer: C. Create a balance between the client’s periods of activity and rest to manage fatigue
without exacerbating symptoms.
Clients with hyperthyroidism may experience symptoms like fatigue and muscle weakness. Balancing
activity with rest helps to conserve energy and prevent exacerbation of symptoms.

A nurse is providing discharge education to a 55-year-old client who has been hospitalized with
symptoms leading to a diagnosis of atherosclerosis. The client has a sedentary lifestyle, a high-stress job,
and a diet high in saturated fats. As part of the client’s comprehensive care plan to manage and reduce
the progression of atherosclerosis, which of the following lifestyle modifications should the nurse
emphasize?

A. Emphasize the importance of not focusing solely on weight as a health measure, but rather on overall
cardiovascular health.

B. Recommend an incremental increase in physical activity, starting with low-intensity exercises such as
walking or swimming.

C. Advise adherence to a heart-healthy diet, rich in fruits, vegetables, whole grains, and lean proteins,
while limiting saturated fats and cholesterol.

D. Counsel on stress management techniques and the importance of incorporating relaxation activities
into daily routines.

E. Discuss smoking cessation strategies if applicable and avoid exposure to secondhand smoke.

Correct Answer: B. Recommend an incremental increase in physical activity, starting with low-intensity
exercises such as walking or swimming.
Increasing physical activity is a key intervention for a client with atherosclerosis in managing and slowing
the disease’s progression. While the other options are valid health measures, they are less directly
impactful on atherosclerosis than increasing physical activity. A heart-healthy diet (C) and stress
management (D) are also essential but support the primary intervention of increased physical activity.
Smoking cessation (E) is critical if the client smokes, and regular monitoring (F) is part of ongoing
management, but these options were not specified in the original question.

In a postoperative unit, a nurse is caring for a client who has recently undergone a laminectomy to
relieve spinal cord compression. The client is alert but has been instructed to minimize movement to
prevent post-surgical complications. In addition to monitoring for the usual postoperative signs such as
infection or bleeding, which technique should the nurse use to reposition the client to promote comfort
and prevent injury safely?

A. Logroll the client carefully to maintain spinal alignment, ensuring that the head, back, and legs move
as one unit.

B. Assist the client to dangle on the side of the bed before standing to promote circulation and reduce
the risk of orthostatic hypotension.

C. Encourage the client to use an overhead trapeze when self-repositioning to enhance independence
and strengthen upper body muscles.

D. Instruct the client to perform gentle range-of-motion exercises to the lower extremities to prevent
venous stasis and deep vein thrombosis.

E. Utilize a transfer board when moving the client from the bed to a chair to reduce shearing forces on
the healing spine.

F. Apply gentle traction to the client's legs when turning to decrease pressure on the surgical site and
alleviate pain.

Correct Answer: A. Logroll the client carefully to maintain spinal alignment, ensuring that the head, back,
and legs move as one unit.
After a laminectomy, it is essential to avoid twisting the spine to prevent damage to the surgical site.
Logrolling is a technique used to turn the client while keeping the spine neutral. The additional choices,
while they may be appropriate for other postoperative scenarios, do not specifically address the needs
of a client who has had a laminectomy.

A 55-year-old client who just had cataract removal with an intraocular lens implant is being prepared for
discharge. The client has a history of hypertension and is moderately active. The client’s postoperative
recovery has been uneventful, but they express anxiety about ensuring a proper recovery. The nurse
needs to provide comprehensive discharge instructions. In addition to avoiding activities that could
increase ocular pressure, which of the following should be included in the discharge education?

A. Restrict fluids to limit the need for frequent urination.

B. Avoid lifting objects heavier than 5 lb (2.25 kg) and engage in light activities like walking.
C. Remain in a prone position while resting to facilitate healing.

D. Keep living spaces dimly lit to avoid glare and discomfort in the healing eye.

E. Refrain from straining during bowel movements and avoid bending at the waist.

Correct Answer: E. Refrain from straining during bowel movements and avoid bending at the waist to
prevent pressure on the eye.

After cataract surgery, clients must avoid activities that can increase intraocular pressure, affecting the
surgical site and the newly placed intraocular lens. Straining during bowel movements and bending at
the waist can increase intraocular pressure and, therefore, should be avoided.

George, a 17-year-old individual, is attending a health education session at a community clinic. The clinic
is conducting screenings and teaching about early detection of common health issues in young adults.
George has a family history of testicular cancer and is seeking information on how to reduce his risk. The
nurse should include education on testicular self-examinations as part of the session. At what age should
the nurse emphasize the initiation of regular testicular self-examinations?

A. At the onset of sexual activity to ensure sexual health is maintained.

B. After the age of 69, as part of a routine examination for senior health.

C. Starting after age 40, coinciding with increased risk for other male health issues.

D. Prior to the age of 20, to establish early detection habits during the peak incidence of testicular
cancer.

E. During the annual physical examination, regardless of age, to ensure consistency.

Correct Answer: D. Prior to the age of 20, to establish early detection habits during the peak incidence of
testicular cancer.

Educating George and other young individuals about the importance of regular testicular self-
examinations can lead to the early detection of abnormalities, which is crucial for early intervention,
especially given George’s family history of testicular cancer. Testicular cancer commonly occurs in men
between ages 20 and 30. A male client should be taught how to perform testicular self-examination
before age 20, preferably when he enters his teens.

A 50-year-old male client with a history of colorectal cancer has recently undergone a colon resection.
Postoperatively, while assisting the client to turn in bed for routine care, the nurse notices the surgical
wound site has suddenly dehisced, and there is evisceration of abdominal contents. In prioritizing the
immediate actions to take, which step should the nurse perform first to address this acute complication?

A. Promptly notify the surgeon to report the critical incident and seek further orders.

B. Immediately cover the eviscerated tissue with a dressing moistened with sterile normal saline.
C. Check the client's vital signs to assess for shock or other immediate life-threatening conditions.

D. Attempt to gently approximate the wound edges without applying pressure to the eviscerated organs.

E. Prepare the client for emergency surgery while ensuring the preservation of the exposed tissues.

F. Administer prescribed analgesia to manage the client's pain due to the dehiscence.

Correct Answer: B. Immediately cover the eviscerated tissue with a dressing moistened with sterile
normal saline.

This action is critical to maintain the viability of the exposed organs and prevent further contamination
and infection. It is the most immediate and appropriate first step in the event of evisceration. Once this
is done, the nurse should then perform other actions, such as notifying the surgeon (A), assessing vital
signs (C), and preparing the client for emergency intervention (E). Attempting to close the wound (D) or
administering pain medication (F) should only be done under the direct instruction of a physician, as
they are not initial emergency measures.

The nurse is monitoring a 78-year-old male patient who has experienced a significant cerebrovascular
accident resulting in extensive brain damage. During a comprehensive evaluation, the nurse observes
the patient’s respiratory pattern and identifies a cycle of respirations that increase and decrease in depth
and rate, culminating in periods where breathing temporarily ceases. This observation is most consistent
with which of the following descriptions?

A. Progressively deeper breaths followed by shallower breaths with apneic periods.

B. Rapid, deep breathing with abrupt pauses between each breath.

C. Rapid, deep breathing and irregular breathing without pauses.

D. Shallow breathing with an increased respiratory rate.

Correct Answer: A: Progressively deeper breaths followed by shallower breaths with apneic periods.

The pattern described is indicative of Cheyne-Stokes respirations, which are often seen in patients with
conditions that affect the brain’s respiratory centers, such as following a severe stroke.

The nurse is evaluating a 63-year-old female patient who has been admitted with worsening heart
failure. During the physical examination, the nurse uses a stethoscope to listen to the patient’s lung
fields. The patient presents with shortness of breath, a cough that worsens when lying down, and
fatigue. Which type of breath sounds is the nurse most likely to auscultate that are typically associated
with heart failure?

A. Tracheal

B. Fine crackles

C. Coarse crackles
D. Friction rubs

E. Wheezes

F. Stridor

G. Pleural knock

Correct Answer: B. Fine crackles

This choice is the most consistent with fluid accumulation in the air spaces of the lungs, a common
complication in patients with heart failure. Fine crackles are created by the opening of small airways and
alveoli that are compromised by fluid, which is often present in heart failure due to the heart’s reduced
ability to pump effectively.

A nurse is attending to a 35-year-old patient with a history of asthma who presents to the emergency
department in the midst of an acute asthma exacerbation. The patient, who was initially wheezing
loudly, suddenly has no audible wheezing and the nurse cannot auscultate breath sounds. The patient
appears anxious and is using accessory muscles to breathe. Considering the change in respiratory status,
what is the most likely explanation for the absence of wheezing?

A. The asthma attack has resolved.

B. The airways are so constricted that air cannot pass through.

C. The inflammation within the airways has subsided.

D. Fine crackles have replaced the wheezes due to fluid in the airways.

E. The patient is holding their breath subconsciously due to anxiety.

F. A foreign body has obstructed the airway passage.

Correct Answer: B. The airways are so swollen that no air cannot get through.

This indicates that the airway constriction has worsened to a critical level, often resulting in a silent
chest, which is a sign of a severe and life-threatening asthma attack. Immediate intervention is necessary
to open the airways and restore adequate ventilation.

A nurse is caring for a 22-year-old individual with a known diagnosis of epilepsy. During the nurse’s shift,
the patient begins to have a tonic-clonic seizure. During the active phase of the seizure, which of the
following actions should the nurse take? Select all that apply.

A. Place the patient on their back, remove dangerous objects from the immediate vicinity, and insert a
padded tongue depressor.

B. Place the patient in a lateral position (on their side), remove any hazardous objects nearby, and
prepare to use a bite block if needed.
 C. Position the patient supine (on their back), clear the area of any items that might cause injury, and
restrain their limbs gently.

D. Turn the patient to a side-lying position, ensure the environment is safe from potential hazards, and
use a pillow or a hand to protect the head.

E. Keep the patient in a prone position, secure the perimeter for safety, and monitor their respiratory
status closely.

F. Roll the patient onto their side to prevent aspiration, remove objects that could cause harm, and
observe for cessation of seizure activity.

Correct Answers: B, D, and F.

During a seizure, it is important to prevent injury to the patient. Placing the patient on their side can help
maintain an open airway and allow any oral secretions or vomitus to drain, preventing aspiration.
Removing dangerous objects helps to minimize the risk of injury. While a bite block may be used in some
situations to prevent the patient from biting their tongue, it is not recommended to insert anything into
the mouth of someone who is actively seizing due to the risk of injury or aspiration. Protecting the head
is also crucial to prevent trauma during convulsive movements.

After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein
distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension
pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

A. Infection of the lung

B. Kinked or obstructed chest tube

C. Excessive water in the water-seal chamber

D. Excessive chest tube drainage

Correct Answer: B. Kinked or obstructed chest tube

Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.

The nurse is providing lunch to a 68-year-old male patient with a history of stroke which has affected his
swallowing reflex. As the patient begins to eat, he suddenly starts choking on a piece of food but is
coughing loudly and forcefully. Observing this, what should the nurse do?

A. Assist the patient to stand up and perform the abdominal thrust maneuver immediately.

B. Lay the patient down and prepare to perform back blows and chest thrusts.

C. Exit the room quickly to summon for additional help from the healthcare team.

D. Stay with the patient, encourage him to keep coughing, and monitor him closely.
E. Provide a drink of water to help the patient swallow the obstructing food.

Correct Answer: D. Stay with the patient, encourage him to keep coughing, and monitor him closely.

When an individual is choking but still able to cough forcefully, it indicates that the airway is not
completely blocked and air is still passing through. The coughing reflex is the most effective way to expel
an obstruction from the airway. Therefore, the nurse should closely observe the client and encourage
them to continue coughing. Performing abdominal thrusts or back blows when the individual is still able
to cough may worsen the situation or cause unnecessary harm.

While conducting an initial health assessment, the nurse is collecting information from an 84-year-old
female patient who has recently been admitted to the geriatric ward due to chronic hypertension and
mild cognitive impairment. Which of the following pieces of information would be most beneficial for
the nurse to gather in order to tailor an individualized care plan?

A. An overview of the patient's general health and major illnesses over the past decade.

B. Details of the patient's engagement in current health promotion activities, such as diet and exercise.

C. A comprehensive family history of chronic diseases like diabetes or cardiovascular conditions.

D. The patient's marital status and living arrangements to understand social support structures.

E. The patient's medication adherence and understanding of the diabetes management plan.

F. Previous experiences with hospitalizations or surgeries that might affect current health status.

Correct Answer: B. Details of the patient’s engagement in current health promotion activities, such as
diet and exercise.

When taking the health history of an elderly client, it is important to understand their current health
promotion activities. This information provides insight into the client’s level of engagement in
maintaining or improving their health, which is crucial for planning care that is tailored to their needs
and capabilities. It helps to identify the client’s current health practices and can guide the nurse in
formulating a care plan that supports these activities, introduces new ones, or modifies existing ones.
This allows the nurse to plan care that supports the patient’s active involvement in managing his health
conditions, which is particularly important given the recent diagnosis of type 2 diabetes and the
presence of other chronic diseases.

The nurse is preparing to provide oral care for a 76-year-old female patient who is comatose following a
cerebral hemorrhage. The patient is unable to manage her secretions and has a history of chronic
obstructive pulmonary disease (COPD). To minimize the risk of aspiration and ensure proper oral
hygiene, what should the nurse do?

A. Frequently apply lemon glycerin swabs to moisturize the patient’s lips and oral mucosa.

B. Brush the patient’s teeth while she is lying flat on her back to ensure a thorough cleaning.
C. Position the patient in a side-lying position and lower the head of the bed before starting oral care.

D. Use hydrogen peroxide to cleanse the patient’s mouth to eliminate bacteria and debris.

E. Utilize a suction toothbrush to simultaneously remove plaque and oral secretions.

F. Moisten the oral mucosa with water before and after oral care to maintain hydration.

Correct Answer: C. Place the client in a side-lying position, with the head of the bed lowered.

When performing oral care on a comatose client, it is essential to prevent aspiration, which can lead to
pneumonia or other complications. Placing the client in a side-lying position with the head of the bed
lowered allows for drainage of oral secretions and reduces the risk of aspiration. Lemon glycerin and
hydrogen peroxide are not recommended for regular oral care as they can dry out the mucous
membranes or cause irritation. Brushing teeth with the client lying supine also increases the risk of
aspiration.

A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s
being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F
(39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may
have which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)

B. Myocardial infarction (MI)

C. Pneumonia

D. Tuberculosis

Correct Answer: C. Pneumonia

Fever, productive cough, and pleuritic chest pain are common signs and symptoms of pneumonia.

In the context of an ongoing tuberculosis (TB) outbreak, the nurse working in a community health clinic
is triaging clients for potential TB exposure and infection. Considering the risk factors and symptoms,
which of these clients should the nurse prioritize for TB screening?

A. The 16-year-old female presenting with a mild cough and fatigue.

B. The 33-year-old daycare worker with a persistent cough and recent travel history.

C. The 43-year-old man with a history of homelessness and alcohol use disorder, coughing up blood.

D. The 54-year-old businessman with a cough and recent unexplained weight loss.

E. The 27-year-old gym instructor who has night sweats and a history of working in a correctional facility.

F. The 50-year-old woman with a chronic cough who has been receiving immunosuppressive therapy.
Correct Answer: C. The 43-year-old man with a history of homelessness and alcohol use disorder,
coughing up blood.

Tuberculosis (TB) is more prevalent in populations with certain risk factors that include homelessness,
substance abuse, and compromised immune systems, among others. A homeless individual with a
history of alcoholism would likely have a higher risk of exposure and possibly a weakened immune
system, making it more difficult to fight infections.

A 42-year-old patient with no significant medical history presents to the clinic with a recent positive
Mantoux tuberculin skin test. The patient reports a productive cough and night sweats that have
persisted for the past three weeks. The nurse understands that a chest X-ray has been ordered. The
nurse considers that this diagnostic test is most crucial for which of the following reasons?

A. To confirm the presence of active pulmonary tuberculosis.

B. To determine if there is a need for a repeat Mantoux test due to potential false-positive results.

C. To assess the size and spread of any lesions within the lung tissue.

D. To differentiate between a primary TB infection or a reactivation of a latent TB infection.

Correct Answer: C. To determine the extent of lesions

If the lesions are large enough, the chest X-ray will show their presence in the lungs.

The nurse is attending to a 35-year-old patient presenting to the emergency department with difficulty
breathing, audible inspiratory and expiratory wheezes, and a significant reduction in peak expiratory flow
rate. The patient has a known history of asthma and is currently experiencing an exacerbation. Which of
the following medication classes should the nurse anticipate administering first to address the patient’s
immediate needs?

A. Beta-adrenergic blockers

B. Bronchodilators

C. Inhaled steroids

D. Oral steroids

E. Anticholinergics

Correct Answer: B. Bronchodilators

In the case of acute asthma, characterized by wheezing and a decreased forced expiratory volume, the
immediate treatment goal is to open the airways and relieve constriction. Bronchodilators, such as short-
acting beta-agonists, are the first line of treatment as they act quickly to dilate the bronchi and
bronchioles, reducing resistance in the respiratory airway and increasing airflow to the lungs.
A nurse is assessing a 56-year-old patient who presents with a persistent cough producing copious thick
sputum, noticeable swelling in the lower extremities, and blue-tinged nail beds. The patient has a
detailed smoking history of consuming one to two packs of cigarettes daily for 40 years. Considering the
patient’s history and current symptoms, which of the following conditions does the patient most likely
have?

A. Adult respiratory distress syndrome (ARDS)

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

D. Emphysema

E. Pulmonary hypertension

F. Lung cancer

Correct Answer: C. Chronic obstructive bronchitis

The symptoms described for the client, particularly the chronic cough producing thick sputum,
peripheral edema, and cyanotic nail beds, along with the long history of significant smoking, are
indicative of chronic obstructive bronchitis. Chronic obstructive bronchitis is a type of chronic obstructive
pulmonary disease (COPD) characterized by a long-term cough with mucus. Smoking is the most
common cause of COPD.

A nurse is caring for a 46-year-old patient admitted with a diagnosis of Chronic Lymphocytic Leukemia
(CLL). As part of the treatment regimen, the patient is scheduled for a bone marrow transplantation. The
nurse is reviewing the patient’s education plan concerning the procedure. Which of the following
statements about bone marrow transplantation is NOT correct?

A. The patient will be under local anesthesia during the procedure.

B. The harvested bone marrow will be treated with heparin to prevent clotting.

C. The bone marrow is typically aspirated from the posterior or anterior iliac crest.

D. The patient will receive cyclophosphamide (Cytoxan) for 4 consecutive days prior to the procedure.

E. A series of chemotherapy and/or radiation therapy may be administered before the transplantation.

F. The patient will be placed in protective isolation following the transplant to reduce the risk of
infection.

Correct Answer: A. The patient will be under local anesthesia during the procedure.

Before the procedure, the patient is administered with drugs that would help to prevent infection and
rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the
transplant, the patient is placed under general anesthesia.
A nurse is caring for a 46-year-old male patient with Chronic Lymphocytic Leukemia who, after several
days of admission, exhibits new-onset disorientation and complains of persistent headaches. What
should the nurse prioritize as an initial action?

A. Notify the primary healthcare provider immediately.

B. Accurately document the new symptoms in the patient's medical records.

C. Initiate oxygen therapy in anticipation of physician's orders.

D. Elevate the side rails to ensure patient safety.

Correct Answer: D. Elevate the side rails to ensure patient safety.

A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising
the side rails to ensure patients’ safety.

A 46-year-old patient with Chronic Lymphocytic Leukemia (CLL) expresses confusion to the nurse about
the development of anemia despite the disease’s characteristic increased white blood cell production.
The patient presents with fatigue and pallor, common symptoms of anemia. To address the patient’s
concern, how should the nurse best explain the reason for anemia in the context of CLL?

A. The overproduction of white blood cells can crowd out red blood cells in the bone marrow.

B. The presence of anemia is unrelated to the proliferation of white blood cells.

C. The excessive white blood cells consume nutrients that would otherwise nourish red blood cells.

D. The abnormal white blood cells have a reduced lifespan, which does not affect red blood cells.

Correct Answer: A. Crowd red blood cells

The excessive production of white blood cells crowds out red blood cells production which causes
anemia to occur.

In assessing a 46-year-old patient with a diagnosis of Chronic Lymphocytic Leukemia (CLL), who presents
with fatigue, lymphadenopathy, and frequent infections, which of the following findings would the nurse
least expect to be reported in the diagnostic assessment?

A. Predominance of lymphoblasts

B. Leukocytosis

C. Abnormal blast cells in the bone marrow

D. Elevated thrombocyte counts

Correct Answer: B. Leukocytosis. Chronic Lymphocytic leukemia (CLL) is characterized by increased

production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells
within the bone marrow, spleen, and liver.
A 57-year-old patient with a recent history of severe left leg pain and diagnosed with acute arterial
occlusion is postoperative following an emergency embolectomy. Six hours after the procedure, the
nurse is unable to detect pulses in the patient’s left foot using a Doppler ultrasound. The nurse informs
the surgical team of the potential need for further intervention. When discussing the situation with the
patient, who expresses a desire to refuse any additional surgical procedures, what should the nurse
prioritize as the initial response?

A. Explain the risks of not having the surgery

B. Notifying the physician immediately

C. Notifying the nursing supervisor

D. Recording the client’s refusal in the nurses’ notes

Correct Answer: A. Explain the risks of not having the surgery

The best initial response is to explain the risks of not having the surgery.

During the endorsement, which of the following clients should the on-duty nurse assess first?

A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm
Hg, and a respiratory rate of 22 breaths/minute.

B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a
“do not resuscitate” order.

C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V.
heparin.

D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving
L.V. diltiazem (Cardizem).

Correct Answer: D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation
and is receiving L.V. diltiazem (Cardizem).

The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication
that requires close monitoring.