Quiz #4: 75 Questions

1. Which action(s) should you delegate to the experienced nursing assistant when caring
for a patient with a thrombotic stroke with residual left-sided weakness? Select all that
apply.

A. Assist the patient to reposition every 2 hours.

B. Reapply pneumatic compression boots.

C. Remind the patient to perform active ROM.

D. Check extremities for redness and edema.

Correct Answer: A, B, & C.

The experienced nursing assistant would know how to reposition the patient and how to
reapply compression boots and would remind the patient to perform activities he has
been taught to perform.
 Option D: Assessing for redness and swelling (signs of deep venous thrombosis
{DVT}) requires additional education and is still appropriate to the professional
nurse.

2. The patient who had a stroke needs to be fed. What instruction should you give to
the nursing assistant who will feed the patient?

A. Position the patient sitting up in bed before you feed her.

B. Check the patient’s gag and swallowing reflexes.

C. Feed the patient quickly because there are three more waiting.

D. Suction the patient’s secretions between bites of food.

Correct Answer: A. Position the patient sitting up in bed before you feed her.
Positioning the patient in a sitting position decreases the risk of aspiration.
 Option B: The nursing assistant is not trained to assess gag or swallowing
reflexes.
 Option C: The patient should not be rushed during feeding.
 Option D: A patient who needs to be suctioned between bites of food is not
handling secretions and is at risk for aspiration. This patient should be assessed
further before feeding.
3. You have just admitted a patient with bacterial meningitis to the medical-surgical
unit. The patient complains of a severe headache with photophobia and has a
temperature of 102.60 F orally. Which collaborative intervention must be
accomplished first?

A. Administer codeine 15 mg orally for the patient’s headache.

B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.

C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.

 D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid
antibiotic treatment is essential.
 Option A: Pain medications may be given after treating the infection that is most
probably causing it.
 Option C: Acetaminophen should be given to decrease the fever after
administering the antibiotics first.
 Option D: Furosemide will help reduce CNS stimulation and irritation and should
be implemented as soon as possible.

4. You are mentoring a student nurse in the intensive care unit (ICU) while caring for a
patient with meningococcal meningitis. Which action by the student requires that you
intervene immediately?
A. The student enters the room without putting on a mask and gown.

B. The student instructs the family that visits are restricted to 10 minutes.

C. The student gives the patient a warm blanket when he says he feels cold.

D. The student checks the patient’s pupil response to light every 30 minutes.

Correct Answer: A. The student enters the room without putting on a mask and
gown.
Meningococcal meningitis is spread through contact with respiratory secretions so use
of a mask and gown is required to prevent the spread of the infection to staff members
or other patients. The other actions may not be appropriate but they do not require
intervention as rapidly.
 Option B: The presence of a family member at the bedside may decrease patient
confusion and agitation.
 Option C: Patients with hyperthermia frequently complain of feeling chilled, but
warming the patient is not an appropriate intervention.
 Option D: Checking the pupil response to light is appropriate, but it is not
needed every 30 minutes and is uncomfortable for a patient with photophobia.
Focus: Prioritization

5. A 23-year-old patient with a recent history of encephalitis is admitted to the medical

unit with new-onset generalized tonic-clonic seizures. Which nursing activities included
in the patient’s care will be best to delegate to an LPN/LVN whom you are
supervising? Select all that apply.
A. Document the onset time, nature of seizure activity, and postictal behaviors for all
seizures.

B. Administer phenytoin (Dilantin) 200 mg PO daily.

C. Teach the patient about the need for good oral hygiene.

D. Develop a discharge plan, including physician visits and referral to the Epilepsy
Foundation.
 E. Gather information about the seizure activity
Correct Answer: B & E
Administration of medications that are not a high risk is included in LPN education and
scope of practice. Collection of data about the seizure activity may be accomplished by
an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the
supervising RN immediately if a patient started to seize.
 Option A: Documentation is a nursing responsibility.
 Option C: Patient education must be accomplished by the registered nurse
because it is within their scope of practice.
 Option D: Planning of care is a complex activity that requires RN level education
and scope of practice.

6. While working in the ICU, you are assigned to care for a patient with a seizure
disorder. Which of these nursing actions will you implement first if the patient has a
seizure?

A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.

B. Administer lorazepam (Ativan) 1 mg IV.

C. Turn the patient to the side and protect the airway.

D. Assess level of consciousness during and immediately after the seizure.

Correct Answer: C. Turn the patient to the side and protect the airway.
The priority action during a generalized tonic-clonic seizure is to protect the airway.
 Option B: Administration of lorazepam should be the next action since it will act
rapidly to control the seizure.
 Option A: Although oxygen may be useful during the postictal phase, the
hypoxemia during tonic-clonic seizures is caused by apnea.
 Option D: Checking the level of consciousness is not appropriate during the
seizure, because generalized tonic-clonic seizures are associated with a loss of
consciousness.

7. A patient recently started on phenytoin (Dilantin) to control simple complex seizures

is seen in the outpatient clinic. Which information obtained during his chart review and
assessment will be of greatest concern?

A. The gums appear enlarged and inflamed.

B. The white blood cell count is 2300/mm3.

C. Patient occasionally forgets to take the phenytoin until after lunch.

D. Patient wants to renew his driver’s license next month.

Correct Answer: B. The white blood cell count is 2300/mm3.

Leukopenia is a serious adverse effect of phenytoin and would require discontinuation
of the medication.
 Option A: Inflammation of the gums should be reported to the physician, but it
does not require immediate attention.
  Option C: The nurse should include in the patient teaching the importance of
taking medications on time to avoid episodes of seizure.
 Option D: Driving is prohibited for a client with a seizure disorder. This should be
included in the patient’s teaching, but will not require a change in medical
treatment for the seizures.

8. After receiving a change-of-shift report at 7:00 AM, which of these patients will you
assess first?
A. A 23-year-old with a migraine headache who is complaining of severe nausea
associated with retching.
B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs
preoperative teaching.

C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment

before breakfast.
D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and
flank pain.

Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral

temperature of 101.80 F and flank pain.
Urinary tract infections are a frequent complication in patients with multiple sclerosis
because of the effect on bladder function. The elevated temperature and decreased
breath sounds suggest that this patient may have pyelonephritis. The physician should
be notified immediately so that antibiotic therapy can be started quickly.
 Option A: This patient needs further assessment, but does not require immediate
attention. A migraine can cause severe throbbing pain or a pulsing sensation,
usually on one side of the head. It’s often accompanied by nausea, vomiting, and
extreme sensitivity to light and sound. Migraine attacks can last for hours to days,
and the pain can be so severe that it interferes with daily activities.
 Option B: Preoperative teaching must be done but it is not the nurse’s priority. A
craniotomy is the surgical removal of part of the bone from the skull to expose
the brain. Specialized tools are used to remove the section of bone called the
bone flap. The bone flap is temporarily removed, then replaced after the brain
surgery has been done.
 Option C: The patient should be assessed soon, but does not have an urgent
need. In MS, the immune system attacks the protective sheath (myelin) that
covers nerve fibers and causes communication problems between your brain and
the rest of your body. Eventually, the disease can cause permanent damage or
deterioration of the nerves.
9. All of these nursing activities are included in the care plan for a 78-year-old man with
Parkinson’s disease who has been referred to your home health agency. Which ones will
you delegate to a nursing assistant (NA)? Select all that apply.
A. Check for orthostatic changes in pulse and blood pressure.

B. Monitor for improvement in tremor after levodopa (L-dopa) is given.

C. Remind the patient to allow adequate time for meals.

D. Monitor for abnormal involuntary jerky movements of extremities.

E. Assist the patient with prescribed strengthening exercises.

F. Adapt the patient’s preferred activities to his level of function.

Correct Answer: A, C, & E

NA education and scope of practice includes taking pulse and blood pressure
measurements. In addition, NAs can reinforce previous teaching or skills taught by the
RN or other disciplines, such as speech or physical therapists.
 Option B: Evaluation of patient response to medication requires the knowledge
of an experienced RN.
 Option D: Development and individualizing the plan of care require RN-level
education and scope of practice.

10. As the manager in a long-term-care (LTC) facility, you are in charge of developing a
standard plan of care for residents with Alzheimer’s disease. Which of these nursing
tasks is best to delegate to the LPN team leaders working in the facility?
A. Check for improvement in resident memory after medication therapy is initiated.

B. Use the Mini-Mental State Examination to assess residents every 6 months.

C. Assist residents to the toilet every 2 hours to decrease the risk for urinary
intolerance.
D. Develop individualized activity plans after consulting with residents and family.

Correct Answer: A. Check for improvement in resident memory after medication

therapy is initiated.
LPN education and team leader responsibilities include checking for the therapeutic and
adverse effects of medications. Changes in the residents’ memory would be
communicated to the RN supervisor, who is responsible for overseeing the plan of care
for each resident.
 Option B: Assessment for changes on the Mini-Mental State Examination is an
RN responsibility.
 Option C: Assisting residents with personal care and hygiene would be delegated
to nursing assistants working in the LTC facility.
 Option D: Developing an activity plan should be done by an RN.
11. An 89-year-old female patient who has been admitted to the medical unit with new-
onset angina also has a diagnosis of Alzheimer’s disease. The patient’s husband reports
to you that he rarely gets a good night’s sleep because he needs to make sure his wife
does not wander during the night. He insists on checking each of the medications you
give her to be sure they are the same as the ones she takes at home. Based on this
information, which nursing diagnosis is most appropriate for this patient?
A. Decreased Cardiac Output related to poor myocardial contractility

B. Caregiver Role Strain related to continuous need for providing care

C. Ineffective Therapeutic Regimen Management related to poor patient memory

D. Risk for Falls related to patient wandering behavior during the night

Correct Answer: B. Caregiver Role Strain related to continuous need for providing
care
The husband’s statement about lack of sleep and anxiety over whether the patient is
receiving the correct medications are behaviors that support this diagnosis.
 Option A: There is no evidence that the patient’s cardiac output is decreased.
Alzheimer?s disease and HF often occur together and thus increase the cost of
care and health resource utilization; this highlights the need to investigate the
relationship between these two conditions. Impaired cognition in HF patients
leads to significantly more frequent hospital readmissions and increases mortality
rates.
 Option C: Ineffective Therapeutic Regimen Management is not a priority as
based on the statement.
 Option D: Risk for falls is not the priority at this time. Falls are a leading cause of
broken hips and other serious injuries in the elderly, and those with Alzheimer’s
are at particularly high risk of falling. Problems with vision, perception, and
balance increase as Alzheimer’s advances, making the risk of a fall more likely.

12. You are caring for a patient with recurrent glioblastoma who is receiving
dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm
weakness and headache. Which assessment information concerns you the most?
A. The patient does not recognize family members.

B. The blood glucose level is 234 mg/dL.

C. The patient complains of a continued headache.

D. The daily weight has increased 1 kg.

Correct Answer: A. The patient does not recognize family members.

The inability to recognize a family member is a new neurologic deficit for this patient,
and indicates a possible increase in intracranial pressure (ICP). This change should be
communicated to the physician immediately so that treatment can be initiated.
 Option B: Increased blood glucose levels is an expected side effect but not an
emergency.
 Option C: The continued headache also indicates that the ICP may be elevated,
but it is not a new problem.
  Option D: The weight gain is a common adverse effect of dexamethasone that
may require treatment, but is not an emergency.

13. A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is
admitted to the hospital ED. His wife tells you that he fell down the stairs about a month
ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually
less active and sleepier over the last 10 days or so. Which of the following collaborative
interventions will you implement first?
A. Place on the hospital alcohol withdrawal protocol.

B. Transfer to radiology for a CT scan.

C. Insert a retention catheter to straight drainage.

D. Give phenytoin (Dilantin) 100 mg PO.

Correct Answer: B. Transfer to radiology for a CT scan.

The patient’s history and assessment data indicate that he may have a chronic subdural
hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to
surgery to have the hematoma evacuated.
 Option A: This can be done after the treatment for any intracranial lesion has
been implemented.
 Option C: This intervention should be done but is not the priority.
 Option D: Administration of phenytoin should be implemented as soon as
possible, but the initial nursing activities should be directed toward treatment of
any intracranial lesion.

14. Which of these patients in the neurologic ICU will be best to assign to an RN who
has floated from the medical unit?
A. A 26-year-old patient with a basilar skull structure who has clear drainage coming
out of the nose.

B. A 42-year-old patient admitted several hours ago with a headache and diagnosed
with a ruptured berry aneurysm.
C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis
and has an antibiotic dose due.
D. A 65-year-old patient with an astrocytoma who has just returned to the unit after
having a craniotomy.

Correct Answer: C. A 46-year-old patient who was admitted 48 hours ago with
bacterial meningitis and has an antibiotic dose due.
This patient is the most stable of the patients listed. An RN from the medical unit would
be familiar with administration of IV antibiotics.
 Option A: This patient may need the attention of an experienced neurologic RN.
 Option B: A rupture of an aneurysm is fatal and should be assigned to a more
experienced RN.
  Option D: This patient requires assessment and care from RNs more experienced
in caring for patients with neurologic diagnoses.

15. What is the priority nursing diagnosis for a patient experiencing a migraine
headache?

A. Acute pain related to biologic and chemical factors

B. Anxiety related to change in or threat to health status

C. Hopelessness related to deteriorating physiological condition

D. Risk for Side effects related to medical therapy

Correct Answer: A. Acute pain related to biologic and chemical factors

The priority for interdisciplinary care for the patient experiencing a migraine headache is
pain management.
 Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension
headaches are common for people that struggle with severe anxiety or anxiety
disorders. Tension headaches can be described as a heavy head, migraine, head
pressure, or feeling like there is a tight band wrapped around their head. These
headaches are due to a tightening of the neck and scalp muscles.
 Option C: Hopelessness should be addressed as part of the nursing care plan,
but it does not require urgency. Hopelessness can result when someone is going
through difficult times or unpleasant experiences. A person may feel
overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to
multiple stresses and losses. He or she might think that challenges are
unconquerable or that there are no solutions to the problems and may not be
able to mobilize the energy needed to act on his or her own behalf.
 Option D: The risk for side effects is accurate, but it is not as urgent as the issue
of pain, which is often incapacitating. Focus: Prioritization

16. Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid
colostomy when the stool is:
A. Green liquid

B. Solid formed

C. Loose, bloody

D. Semiformed

Correct Answer: C. Loose, bloody

Normal bowel function and soft-formed stool usually do not occur until around the
seventh day following surgery. The stool consistency is related to how much water is
being absorbed.
 Option A: Food, medicines, and other things ingested can affect the consistency
or color of the stool.
 Option B: A formed stool may occur a week after the surgery.
 Option D: The stool from a colostomy can be thin or thick liquid, or semiformed.
17. Where would nurse Kristine place the call light for a male client with a right-sided
brain attack and left homonymous hemianopsia?
A. On the client’s right side

B. On the client’s left side

C. Directly in front of the client

D. Where the client like

Correct Answer: A. On the client’s right side

The client has left visual field blindness. The client will see only from the right side.
Homonymous hemianopsia is a condition in which a person sees only one side?right or
left?of the visual world of each eye. The person may not be aware that the vision loss is
happening in both eyes, not just one. An injury to the right part of the brain produces
loss of the left side of the visual world of each eye.
 Option B: The client would not be able to see the call light on his right side
because he can only see the left side.
 Option C: Only the right half of the visual world can be seen by the client.
 Option D: The most ideal place to put the call light is on the client’s right side to
avoid any injuries.

18. A male client is admitted to the emergency department following an accident. What
are the first nursing actions of the nurse?
A. Check respiration, circulation, neurological response

B. Align the spine, check pupils, and check for hemorrhage

C. Check respirations, stabilize the spine, and check the circulation

D. Assess level of consciousness and circulation

Correct Answer: C. Check respirations, stabilize the spine, and check the circulation
Checking the airway would be the priority, and a neck injury should be suspected.
Airway patency and adequate respiratory effort are both essential for normal
oxygenation and ventilation within the body so that normal physiological processes can
proceed without metabolic derangement.
 Option A: These assessments should be made, but keeping the spine stable is
also a priority since the patient has been in an accident.
 Option B: The first priority is always to check the airway, then the rest of the
assessments would follow. Patency is assessed through the presence/absence of
obstructive symptoms or findings suggesting an airway that may become
obstructed.
 Option D: The level of consciousness and circulation can be assessed after
securing a patent airway.
19. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces
preload and relieves angina by:
A. Increasing contractility and slowing heart rate

B. Increasing AV conduction and heart rate

C. Decreasing contractility and oxygen consumption

D. Decreasing venous return through vasodilation

Correct Answer: D. Decreasing venous return through vasodilation.

The significant effect of nitroglycerin is vasodilation and decreased venous return, so the
heart does not have to work hard.
 Option A: Nitroglycerin does not increase contractility. Cardiac work is decreased
by venodilation, reducing anginal symptoms secondary to demand ischemia.
 Option B: AV conduction is not increased through nitroglycerin, and an
increased heart may increase the blood pressure, which is contrary to the desired
effects of nitroglycerin,
 Option C: Contractility is not significantly affected by nitroglycerin. The desired
vasodilatory effect increases perfusion and does not directly reduce oxygen
consumption.

20. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped
on the side rails of the bed and unresponsive to shaking or shouting. Which is the
nurse’s next action?

A. Call for help and note the time

B. Clear the airway

C. Give two sharp thumps to the precordium and check the pulse

D. Administer two quick blows

Correct Answer: A. Call for help and note the time

Having established, by stimulating the client, that the client is unconscious rather than
sleep, the nurse should immediately call for help. This may be done by dialing the
operator from the client’s phone and giving the hospital code for cardiac arrest and the
client’s room number to the operator, or if the phone is not available, by pulling the
emergency call button. Noting the time is important baseline information for cardiac
arrest procedures.
 Option B: A patent airway has been established the moment the nurse declares
that the client is unconscious and calls for help.
 Option C: This action can be done if there is an unwitnessed, unmonitored,
unstable ventricular tachycardia when a defibrillator is not immediately available.
 Option D: Administering two quick blows to the precordium is less effective and
its use is more limited ideally.
21. Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The
nurse should:
A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.

B. Monitor vital signs every 2 hours.

C. Make sure that the client takes food and medications at prescribed intervals.

D. Provide milk every 2 to 3 hours.

Correct Answer: C. Make sure that the client takes food and medications at
prescribed intervals.
Food and drug therapy will prevent the accumulation of hydrochloric acid or will
neutralize and buffer the acid that does accumulate.
 Option A: Uninterrupted sleep for 8 hours is good, but it does not directly affect
the production of acid.
 Option B: Monitoring vital signs every 2 hours is unnecessary. It can be
monitored every shift or every 4 hours.
 Option D: Milk could aggravate the production of hydrochloric acid. The
nutrients in milk, particularly fat, may stimulate the stomach to produce more
acid.

22. A male client was on warfarin (Coumadin) before admission and has been receiving
heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should
Nurse Carla do?

A. Stop the I.V. infusion of heparin and notify the physician.

B. Continue treatment as ordered.

C. Expect the warfarin to increase the PTT.

D. Increase the dosage, because the level is lower than normal.

Correct Answer: B. Continue treatment as ordered.

The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the
therapeutic level is 1.5 to 2 times the normal level.
 Option A: There is no need to stop the infusion since the PTT is at a therapeutic
level. In patients receiving concomitant heparin and warfarin therapy, PTT reflects
the combined effects of both drugs. Because of the marked effect of warfarin on
the PTT, decreasing heparin dose in response to a high PTT frequently results in
subtherapeutic heparin levels.
 Option C: The PTT is not used to monitor warfarin therapy, but PTT may be
prolonged by warfarin at high doses.
 Option D: The level is correct; increasing the dosage is unnecessary. Warfarin
markedly affects PTT, for each increase of 1.0 in the international normalized
ratio, the PTT increases 16 seconds.
23. A client underwent ileostomy, when should the drainage appliance be applied to the
stoma?
A. 24 hours later, when edema has subsided

B. In the operating room

C. After the ileostomy begins to function

D. When the client is able to begin self-care procedures

Correct Answer: B. In the operating room

The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin.
Protection of the skin from the effects of these enzymes is begun at once. Skin exposed
to these enzymes even for a short time becomes reddened, painful, and excoriated.
 Option A: If the application of the drainage appliance is delayed after surgery,
the skin around the stoma would be most likely irritated and damaged due to the
digestive enzymes present in the secretions of the drainage.
 Option C: An ileostomy needs a drainage bag before it starts to function so that
the secretions from the drainage would be caught up by the bag, preventing
contamination of the skin.
 Option D: The client would have irritated, damaged skin once the drainage
comes out from the stoma and comes into contact with the skin.

24. A client has undergone spinal anesthetic, it will be important that the nurse
immediately position the client in:
A. On the side, to prevent obstruction of the airway by the tongue
B. Flat on back

C. On the back, with knees, flexed 15 degrees

D. Flat on the stomach, with the head, turned to the side

Correct Answer: B. Flat on back

To avoid the complication of a painful spinal headache that can last for several days, the
client is kept flat in a supine position for approximately 4 to 12 hours postoperatively.
Headaches are believed to be caused by the seepage of cerebrospinal fluid from the
puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized,
which avoids trauma to the neurons.
 Option A: The client may experience a severe headache if kept in a side-lying
position. Spinal headaches are caused by leakage of spinal fluid through a
puncture hole in the tough membrane (dura mater) that surrounds the spinal
cord.
 Option C: A supine position for 4 to 12 hours would prevent seepage of
cerebrospinal fluid from the puncture site. There is no need to flex the knees.
 Option D: Lying on his stomach would be uncomfortable to a postoperative
patient, and would cause a painful spinal headache from the spinal anesthesia.
25. While monitoring a male client several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?
A. Blood pressure has decreased from 160/90 to 110/70.

B. Pulse is increased from 87 to 95, with an occasional skipped beat.

C. The client is oriented when aroused from sleep and goes back to sleep
immediately.

D. The client refuses dinner because of anorexia.

Correct Answer: C. The client is oriented when aroused from sleep and goes back
to sleep immediately.
This finding suggests that the level of consciousness is decreasing.
 Option A: A blood pressure level of 110/70 mmHg is within normal limits.
Increased intracranial pressure is caused by an increase in blood pressure.
 Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood
pressure exceeds the intracranial pressure, blood flow to the brain is restored.
The increased arterial blood pressure caused by the CNS ischemic response
stimulates the baroceptors in the carotid bodies, thus slowing the heart rate
drastically often to the point of bradycardia.
 Option D: Anorexia is not related to increased intracranial pressure. Anorexia is
an eating disorder characterized by abnormally low body weight, an intense fear
of gaining weight, and a distorted perception of weight.

26. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following
symptoms may appear first?

A. Altered mental status and dehydration

B. Fever and chills

C. Hemoptysis and Dyspnea

D. Pleuritic chest pain and cough

Correct Answer: A. Altered mental status and dehydration

Elderly clients may first appear with only an altered mental status and dehydration due
to a blunted immune response.
 Option B: Fever and chills are classic signs of pneumonia that may appear later in
the elderly. The inflammatory response results in a proliferation of neutrophils.
This can damage lung tissue, leading to fibrosis and pulmonary edema, which
also impairs lung expansion.
 Option C: Hemoptysis is a late sign of pneumonia. Bleeding in the lungs may
originate from bronchial arteries, pulmonary arteries, bronchial capillaries, and
alveolar capillaries. Dyspnea may occur early, especially among the elderly.
Swelling and mucus can make it harder to move air through the airways, making
it harder to breathe. This leads to shortness of breath, difficulty of breathing, and
feeling more tired than normal.
  Option D: Cough and pleuritic chest pain are the common symptoms of
pneumonia. The air sacs may fill with fluid or pus, causing cough with phlegm or
ous, fever, chills, and difficulty breathing.

27. A male client has active tuberculosis (TB). Which of the following symptoms will be
exhibited?
A. Chest and lower back pain

B. Chills, fever, night sweats, and hemoptysis

C. Fever of more than 104°F (40°C) and nausea

D. Headache and photophobia

Correct Answer: B. Chills, fever, night sweats, and hemoptysis

Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.
 Option A: Chest pain may be present from coughing but isn’t usual. Pleurisy is a
condition where there is inflammation or irritation of the lining of the lungs and
chest. There is a sharp pain felt when breathing, coughing, or sneezing.
 Option C: Clients with TB typically have low-grade fevers, not higher than 102°F
(38.9°C). Fever typically develops in the late afternoon or evening in 68% of the
cases, and this typical fever is significantly more common in patients less 60 years
of age.
 Option D: Nausea, headache, and photophobia aren’t usual TB symptoms.
Typical symptoms include a cough that lasts for more than 3 weeks, loss of
appetite and unintentional weight loss, fever, chills, and night sweats.

28. Mark, a 7-year-old client, is brought to the emergency department. He’s tachypneic
and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive
cough. He recently had a cold. Form this history; the client may have which of the
following conditions?
A. Acute asthma

B. Bronchial pneumonia

C. Chronic obstructive pulmonary disease (COPD)

D. Emphysema

Correct Answer: A. Acute asthma

Based on the client’s history and symptoms, acute asthma is the most likely diagnosis.
 Option B: Bronchial pneumonia most often exhibits a productive cough. It is the
type of pneumonia that affects the bronchi in the lungs. This condition commonly
results from a bacterial infection, but viral and fungal infections can also cause it.
 Option C: COPD commonly occurs in middle-aged people, mostly over the age
of 40. Chronic obstructive pulmonary disease is a chronic inflammatory lung
disease that causes obstructed airflow from the lungs.
 Option D: Emphysema is most common in men between the ages of 50 and 70.
It is a lung condition that causes shortness of breath. The air sacs in the lungs are
 damaged. Over time, the inner walls of the air sacs weaken and rupture-creating
larger air spaces instead of many small ones.

29. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate
is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following
reactions?
A. Asthma attack

B. Respiratory arrest

C. Seizure

D. Wake up on her own

Correct Answer: B. Respiratory arrest

Narcotics can cause respiratory arrest if given in large quantities.
 Option A: The client’s respiratory system is most likely being suppressed, so an
acute asthma attack would be unlikely. In an asthma attack, the airways become
swollen and inflamed. The muscles around the airways contract and the airways
produce extra mucus, causing the breathing (bronchial) tubes to narrow.
 Option C: A seizure is not likely to occur in the situation. Seizures are mostly
caused by paroxysmal discharges from groups of neurons, which arise as a result
of excessive excitation or loss of inhibition.
 Option D: The client’s respiratory rate is too low and she might be going into a
respiratory arrest. Respiratory depression happens when the lungs fail to
exchange carbon dioxide and oxygen efficiently. This dysfunction leads to a
buildup of carbon dioxide in the body, which can result in health complications.

30. A 77-year-old male client is admitted for elective knee surgery. Physical examination
reveals shallow respirations but no sign of respiratory distress. Which of the following is
a normal physiologic change related to aging?
A. Increased elastic recoil of the lungs

B. Increased number of functional capillaries in the alveoli

C. Decreased residual volume

D. Decreased vital capacity

Correct Answer: D. Decreased vital capacity

Reduction in vital capacity is a normal physiologic change including decreased elastic
recoil of the lungs, fewer functional capillaries in the alveoli, and an increase in residual
volume.
 Option A: Elastic recoil in the lungs of the elderly are decreased. There is
homogenous degeneration of the elastic fibers around the alveolar duct starting
around 0 years of age resulting in enlargement of air spaces.
 Option B: There are fewer functional capillaries in the alveoli as one ages. The
alveoli can lose their shape and become baggy.
  Option C: Decreases in the measures of lung function such as the vital capacity
occurs as part of the age-related changes.

31. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is
the most relevant 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)

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

cardiac monitor.
Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been
controlled with oral medication and who are having PVCs that are visible on the cardiac
monitor.
 Option A: This should be reported to the physician but it is not the priority in this
situation.
 Option B: An increase in the blood pressure is also significant, but does not need
immediate attention.
 Option D: Increase in ICP is an important factor but isn’t as significant as PVCs in
the situation.

32. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach
the client to:

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

Correct Answer: B. Avoid foods high in vitamin K

The client should avoid consuming large amounts of vitamin K because vitamin K can
interfere with anticoagulation.
 Option A: The client may need to report diarrhea but it doesn’t have the effect of
taking an anticoagulant.
 Option C: An electric razor-not a straight razor-should be used to prevent cuts
that cause bleeding.
 Option D: Aspirin may increase the risk of bleeding; acetaminophen should be
used for pain relief.
33. Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse
should treat excess hair at the site by:
A. Leaving the hair intact

B. Shaving the area

C. Clipping the hair in the area

D. Removing the hair with a depilatory

Correct Answer: C. Clipping the hair in the area

Hair can be a source of infection and should be removed by clipping.
 Option A: Leaving the hair intact can cause infections.
 Option B: Shaving the area can cause skin abrasions.
 Option D: Depilatories can irritate the skin.

34. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the
client, the nurse should include information about which major complication:
A. Bone fracture

B. Loss of estrogen
C. Negative calcium balance

D. Dowager’s hump

Correct Answer: A. Bone fracture

Bone fracture is a major complication of osteoporosis that results when a loss of calcium
and phosphate increases the fragility of bones.
 Option B: Estrogen deficiencies result from menopause and not osteoporosis.
 Option C: Calcium and vitamin D supplements may be used to support normal
bone metabolism, But a negative calcium balance isn’t a complication of
osteoporosis.
 Option D: Dowager’s hump results from bone fractures. It develops when
repeated vertebral fractures increase spinal curvature.

35. Nurse Len is teaching a group of women to perform BSE. The nurse should explain
that the purpose of performing the examination is to discover:
A. Cancerous lumps

B. Areas of thickness or fullness

C. Changes from previous examinations

D. Fibrocystic masses

Correct Answer: C. Changes from previous examinations

Women are instructed to examine themselves to discover changes that have occurred in
the breast.
  Option A: Lumps may be detected through BSE, but it does not diagnose
whether it is benign or cancerous.
 Option B: Only a physician can diagnose areas of thickness or fullness that signal
the presence of a malignancy.
 Option D: Only a physician can diagnose masses that are fibrocystic as opposed
to malignant.

36. When caring for a female client who is being treated for hyperthyroidism, it is
important to:

A. Provide extra blankets and clothing to keep the client warm.

B. Monitor the client for signs of restlessness, sweating, and excessive weight loss
during thyroid replacement therapy.

C. Balance the client’s periods of activity and rest.

D. Encourage the client to be active to prevent constipation.

Correct Answer: C. Balance the client’s periods of activity and rest.

A client with hyperthyroidism needs to be encouraged to balance periods of activity and
rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very
warm.
 Option A: One of the signs of hyperthyroidism is increased sensitivity to heat. So
extra blankets and clothing would be unnecessary.
 Option B: Restlessness, sweating, and unintentional weight loss are common
signs of hyperthyroidism.
 Option D: There should be equal moments of activity and rest for the client.

37. Nurse Kris is teaching a client with a history of atherosclerosis. To decrease the risk
of atherosclerosis, the nurse should encourage the client to:

A. Avoid focusing on his weight

B. Increase his activity level

C. Follow a regular diet

D. Continue leading a high-stress lifestyle

Correct Answer: B. Increase his activity level

The client should be encouraged to increase his activity level.
 Option A: Clients with atherosclerosis should be vigilant about their weight and
maintain the ideal number of kilograms/pounds.
 Option C: The client should be following a low cholesterol, low sodium diet.
 Option D: Avoiding stress is an important factor in decreasing the risk of
atherosclerosis.
38. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
following a:
A. Laminectomy

B. Thoracotomy

C. Hemorrhoidectomy

D. Cystectomy

Correct Answer: A. Laminectomy

The client who has had spinal surgery, such as laminectomy, must be log rolled to keep
the spinal column straight when turning.
 Option B: Thoracotomy clients may turn themselves or may be assisted in a
comfortable position.
 Option C: Under normal circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities immediately after surgery.
 Option D: A client who has undergone cystectomy would be able to turn
themselves or may need minimal assistance.

39. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse
Oliver is giving the client discharge instructions. These instructions should include which
of the following?

A. Avoid lifting objects weighing more than 5 lb (2.25 kg)

B. Lie on your abdomen when in bed

C. Keep rooms brightly lit

D. Avoiding straining during a bowel movement or bending at the waist

Correct Answer: D. Avoiding straining during a bowel movement or bending at the

waist.
The client should avoid straining, lifting heavy objects, and coughing harshly because
these activities increase intraocular pressure.
 Option A: Typically, the client is instructed to avoid lifting objects weighing more
than 15 lb (7kg) – not 5lb.
 Option B: Instruct the client when lying in bed to lie on either the side or back.
 Option C: The client should avoid bright light by wearing sunglasses.

40. George should be taught about testicular examinations during:

A. When a sexual activity starts

B. After age 69

C. After age 40

D. Before age 20
Correct Answer: D. Before age 20
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.
 Option A: Sexual activity is not an accurate indicator of when to start testicular
exams.
 Option B: The age of 69 would be too old to start on testicular exams. Most
elderly men may have testicular problems at this age.
 Option C: The age of 40 is not an ideal age to start the testicular exams. It might
be too late to detect a problem at this stage.

41. A male client has undergone a colon resection. While turning him, wound
dehiscence with evisceration occurs. Nurse Trish first response is to:

A. Call the physician

B. Place a saline-soaked sterile dressing on the wound

C. Take blood pressure and pulse

D. Pull the dehiscence closed

Correct Answer: B. Place a saline-soaked sterile dressing on the wound.

The nurse should first place saline-soaked sterile dressings on the open wound to
prevent tissue drying and possible infection.
 Option A: After placing a saline-soaked gauze, the nurse should call the
physician.
 Option C: After notifying the physician, the nurse should take the client’s vital
signs.
 Option D: The dehiscence needs to be surgically closed, so the nurse should
never try to close it

42. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular
accident. During routine assessment, the nurse notices Cheyne- Stokes respirations.
Cheyne-stokes respirations are:

A. Progressively deeper breath 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.
Cheyne-Stokes respirations are breaths that become progressively deeper followed by
more shallow respirations with apneic periods.
 Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses
between each breath, and equal depth between each breath.
 Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.
  Option D: Tachypnea is shallow breathing with increased respiratory rate.

43. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly
auscultated in clients with heart failure are:
A. Tracheal

B. Fine crackles

C. Coarse crackles

D. Friction rubs

Correct Answer: B. Fine crackles

Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart
failure.
 Option A: Tracheal breath sounds are auscultated over the trachea.
 Option C: Coarse crackles are caused by secretion accumulation in the airways.
 Option D: Friction rubs occur with pleural inflammation.

44. The nurse is caring for Kenneth experiencing an acute asthma attack. The client
stops wheezing and breath sounds aren’t audible. The reason for this change is that:
A. The attack is over.

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

C. The swelling has decreased.

D. Crackles have replaced wheezes.

Correct Answer: B. The airways are so swollen that no air cannot get through.
During an acute attack, wheezing may stop and breath sounds become inaudible
because the airways are so swollen that air can’t get through.
 Option A: Breath sounds should still be audible even if the attack is over.
 Option C: A decrease in swelling does not cause diminished breath sounds.
 Option D: Crackles do not replace wheezes during an acute asthma attack.

45. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse
should:

A. Place the client on his back, remove dangerous objects, and insert a bite block.

B. Place the client on his side, remove dangerous objects, and insert a bite block.

C. Place the client on his back, remove dangerous objects, and hold down his arms.

D. Place the client on his side, remove dangerous objects, and protect his head.
Correct Answer: D. Place the client on his side, remove dangerous objects, and
protect his head.
During the active seizure phase, initiate precautions by placing the client on his side,
removing dangerous objects, and protecting his head from injury.
 Option A: Do not insert anything on a client’s mouth during an active seizure
because it may damage the teeth. Placing the client on his back may cause
obstruction of the airway.
 Option B: A bite block should never be inserted during the active seizure phase.
Insertion can break the teeth and lead to aspiration.
 Option C: The client should be placed in a side-lying position to facilitate
drainage of secretions and prevent aspiration.

46. 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.
 Option A: Infection of the lung won’t cause a tension pneumothorax. A tension
pneumothorax is a life-threatening condition that develops when air is trapped in
the pleural cavity under positive pressure, displacing mediastinal structures and
compromising cardiopulmonary function.
 Option C: Excessive water won’t affect the chest tube drainage. The main
purpose of the water seal is to allow air to exit from the pleural space on
exhalation and prevent air from entering the pleural cavity or mediastinum on
inhalation.
 Option D: An excessive chest tube drainage cannot cause tension pneumothorax.
Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus.
The tube around the lung is placed between the ribs and into the space between
the inner lining and the outer lining of the chest cavity.

47. Nurse Maureen is talking to a male client, the client begins choking on his lunch.
He’s coughing forcefully. The nurse should:
A. Stand him up and perform the abdominal thrust maneuver from behind.

B. Lay him down, straddle him, and perform the abdominal thrust maneuver.

C. Leave him to get assistance.

D. Stay with him but not intervene at this time.

Correct Answer: D. Stay with him but not intervene at this time.
If the client is coughing, he should be able to dislodge the object or cause complete
obstruction. If a complete obstruction occurs, the nurse should perform the abdominal
thrust maneuver with the client standing.
 Option A: This would only be applicable if there is a complete obstruction, in
which the client would not be able to cough anymore.
 Option B: If the client is unconscious, she should lay him down.
 Option C: A nurse should never leave a choking client alone.

48. Nurse Ron is taking the health history of an 84-year-old client. Which information
will be most useful to the nurse for planning care?

A. General health for the last 10 years

B. Current health promotion activities

C. Family history of diseases

D. Marital status

Correct Answer: B. Current health promotion activities

Recognizing an individual’s positive health measures is very useful.
 Option A: General health in the previous 10 years is important, however, the
current activities of an 84-year-old client are most significant in planning care.
 Option C: Family history of disease for a client in later years is of minor
significance.
 Option D: Marital status information may be important for discharge planning
but is not as significant for addressing the immediate medical problem.

49. When performing oral care on a comatose client, Nurse Krina should:
A. Apply lemon glycerin to the client’s lips at least every 2 hours.

B. Brush the teeth with a client lying supine.

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

D. Clean the client’s mouth with hydrogen peroxide.

Correct Answer: C. Place the client in a side-lying position, with the head of the
bed lowered.
The client should be positioned in a side-lying position with the head of the bed
lowered to prevent aspiration. A small amount of toothpaste should be used and the
mouth swabbed or suctioned to remove pooled secretions.
 Option A: Lemon glycerin can be drying if used for extended periods.
 Option B: Brushing the teeth with the client lying supine may lead to aspiration.
 Option D: Hydrogen peroxide is caustic to tissues and should not be used.
50. 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.
 Option A: The client with ARDS has dyspnea and hypoxia with worsening
hypoxia over time, if not treated aggressively.
 Option B: Pleuritic chest pain varies with respiration, unlike the constant chest
pain during an MI; so this client most likely isn’t having an MI.
 Option D: The client with TB typically has a cough producing blood-tinged
sputum. A sputum culture should be obtained to confirm the nurse’s suspicions.

51. Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an
outbreak of tuberculosis (TB). Which of the following clients entering the clinic today
is most likely to have TB?
A. A 16-year-old female high school student
B. A 33-year-old daycare worker

C. A 43-year-old homeless man with a history of alcoholism

D. A 54-year-old businessman

Correct Answer: C. A 43-year-old homeless man with a history of alcoholism

Clients who are economically disadvantaged, malnourished, and have reduced
immunity, such as a client with a history of alcoholism, are at extremely high risk for
developing TB.
 Option A: The high school student may be at low risk of developing TB, and she
does not exhibit any signs and symptoms.
 Option B: The daycare worker may have a lesser risk of developing TB than the
homeless man with alcoholism.
 Option D: A businessman probably has a much lower risk of contracting TB.
52. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is
aware that which of the following reasons this is done?
A. To confirm the diagnosis

B. To determine if a repeat skin test is needed

C. To determine the extent of lesions

D. To determine if this is a primary or secondary 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.
 Option A: Sputum culture confirms the diagnosis. It is a test to detect and
identify bacteria or fungi that infect the lungs or breathing passages.
 Option B: There can be false-positive and false-negative skin test results. False-
positive results happen with the skin test because the person has been infected
with a different type of bacteria, rather than the one that causes TB. It can also
happen because the person has been vaccinated with the BCG vaccine. A false-
negative result may happen if the immune function is compromised by chronic
medical conditions, cancer chemotherapy, or AIDS.
 Option D: A chest X-ray can’t determine if this is a primary or secondary
infection. In active pulmonary TB, infiltrates or consolidations and/or cavities are
often seen in the upper lungs with or without mediastinal or hilar
lymphadenopathy.

53. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a
decreased forced expiratory volume should be treated with which of the following
classes of medication right away?
A. Beta-adrenergic blockers

B. Bronchodilators

C. Inhaled steroids

D. Oral steroids

Correct Answer: B. Bronchodilators

Bronchodilators are the first line of treatment for asthma because broncho-constriction
is the cause of reduced airflow.
 Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause
bronchoconstriction.
 Option C: Inhaled steroids are not ideal for emergency cases because of their
slow onset.
 Option D: Oral steroids may be given to reduce the inflammation but aren’t used
for emergency relief.
54. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs
of cigarettes per day has a chronic cough producing thick sputum, peripheral edema,
and cyanotic nail beds. Based on this information, he most likely has which of the
following conditions?
A. Adult respiratory distress syndrome (ARDS)

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct Answer: C. Chronic obstructive bronchitis

Because of this extensive smoking history and symptoms, the client most likely has
chronic obstructive bronchitis.
 Option A: Clients with ARDS have acute symptoms of hypoxia and typically need
large amounts of oxygen.
 Option B: Clients with asthma do not exhibit a chronic cough. Symptoms of
asthma include shortness of breath, chest tightness or pain, wheezing when
exhaling, and coughing or wheezing attacks.
 Option D: Clients with emphysema tend not to have a chronic cough or
peripheral edema. The main symptom of emphysema is shortness of breath,
which usually begins gradually.

55. Situation: Francis, age 46 is admitted to the hospital with a diagnosis of Chronic
Lymphocytic Leukemia. The treatment for patients with leukemia is bone marrow
transplantation. Which statement about bone marrow transplantation is not correct?

A. The patient is under local anesthesia during the procedure.

B. The aspirated bone marrow is mixed with heparin.

C. The aspiration site is the posterior or anterior iliac crest.

D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before

the procedure.

Correct Answer: A. The patient is 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.
 Option B: An anticoagulant is often added to prevent cell clumping.
 Option C: The iliac crest is preferred for safety reasons, because there are no
major blood vessels or organs located close to this area.
 Option D: Cyclophosphamide is given to prevent the incidence of graft-versus-
host disease.
56. After several days of admission, Francis becomes disoriented and complains of
frequent headaches. The nurse in-charge first action would be:
A. Call the physician

B. Document the patient’s status in his charts

C. Prepare oxygen treatment

D. Raise the side rails

Correct Answer: D. Raise the side rails

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.
 Option A: Calling the physician would be unnecessary. These findings can be
reported after ensuring the patient’s safety first.
 Option B: After notifying the physician, the nurse should document these
findings.
 Option C: Oxygen treatment would be needed as ordered by the physician.

57. During routine care, Francis asks the nurse, “How can I be anemic if this disease
causes increased white blood cell production?” The nurse in-charge best response
would be that the increased number of white blood cells (WBC) is:
A. Crowded red blood cells

B. Is not responsible for the anemia

C. Uses nutrients from other cells

D. Have an abnormally short lifespan of 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.
 Option B: The increase in WBCs most likely caused the anemia.
 Option C: The overcrowding of WBC pushes out the RBCs, thereby decreasing
them and causing anemia.
 Option D: The lifespan of WBCs is 13 to 20 days, while the RBCs live for
approximately 115 days.

58. Diagnostic assessment of Francis would probably not reveal:

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.
 Option A: Lymphoblasts are most probably common in clients with CLL.
 Option C: The increase in WBC production also involves abnormal blast cell
production.
 Option D: Elevated thrombocyte counts follow as the WBCs increase.

59. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an
emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left
foot using Doppler ultrasound. The nurse immediately notifies the physician and asks
her to prepare the client for surgery. As the nurse enters the client’s room to prepare
him, he states that he won’t have any more surgery. Which of the following is
the best initial response by the nurse?
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.
 Option B: If the client understands the risks but still refuses the nurse should
notify the physician.
 Option C: Notify the nurse supervisor if the client still refuses the surgery after an
explanation of risks.
 Option D: Record the client’s refusal in the nurses’ notes if he still refuses after a
thorough explanation.

60. 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.
 Option A: After assessing the client with thrombophlebitis, the nurse should
assess the 58- year-old client admitted 2 days ago with heart failure (his signs
and symptoms are resolving and don’t require immediate attention).
 Option B: The lowest priority is the 89-year-old with end-stage right-sided heart
failure, who requires time-consuming supportive measures.
 Option C: Assess this patient next because he is at high risk for developing an
emboli, which is fatal.

61. Honey, a 23-year old client complains of substernal chest pain and states that her
heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders.
The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and the respiratory rate is 26
breaths/minutes. Which of the following drugs should the nurse question the client
about using?

A. Barbiturates

B. Opioids

C. Cocaine

D. Benzodiazepines

Correct Answer: C. Cocaine

Because of the client’s age and negative medical history, the nurse should question her
about cocaine use. Cocaine increases myocardial oxygen consumption and can cause
coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial
ischemia, and myocardial infarction.
 Option A: Barbiturate overdose may trigger respiratory depression and slow
pulse.
 Option B: Opioids can cause marked respiratory depression.
 Option D: Benzodiazepines can cause drowsiness and confusion.

62. A 51-year-old female client tells the nurse-in-charge that she has found a painless
lump in her right breast during her monthly self-examination. Which assessment finding
would strongly suggest that this client’s lump is cancerous?
A. Eversion of the right nipple and mobile mass

B. Nonmobile mass with irregular edges

C. Mobile mass that is soft and easily delineated

D. Nonpalpable right axillary lymph nodes

Correct Answer: B. Nonmobile mass with irregular edges
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges.
 Option A: Nipple retraction — not eversion — may be a sign of cancer.
 Option C: A mobile mass that is soft and easily delineated is most often a fluid-
filled benign cyst.
 Option D: Axillary lymph nodes may or may not be palpable on initial detection
of a cancerous mass.

63. A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment
for this type of cancer?” Which treatment should the nurse name?
A. Surgery

B. Chemotherapy

C. Radiation

D. Immunotherapy

Correct Answer: C. Radiation

The usual treatment for vaginal cancer is external or intravaginal radiation therapy.
 Option A: Less often, surgery is performed. Surgery is usually only used for small
stage I or II vaginal cancers and for cancers that were not cured with radiation.
 Option B: Chemotherapy typically is prescribed only if vaginal cancer is
diagnosed at an early stage, which is rare.
 Option D: Immunotherapy isn’t used to treat vaginal cancer. It is a type of cancer
treatment that helps the immune system fight cancer. Immunotherapy is a type
of biological therapy. Biological therapy is a type of treatment that uses
substances made from living organisms to treat cancer.

64. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the
lesion according to the TNM staging system as follows: TIS, N0, M0. What does this
classification mean?

A. No evidence of primary tumor, no abnormal regional lymph nodes, and no

evidence of distant metastasis.
B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant
metastasis.

C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis.

D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and

ascending degrees of distant metastasis.

Correct Answer: B. Carcinoma in situ, no abnormal regional lymph nodes, and no

evidence of distant metastasis
TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no
evidence of distant metastasis.
 Option A: No evidence of primary tumor, no abnormal regional lymph nodes,
and no evidence of distant metastasis is classified as T0, N0, M0.
  Option C: If the tumor and regional lymph nodes can’t be assessed and no
evidence of metastasis exists, the lesion is classified as TX, NX, M0.
 Option D: A progressive increase in tumor size, no demonstrable metastases of
the regional lymph nodes, and ascending degrees of distant metastasis is
classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

65. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client
how to care for the neck stoma, the nurse should include which instruction?
A. “Keep the stoma uncovered.”

B. “Keep the stoma dry.”

C. “Have a family member perform stoma care initially until you get used to the
procedure.”
D. “Keep the stoma moist.”

Correct Answer: D. “Keep the stoma moist.”

The nurse should instruct the client to keep the stoma moist, such as by applying a thin
layer of petroleum jelly around the edges, because a dry stoma may become irritated.
 Option A: The nurse should recommend placing a stoma bib over the stoma to
filter and warm air before it enters the stoma.
 Option B: The stoma should be kept moist to avoid irritation.
 Option C: The client should begin performing stoma care without assistance as
soon as possible to gain independence in self-care activities.

66. A 37-year-old client with uterine cancer asks the nurse, “Which is the most common
type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer
causes the most deaths in women?
A. Breast cancer

B. Lung cancer

C. Brain cancer

D. Colon and rectal cancer

Correct Answer: B. Lung cancer

Lung cancer is the most deadly type of cancer in both women and men.
 Option A: Breast cancer is the second most deadly type of cancer in women.
 Option C: Brain cancer is the 10th most deadly type of cancer among women.
 Option D: Colon and rectal cancer rank third in women.
67. Antonio with lung cancer develops Horner’s syndrome when the tumor invades the
ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms
of this syndrome, the nurse should note:

A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.

B. Chest pain, dyspnea, cough, weight loss, and fever.

C. Arm and shoulder pain and atrophy of arm and hand muscles, both on the
affected side.
D. Hoarseness and dysphagia.

Correct Answer: A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side
of the face.
Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the
sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face.
 Option B: Chest pain, dyspnea, cough, weight loss, and fever are associated with
pleural tumors.
 Option C: Arm and shoulder pain and atrophy of the arm and hand muscles on
the affected side suggest Pancoast’s tumor, a lung tumor involving the first
thoracic and eighth cervical nerves within the brachial plexus.
 Option D: Hoarseness in a client with lung cancer suggests that the tumor has
extended to the recurrent laryngeal nerve; dysphagia suggests that the lung
tumor is compressing the esophagus.

68. Vic asks the nurse what PSA is. The nurse should reply that it stands for:

A. Prostate-specific antigen, which is used to screen for prostate cancer.

B. Protein serum antigen, which is used to determine protein levels.

C. Pneumococcal strep antigen, which is a bacteria that causes pneumonia.

D. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

Correct Answer: A. Prostate-specific antigen, which is used to screen for prostate

cancer.
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.
 Option B: There is no protein serum antigen test for protein levels.
 Option C: There is no pneumococcal strep antigen test that tests for bacteria in
pneumonia.
 Option D: There is no Papanicolau-specific antigen test available for cervical
cancer.
69. What is the most important postoperative instruction that nurse Kate must give a
client who has just returned from the operating room after receiving a subarachnoid
block?

A. “Avoid drinking liquids until the gag reflex returns.”

B. “Avoid eating milk products for 24 hours.”

C. “Notify a nurse if you experience blood in your urine.”

D. “Remain supine for the time specified by the physician.”

Correct Answer: D. “Remain supine for the time specified by the physician.”
The nurse should instruct the client to remain supine for the time specified by the
physician.
 Option A: Local anesthetics used in a subarachnoid block don’t alter the gag
reflex.
 Option B: No interactions between local anesthetics and food occur.
 Option C: Local anesthetics don’t cause hematuria.

70. A male client suspected of having colorectal cancer will require which diagnostic
study to confirm the diagnosis?
A. Stool Hematest

B. Carcinoembryonic antigen (CEA)

C. Sigmoidoscopy

D. Abdominal computed tomography (CT) scan

Correct Answer: C. Sigmoidoscopy

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection
of two-thirds of all colorectal cancers.
 Option A: Stool Hematest detects blood, which is a sign of colorectal cancer;
however, the test doesn’t confirm the diagnosis.
 Option B: CEA may be elevated in colorectal cancer but isn’t considered a
confirming test. Carcinoembryonic antigen is a protein normally found in very low
levels in the blood of adults. It is most commonly used for colorectal cancer.
 Option D: An abdominal CT scan is used to stage the presence of colorectal
cancer.

71. During a breast examination, which finding most strongly suggests that the Luz has
breast cancer?
A. Slight asymmetry of the breasts

B. A fixed nodular mass with dimpling of the overlying skin

C. Bloody discharge from the nipple

D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B. A fixed nodular mass with dimpling of the overlying skin
A fixed nodular mass with dimpling of the overlying skin is common during the late
stages of breast cancer.
 Option A: Many women have slightly asymmetrical breasts.
 Option C: Bloody nipple discharge is a sign of intraductal papilloma, a benign
condition.
 Option D: Multiple firm, round, freely movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a benign condition.

72. A female client with cancer is being evaluated for possible metastasis. Which of the
following is one of the most common metastasis sites for cancer cells?

A. Liver

B. Colon

C. Reproductive tract

D. White blood cells (WBCs)

Correct Answer: A. Liver

The liver is one of the five most common cancer metastasis sites. The others are the
lymph nodes, lung, bone, and brain.
 Option B: The colon is a rare cancer metastasis site. The most common pathway
of metastatic spreading to the bowel is through peritoneal seeding, through
hematogenous and lymphatic dissemination to the colon has also been reported.
 Option C: Metastasis rarely occurs in the reproductive tract. Ovary and vagina are
the most frequent metastatic sites for extragenital and genital primaries.
 Option D: The WBCs are occasional metastasis sites. A human metastatic tumor
can arise when a leukocyte and a cancer cell fuse to form a genetic hybrid.

73. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm
or rule out a spinal cord lesion. During the MRI scan, which of the following would pose
a threat to the client?
A. The client lies still

B. The client asks questions

C. The client hears thumping sounds

D. The client wears a watch and wedding band

Correct Answer: D. The client wears a watch and wedding band

During an MRI, the client should wear no metal objects, such as jewelry, because the
strong magnetic field can pull on them, causing injury to the client and (if they fly off) to
others.
 Option A: The client must lie still during the MRI. When clients move during an
MRI, they create motion artifacts in magnetic resonance images that often appear
as ghosting artifacts, obscuring clinical information.
  Option B: The client may talk to those performing the test by way of the
microphone inside the scanner tunnel.
 Option C: The client should hear thumping sounds, which are caused by the
sound waves thumping on the magnetic field.

74. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the
following teaching points is correct?

A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone

loss.

B. To avoid fractures, the client should avoid strenuous exercise.

C. The recommended daily allowance of calcium may be found in a wide variety of

foods
D. Obtaining the recommended daily allowance of calcium requires taking a calcium
supplement.

Correct Answer: C. The recommended daily allowance of calcium may be found in

a wide variety of foods.
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women
require 1,500 mg per day. It’s often, though not always, possible to get the
recommended daily requirement in the foods we eat.
 Option D: Supplements are available but not always necessary.
 Option A: Osteoporosis doesn’t show up on ordinary X-rays until 30% of the
bone loss has occurred. Bone densitometry can detect bone loss of 3% or less.
This test is sometimes recommended routinely for women over 35 who are at
risk.
 Option B: Strenuous exercise won’t cause fractures. Weight-bearing aerobics
exercises and resistance training are good for people with osteoporosis.

75. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for
contraindications for this procedure. Which finding is a contraindication?
A. Joint pain

B. Joint deformity

C. Joint flexion of less than 50%

D. Joint stiffness

Correct Answer: C. Joint flexion of less than 50%

Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of
technical problems in inserting the instrument into the joint to see it clearly. Other
contraindications for this procedure include skin and wound infections.
 Option A: Joint pain may be an indication, not a contraindication, for
arthroscopy.
 Option B: Joint deformity is not a contraindication for the procedure. Joint
surgery can improve the appearance of deformed joints, especially in the hands.
 Option D: Joint stiffness is not a contraindication for this procedure. Arthroscopic
surgery usually results in less joint pain and stiffness.