RN VATI Adult Medical Surgical 2023 version 1-100 questions
04 September 2024RN VATI Adult Medical Surgical 2023 version 1-100 questions with Correct Answers
Capstone Course (Chamberlain University)
A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects?
Thinning of the skin
delayed healing
MY ANSWER
Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid preparations. The client should only apply the ointment to dry patches of the skin because topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning of the skin.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? Frothy sputum
MY ANSWER
The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client’s ABGs are: pH 7.48, PCO230 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?
MA nurse is assessing a client who has Cushing’s syndrome. Which of the following findings should the nurse expect?
Osteoporosis
Osteoporosis is a common finding with Cushing’s syndrome. Bones become thinner as a result of mineral loss and nitrogen depletion, and the risk for fractures increases.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client’s skin?
MY ANSWER
A client who has basal cell carcinoma has a nodular lesion with welldefined borders and a pearly or waxy appearance, resulting from overexposure to the sun, especially on the face, head, and neck.
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the client’s face to detect the presence of Chvostek’s sign? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer).
A is correct. The nurse should tap the client’s cheek just in front of the ear and below the zygomatic arch. The client who has hypocalcemia will display a Chvostek’s sign, which is a twitching of the facial muscle.
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the
MY ANSWER
A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.
**A home health nurse is assisting a client with planning care for a family member who has Alzheimer’s disease. Which of the following instructions should the nurse include? **
Remove clutter from rooms and hallways.
The nurse should instruct the family member to remove clutter from rooms and hallways so the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse identify as a manifestation of this syndrome?
Refractory hypoxemia
MY ANSWER
ARDS is a systemic inflammatory response to trauma, sepsis, burns, pancreatitis, and blood transfusions, when excess lung fluid dilutes surfactant activity in the lungs. A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
Use of accessory muscles
MY ANSWER
A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
MY ANSWER
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately.
**A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery? **
Clear drainage on the dressings
The nurse should identify clear drainage on or around the dressing as an indication of a cerebral spinal leak and should report this finding to the provider immediately.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
Increased abdominal girth
MY ANSWER
Increased abdominal girth is an expected finding with right-sided heart failure due to systemic congestion and an enlarged liver and spleen. Systemic congestion can lead to fluid retention and increased pressure in the venous system, which can manifest with edema in the lower extremities.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
“I changed the floor plan of our home to accommodate my father’s wheelchair.”
The nurse should identify that the client has accepted the role change of caring for their aging parents by changing the floor plan of the home to accommodate their father’s wheelchair.
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
The client is becoming flushed.
MY ANSWER
Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome. Red man syndrome results from infusing vancomycin too rapidly. The nurse
should infuse the medication over at least 60 min. -
The client can have an adverse effect called red man syndrome, which causes hypotension and tachycardia, due to infusing the vancomycin too rapidly
**A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? **
BUN 24 mg/dL
MY ANSWER
A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the client for increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate transplant rejection.
**A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome? **
Iron-deficiency anemia
MY ANSWER
The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia.
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
The client’s daily peak expiratory flow (PEF) measures 85% above personal best.
A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy.
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
“I will check my blood sugar level before exercising.”
MY ANSWER
Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise. The nurse should instruct the client to monitor blood glucose levels before, during, and following exercise.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply.) Ferrous sulfate
Echinacea
Aspirin
Dextromethorphan
Naproxen
MY ANSWER
Aspirin is correct.Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin.
Naproxen is correct.Naproxen is an NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin.
A nurse is assisting with the care of a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse plan to take?
Place the client leaning forward over the bedside table for the procedure.
MY ANSWER
The nurse should place the client leaning forward over the bedside table for a thoracentesis. This allows the provider complete access to the client’s chest and back. This position also expands the spaces between the ribs where the pleural fluid accumulates.
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
“I will place my used tissues in a plastic bag.”
MY ANSWER
The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client’s sputum should be placed in a plastic bag and sealed to avoid spreading the infection.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
Use disposable utensils for meals.
MY ANSWER
The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for several weeks following treatment. The nurse should instruct the client to use disposable utensils, plates, and cups during this time period to decrease the risk for radiation exposure to other members of the household.
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
A PCA pump will be used for postoperative pain control.
MY ANSWER
A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication.
A nurse is assessing a client’s ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
MY ANSWER
With atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
Report cloudy dialysate drainage to the provider.
MY ANSWER
The most serious complication of peritoneal dialysis is peritonitis, an inflammation of the peritoneum. Assessment findings include cloudy dialysate drainage, rebound abdominal tenderness, and diffuse abdominal pain. The nurse should report these findings immediately to the provider, who can then prescribe a fluid culture, quick exchanges to wash out mediators of infection, and antibiotics.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia
MY ANSWER
Elevated WBC count is correct.A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix.
Rebound tenderness is correct.A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client’s abdomen.
Anorexia is correct.A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan? Apply moisturizer to damp skin after bathing.
MY ANSWERApplying a moisturizer to damp skin after bathing helps prevent dry skin.
The drier the skin is, the greater the risk is for skin breakdown.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
MY ANSWER
Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels.
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client’s vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse’s priority?
Assess the surgical incision for signs of infection.
MY ANSWER
A surgical wound infection typically appears 3 to 6 days following the surgery. Fever from the third postoperative day onward indicates that this client’s greatest risk is either a wound infection or a pulmonary infection; therefore, this is the priority action the nurse should take.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
“I may have mild cramping for several hours.”
MY ANSWER
The client should expect very little discomfort from the LEEP procedure, which is performed in ambulatory care using a painless electrical current.
A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?
A client whose medications to manage Parkinson’s disease are no longer effective
MY ANSWER
Parkinson’s disease is a neurodegenerative disease marked by alterations in mobility, cognition, mood, and functioning of the sympathetic nervous system. The effectiveness of medications used to manage the symptoms can decrease over time. When this occurs, the nurse should make a referral to palliative care. Palliative care is designed to maintain the client’s current quality of life through symptom management, assist with decision making regarding care needs, and work with families to identify care outcomes.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?
“I will keep the medication refrigerated.”
MY ANSWER
The nurse should instruct the client to refrigerate the oral cephalosporin suspension to maintain its full strength until the completion of the medication regimen.
A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
Peaked T waves
Elevated potassium levels result in tall, peaked T waves, flat or absent P waves, prolonged PR intervals, wide QRS complexes, and ectopic beats. Hyperkalemia can progress to complete heart block, ventricular fibrillation, and asystole.
A nurse is caring for a client who had abdominal surgery. The client tells the nurse that “something gave way.” The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
•             Place the client in a low Fowler’s position with the knees bent.
•             Cover the client’s wound with a sterile saline-soaked dressing.
•             Notify the surgeon about the finding.
•             Prepare the client for transfer to surgery.
Based on evidence-based practice, the nurse should immediately contact the surgeon and notify them of the wound evisceration. The nurse should then cover the client’s wound with a sterile saline soaked dressing to protect it from infection. The nurse should then place the client in a low Fowler’s position with their knees bent and then prepare the client to be transferred to surgery.
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
Verify that the client has adequate IV access.
MY ANSWER
When using the airway, breathing, and circulation approach to client care, the nurse should first verify that the client has at least a 20gauge IV for the administration of blood.
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia? Increased thirst
MY ANSWER
The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue.
A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?
Diabetes mellitus
MY ANSWER
Diabetes mellitus is a predisposing factor for UTIs. Clients who have underlying diseases that compromise their immune response have an increased risk for UTIs.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
Elevated toilet seat
MY ANSWER
A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client’s home prior to the client’s discharge.
**A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication? **
Retinopathy
MY ANSWER
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness.
A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client’s blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take?
Monitor the client for any adverse reactions.
MY ANSWER
Although the client is a universal recipient and can receive any ABO blood type, the nurse should continue to monitor for any adverse reactions, which is standard procedure for any blood transfusion.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Turn the client by log rolling with a turning sheet.
MY ANSWER
The nurse should turn the client by log rolling with a turning sheet to keep the client’s back straight and to prevent back spasms from occurring.
A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen?
Avoid eating red meat.
MY ANSWER
A client should not eat red meat for 3 days before collecting the specimen because red meat contains hemoglobin, myoglobin, and some enzymes that can cause a false-positive result in a fecal occult blood test.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
Check for end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement.
A nurse notes that a client’s eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
Increased T
4 levels
MY ANSWER
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism.
A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
“Increase your intake of protein to 1 to 1.5 grams per kilogram per day.”
MY ANSWER
A client who receives hemodialysis for chronic kidney disease needs protein to prevent a negative nitrogen balance and muscle wasting. A client who is receiving hemodialysis is allowed 1 g to 1.5 g of protein/kg/day.
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client’s weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take? (Click on the “Exhibit” button below for additional information about the client. There are three tabs that contain separate categories of data.)
Stop the heparin infusion for 1 hr.
MY ANSWER
According to the titration table, when the aPTT is greater than 95, the nurse should stop the infusion for 1 hr, then restart the infusion with a decrease of 3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80 kg (176.4 lb).
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse’s priority?
ABGs
MY ANSWER
When using the airway, breathing, and circulation (ABC) approach to client care, the nurse’s priority assessment is to monitor the client’s ABGs, including respiratory status.
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
Paradoxical pulse
Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or more on expiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately.
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
Skin changes
MY ANSWER
A client who is receiving radiation therapy to the breast will have localized adverse effects of the treatment, such as skin changes, esophagitis, and lymphedema.
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
The nurse refers a client who has chronic obstructive pulmonary disease for palliative care
services.
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MY ANSWER
Palliative care is an interdisciplinary approach to client care that works toward optimizing the quality of life for a client who has a chronic illness. Nurses advocate for their clients when they promote the health, safety, and rights of the client, such as providing a referral for needed services to relieve suffering and promote a client’s quality of life.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.) Excessive somnolence
Epistaxis
Pink, frothy sputum
Tachypnea
Urinary frequency
MY ANSWER
Excessive somnolence is correct.Manifestations of pulmonary edema can include a change in orientation or mental status. A client who has excessive somnolence might be experiencing pulmonary edema.
Pink, frothy sputum is correct.A client who has pulmonary edema can develop pink, frothy sputum, wheezing, and tachypnea.
Tachypnea is correct.A client who has pulmonary edema can develop pink, frothy sputum, wheezing, and tachypnea.
A nurse is teaching a client about preventing the transmission of HIV. Which of the following information should the nurse include?
Medication is available that will reduce the risk for HIV transmission.
Tenofovir/emtricitabine is an oral medication that can be used prophylactically by a client who does not have an HIV infection to reduce the risk for HIV transmission. Pre-exposure prophylaxis is recommended for men who have sexual relationships with men, clients who are heterosexual and sexually active, noninfected partners who have a sexual relationship with a partner who has HIV, and clients who use intravenous drugs.
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
Apply a sterile hydrocolloid dressing every 24 hr.
Initially, a sterile, absorbent, nonadherent dressing covers the pin sites. Hydrocolloid dressings are for necrotic or granulating wounds.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
Provide finger food at mealtime.
MY ANSWER
The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?
Surgical mask
MY ANSWER
The nurse should adhere to droplet precautions in addition to standard precautions for clients who have bacterial meningitis, provided the causative pathogen spreads via droplets. Examples of pathogens that spread via droplets include Haemophilus influenzaeand Neisseria meningitidis. The nurse should place these clients in a private room and wear a mask when within 0.9 m (3 feet) of the client to prevent acquiring the infection. Clients should wear a mask whenever they are outside their room. These precautions are essential until 24 hr after the initiation of antibiotic therapy.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
Surgical drain output 300 mL during an 8-hr shift
MY ANSWER
A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit.
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Close the pinch clamp on the CVC.
MY ANSWER
The greatest risk to this client is air embolism resulting from accidental disconnection of the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the pinch clamp to prevent any further air from entering the system. When an air embolism occurs, air enters through the central vein into the right ventricle and lodges by the pulmonary valve, decreasing the amount of blood that is able to enter into the ventricle and the pulmonary arteries.
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
Place monitoring cords and tubes in a stockinette.
MY ANSWER
The nurse should place monitoring devices in a stockinette to prevent direct contact with the client’s skin.
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
The stool will have a high volume of liquid.
MY ANSWER
The nurse should include in the teaching that when peristalsis returns, the client can have an initial period of high-volume liquid stool output, more than 1,000 mL/day. Later, as the proximal small bowel adapts, stool volume should decrease.
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
“If my heart starts racing, my provider might need to adjust my dosage.”
MY ANSWER
Levothyroxine increases metabolism, which can increase oxygen consumption and heart rate. If the client’s heart is racing, the dosage might be too high, causing thyrotoxicosis with manifestations of tachycardia, insomnia, tremors and nervousness, hyperthermia, heat intolerance, and sweating. The provider should retest the client’s thyroid hormone levels and adjust the dosage accordingly.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
Left lower quadrant
Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to move stool into the rectum. Therefore, the pain with this disorder is often in the left lower quadrant.
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client’s risk of developing breast cancer?
Oral contraceptives were taken for the last 6 years
Clients who take hormones, such as estrogen therapy, fertility drugs, and oral contraceptives, have an increased risk of developing breast cancer.
A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
“Take a dose of loperamide each morning.”
A client who has diarrhea-predominant IBS should take loperamide, which is an antidiarrheal agent that decreases peristalsis and the volume of the stool.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client’s risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
Wear a protective gown when suctioning the client’s airway.
Monitor for oral secretions every 2 hr.
Provide oral care every 2 hr.
Maintain the client in a supine position.
Assess the client daily for readiness of extubation.
MY ANSWER
Monitorfor oral secretions every 2 hr is correct.The nurse should monitor for oral secretions at least every 2 hr to decrease the likelihood of micro-organisms moving from the mouth into the respiratory tract.
Provide oral care every 2 hr is correct. The nurse should provide oral care every 2 hr using chlorhexidine rinse or sodium chloride solution with swabbing or tooth brushing.
Assess the client daily for readiness of extubation is correct. To lower the risk of the client acquiring VAP, the nurse should assess the client daily for neurological readiness for discontinuing mechanical ventilation.
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client’s plan of care?
Assess the PICC infusion system systematically.
MY ANSWER
The nurse should assess the infusion system in a systematic fashion beginning with the insertion site, observing for signs of infection, and working upward and following the tubing to ensure that all connections are secure.
A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the client’s risk for falls?
The client had cataract surgery 1 day ago.
MY ANSWER
A client who had recent eye surgery is at increased risk for falls. The nurse should ensure the client is wearing prescription glasses when ambulating and that environmental hazards, such as loose rugs, are removed because the client’s vision might be blurred.
A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?
Walk 30 min daily at a comfortable pace.
MY ANSWER
The clients should walk 30 min daily at a comfortable pace to prevent weight gain and decrease the risk of coronary artery disease.
A home health nurse is inspecting a client’s residence for electrical hazards as part of the agency’s quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
An IV pump is plugged into an outlet near a sink.
MY ANSWER
The nurse should plug all electrical appliances into outlets away from wet areas. Water conducts electricity and places the client at risk for electrocution.
A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?
Place a small pillow under the head while lying supine.
MY ANSWER
The halo fixator device is worn for a period of 8 to 12 weeks and immobilizes the cervical spine, preventing flexion and hyperextension of the neck. The use of a small pillow under the head provides support to the head and neck, preventing additional discomfort and pressure from the device.
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching?
“Use water-based lubricant during intercourse to reduce discomfort.”
MY ANSWER
The nurse should instruct the client to use water-based lubricants to help relieve vaginal dryness and irritation during sexual intercourse. Atrophic vaginitis is a common manifestation of menopause.
**A nurse is caring for a client who has chronic venous insufficiency. Which of following areas should the nurse assess for the presence of a venous ulcer? **
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A is correct. The nurse should assess the medial malleolus (ankle) of a client who has chronic venous insufficiency for the presence of a venous ulcer. The ankle is the most common area for a venous ulcer. A client who has venous insufficiency can exhibit skin discoloration and edema as well as a large or superficial ulcer with irregular borders at the site of the medial or lateral malleolus that weeps exudate. A pulse is palpable in this area and the client typically experiences a moderate level of pain at the site.
A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first?
Administer oxygen using a high-concentration mask.
MY ANSWER
The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to ensure that the client has a patent airway and administer oxygen using a highconcentration mask to promote oxygen perfusion to vital organs.
**A nurse is caring for a client who has a prescription for lactated Ringer’s by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is effective? **
Urine specific gravity 1.020
The concentration of the urine regulated by hydration is measured by the weight of the particles in the urine. A urine specific gravity within the expected reference range of 1.005 to 1.030 indicates that fluid replacement is keeping up with fluid loss from gastric drainage.
A nurse is caring for a client who has a prescription for lactated Ringer’s by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is effective?
Urine specific gravity 1.020
MY ANSWER
The concentration of the urine regulated by hydration is measured by the weight of the particles in the urine. A urine specific gravity within the expected reference range of 1.005 to 1.030 indicates that fluid replacement is keeping up with fluid loss from gastric drainage.
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia.
**Which of the following findings should the nurse identify as a manifestation of hypovolemia? **
Rapid pulse rate
MY ANSWER
A client who has hypovolemia has a rapid, weak pulse rate to compensate for the decrease in blood volume in an attempt to increase blood pressure.
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
Airborne precautions
MY ANSWER
Tuberculosis, like measles, chickenpox, and varicella zoster, spreads by airborne transmission of micro-organisms that suspend in the air for prolonged periods. The nurse should implement airborne precautions by placing the client in a negative-pressure airflow room and wearing an N95 respirator mask.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
Retention of carbon dioxide
Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon dioxide can result from respiratory depression, inadequate chest expansion, airway obstruction, or decreased alveolar capillary diffusion.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration? A client who has a history of asthma
MY ANSWER
Propranolol is a nonselective beta-adrenergic blocker.
Contraindications include asthma, COPD, and heart failure because the blockade of beta2 receptors in the lungs can cause bronchoconstriction.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
“I will avoid crowds.”
“I will wash my toothbrush weekly.”
“I will change my cat’s litter box twice weekly.”
“I will take my temperature daily.”
“I will eat plenty of fresh fruits and vegetables.”
MY ANSWER
“I will avoid crowds” is correct. The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce the risk of infection.
“I will take my temperature daily” is correct. The client who is immunocompromised should take daily temperature readings and report an elevated temperature to the provider.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
Constant bubbling in the water seal chamber
Constant bubbling in the water seal chamber can be an indication of an air leak, which is caused by a disruption in the system such as a loose connection. Pulmonary air leaks create intermittent bubbling that is synchronous with respiration. This finding should be reported to the provider immediately.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
Maintain low intermittent suction.
MY ANSWER
The nurse should maintain low intermittent suction to prevent gastric irritation and ulceration. With a small bowel obstruction, the NG tube removes gastric secretions and decompresses the bowel.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
“I am aware that my diabetes is caused by an autoimmune disorder.”
Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This autoimmune reaction is often triggered by a viral infection.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing’s triad?
Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
MY ANSWERA change in blood pressure from 130/80 mm Hg to 180/100 mm Hg indicates a widened pulse pressure and hypertension, which are components of Cushing’s triad, a sign of increased intracranial pressure.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
“Select desserts such as angel-food cake.”
Clients who have acute cholelithiasis will be prescribed a low-fat diet. Desserts such as sherbet, gelatin, and angel food cake are dessert choices that are low in fat.
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
“Consume a diet that is high in calories.”
MY ANSWER
Dyspnea decreases energy available for eating. Therefore, the nurse should encourage the client to eat soft, high-calorie and highprotein foods to prevent weight loss.
A nurse is assessing a client’s understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?
Contact the provider who will be performing the procedure.
MY ANSWER
The nurse should advocate for the client by informing the provider if the client does not understand the procedure. It is the responsibility of the provider to discuss the procedure more fully with the client.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
“You will not be able to eat or drink after the procedure until you are able to cough.”
MY ANSWER
A client who had a bronchoscopy received a local anesthetic that can suppress the cough reflex. The cough reflex protects the client from aspirating fluids or food. Therefore, the client should not eat or drink until the cough reflex returns.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Maintain abduction of the affected extremity.
MY ANSWER
The nurse should ensure that the affected extremity is in a position of abduction to prevent hip dislocation. The nurse should place an abductor pillow or several pillows between the client’s legs to keep the affected extremity in abduction while the client is in bed.
