Title: ASN 210 Final Exam (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 8

Please answer each question carefuly with BEST possible answer.

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Q: <span style="font-size:12pt">The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning?</span>
- <span style="font-size:12pt">Palpation of abdominal cavity</span>
- <span style="font-size:12pt">Inspection of skin color</span>
- <span style="font-size:12pt">Auscultation of lungs</span>
- <span style="font-size:12pt">Palpation of pulse strength</span>
A: <span style="font-size:12pt">Auscultation of lungs</span>
If right: <span style="font-size:12pt">Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate complications.</span>
If wrong: <span style="font-size:12pt">Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate complications.</span>

Q: A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse?
- Potassium (K^+), 4.2 mEq/L
- International normalized ratio (INR), 7.1
- Prothrombin time (PT), 13.4 seconds
- Hemoglobin (Hg), 16 g/dL
A: International normalized ratio (INR), 7.1
If right: Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K^+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.
If wrong: Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K^+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.

Q: <span style="font-size:12pt">A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for?</span>
- <span style="font-size:12pt">Crepitus when the client moves the shoulders</span>
- <span style="font-size:12pt">Numbness and tingling in the client’s fingers</span>
- <span style="font-size:12pt">Client has cool feet, with weak pedal pulses</span>
- <span style="font-size:12pt">Low-grade fever, fatigue, anorexia with weight loss</span>
A: <span style="font-size:12pt">Low-grade fever, fatigue, anorexia with weight loss</span>
If right: <span style="font-size:12pt">Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.</span>
If wrong: <span style="font-size:12pt">Low-grade fever is common with rheumatoid arthritis because of the inflammatory response. Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status, popping sounds with range of motion (ROM), and poor circulation are not common symptoms of rheumatoid arthritis.</span>

Q: <span style="font-size:12pt">A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, “The doctor said that my viral load is reduced. What does this mean?” What is the nurse’s best response?</span>
- <span style="font-size:12pt">“The HAART medications are working well right now.”</span>
- <span style="font-size:12pt">“You are not as contagious as you were anymore.”</span>
- <span style="font-size:12pt">“Your HIV infection is becoming resistant to your medications.”</span>
- <span style="font-size:12pt">“You are developing an opportunistic infection.”</span>
A: <span style="font-size:12pt">“The HAART medications are working well right now.”</span>
If right: <span style="font-size:12pt">The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or to resistance to medication.</span>
If wrong: <span style="font-size:12pt">The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or to resistance to medication.</span>

Q: <span style="font-size:12pt">Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?</span>
- <span style="font-size:12pt">Always use Standard Precautions with all clients in the workplace.</span>
- <span style="font-size:12pt">Place clients who are HIV positive in Contact Precautions.</span>
- <span style="font-size:12pt">Wash hands before and after contact with clients who are HIV positive.</span>
- <span style="font-size:12pt">Convert parenteral medications to an oral form for clients who are HIV positive.</span>
A: <span style="font-size:12pt">Always use Standard Precautions with all clients in the workplace.</span>
If right: <span style="font-size:12pt">The best prevention for health care providers is the consistent use of Standard Precautions with all clients, as recommended by the Centers for Disease Control and Prevention (CDC). Contact Precautions are not indicated unless the client has an infection such as <i>Clostridium difficile</i> or MRSA (methicillin-resistant<i> Staphylococcus aureus</i>).</span>
If wrong: <span style="font-size:12pt">The best prevention for health care providers is the consistent use of Standard Precautions with all clients, as recommended by the Centers for Disease Control and Prevention (CDC). Contact Precautions are not indicated unless the client has an infection such as <i>Clostridium difficile</i> or MRSA (methicillin-resistant<i> Staphylococcus aureus</i>).</span>

Q: A client with comes to the clinic reporting a low-grade fever, fatigue, and bilateral joint pain. What action by the nurse is most appropriate?
- Assess the client for a systemic infection.
- Discuss decreasing the dose of anti-arthritis drugs.
- Prepare the client for a laboratory draw for rheumatoid factor.
- Teach the client joint protection activities.
A: Prepare the client for a laboratory draw for rheumatoid factor.
If right: . The manifestations that this client exhibits are more consistent with rheumatoid arthritis, so the nurse will prepare the client for a blood draw. The nurse may need to teach joint protection measures, but an accurate diagnosis is most important.
If wrong: The manifestations that this client exhibits are more consistent with rheumatoid arthritis, so the nurse will prepare the client for a blood draw. The nurse may need to teach joint protection measures, but an accurate diagnosis is most important.

Q: The nurse is caring for a postoperative older client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the client’s left leg is cool, with weak pedal pulses. What is the nurse’s first action?
- Assess circulatory status of the right leg.
- Notify the surgeon immediately.
- Measure leg circumference at the calf.
- Check for bilateral Homans’ signs.
A: Assess circulatory status of the right leg.
If right: The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the client’s baseline. Homans’ sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.
If wrong: The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the client’s baseline. Homans’ sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.

Q: <span style="font-size:12pt">The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV?</span>
- <span style="font-size:12pt">Six vaginal yeast infections in the last 12 months</span>
- <span style="font-size:12pt">Unable to become pregnant for the last 2 years</span>
- <span style="font-size:12pt">Severe cramping and irregular periods</span>
- <span style="font-size:12pt">Very heavy periods and breakthrough bleeding</span>
A: <span style="font-size:12pt">Six vaginal yeast infections in the last 12 months</span>
If right: <span style="font-size:12pt">Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.</span>
If wrong: <span style="font-size:12pt">Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.</span>

Q: <span style="font-size:12pt">The nurse is completing a health history for a client and begins to obtain a sexual history. What is the nurse’s best opening question?</span>
- <span style="font-size:12pt">“How long have you been sexually active?”</span>
- <span style="font-size:12pt">“Are you in a monogamous relationship with your spouse?”</span>
- <span style="font-size:12pt">“How do you feel about answering questions about your sexual history?”</span>
- <span style="font-size:12pt">“Have you noticed any problems with your ability to have or enjoy sex?”</span>
A: <span style="font-size:12pt">“How do you feel about answering questions about your sexual history?”</span>
If right: <span style="font-size:12pt">The nurse should begin with an assessment of the client’s comfort level with the topic. The nurse should not assume that the client is sexually active or start with questions about the client’s spouse. The nurse also should not use words like “monogamous,” which frequently are misunderstood by the public. The question about sexual ability and enjoyment is a closed-ended question, and if the client answers “no,” it will be awkward for the nurse to continue discussing this topic.</span>
If wrong: <span style="font-size:12pt">The nurse should begin with an assessment of the client’s comfort level with the topic. The nurse should not assume that the client is sexually active or start with questions about the client’s spouse. The nurse also should not use words like “monogamous,” which frequently are misunderstood by the public. The question about sexual ability and enjoyment is a closed-ended question, and if the client answers “no,” it will be awkward for the nurse to continue discussing this topic.</span>

Q: A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks.  Which action by the nurse is most appropriate?
- Place the client in Airborne Precautions.
- Facilitate the client’s chest x-ray.
- Initiate a 3-day calorie count.
- Start an IV of normal saline.
A: Place the client in Airborne Precautions.
If right: The client’s symptoms are indicative of tuberculosis (TB). With AIDS, the client’s CD4+ T-cell count is so low that the client cannot mount an immune response to the PPD; thus it appears negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out TB. The other interventions are appropriate, but they do not take priority over infection control principles.
If wrong: The client’s symptoms are indicative of tuberculosis (TB). With AIDS, the client’s CD4+ T-cell count is so low that the client cannot mount an immune response to the PPD; thus it appears negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out TB. The other interventions are appropriate, but they do not take priority over infection control principles.

Q: <span style="font-size:12pt">A client has been admitted with suspected <i>Clostridium difficile</i> infection. Which medication does the nurse plan to administer as a priority?</span>
- <span style="font-size:12pt">Metronidazole (Flagyl)</span>
- <span style="font-size:12pt">Acetaminophen (Tylenol)</span>
- <span style="font-size:12pt">Tetracycline (Sumycin)</span>
- <span style="font-size:12pt">Doxycycline (Vibramycin)</span>
A: <span style="font-size:12pt">Metronidazole (Flagyl)</span>
If right: <span style="font-size:12pt">Metronidazole and vancomycin are the antibiotics of choice for <i>C. difficile</i> infection. Tylenol might be used if the client is febrile. The other two antibiotics are not appropriate.</span>
If wrong: <span style="font-size:12pt">Metronidazole and vancomycin are the antibiotics of choice for <i>C. difficile</i> infection. Tylenol might be used if the client is febrile. The other two antibiotics are not appropriate.</span>

Q: An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 100.2° F , blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate?
- Perform a Mini-Mental Status Examination.
- Assess the client for other signs of infection.
- Document the findings and continue to monitor.
- Assess the client’s pain level and treat if needed.
A: Assess the client for other signs of infection.
If right: Because of an age-related decline in immune function, an older adult’s normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.
If wrong: Because of an age-related decline in immune function, an older adult’s normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

Q: <span style="font-size:12pt">Malignant cell growth is uncontrolled because of which action?</span>
- <span style="font-size:12pt">Cancer cells always divide more rapidly than normal cells.</span>
- <span style="font-size:12pt">Mitosis of malignant cells usually produces more than two daughter cells.</span>
- <span style="font-size:12pt">Malignant cells bypass one or more phases of the cell cycle during cell division.</span>
- <span style="font-size:12pt">Malignant cells enter the cell cycle frequently, making cell division continuous.</span>
A: <span style="font-size:12pt">Malignant cells enter the cell cycle frequently, making cell division continuous.</span>
If right: <span style="font-size:12pt">Malignant cells have bypassed the normal control mechanisms that restrict entry into the cell cycle, so they re-enter the cell cycle as soon as they finish a round of cell division. Thus, cancer cell division is relentless.</span>
If wrong: <span style="font-size:12pt">Malignant cells have bypassed the normal control mechanisms that restrict entry into the cell cycle, so they re-enter the cell cycle as soon as they finish a round of cell division. Thus, cancer cell division is relentless.</span>

Q: What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb?
- 1 mL of a 1:1000 solution
- 0.3 - 0.5 mL of a 1:1000 solution
- 0.3 -0.5 mL of a 1:10,000 solution
- 0.8 mL of a 1:10,000 solution
A: 0.3 - 0.5 mL of a 1:1000 solution
If right: Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially.
If wrong: Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially.

Q: <span style="font-size:12pt">A client who is near death appears to be having difficulty breathing. What is the nurse’s highest-priority intervention?</span>
- <span style="font-size:12pt">Teach the family how to perform nasotracheal suctioning.</span>
- <span style="font-size:12pt">Request that the physician order morphine sulfate.</span>
- <span style="font-size:12pt">Document the finding in the client’s chart.</span>
- <span style="font-size:12pt">Call a respiratory therapist to intubate the client.</span>
A: <span style="font-size:12pt">Request that the physician order morphine sulfate.</span>
If right: <span style="font-size:12pt">Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client discomfort. Documentation is important, but it is not the priority intervention because it does nothing to relieve the client’s distress.</span>
If wrong: <span style="font-size:12pt">Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client discomfort. Documentation is important, but it is not the priority intervention because it does nothing to relieve the client’s distress.</span>

Q: <span style="font-size:12pt">A dying client’s family members are spending time with the client. What instruction is best to give to family members regarding noise in the client’s room?</span>
- <span style="font-size:12pt">“Remember that she cannot hear you.”</span>
- <span style="font-size:12pt">“Try to get her to talk or respond to you.”</span>
- <span style="font-size:12pt">“Avoid making any noise when you are with her.”</span>
- <span style="font-size:12pt">“Talk in your normal speaking voice.”</span>
A: <span style="font-size:12pt">“Talk in your normal speaking voice.”</span>
If right: <span style="font-size:12pt">The sense of hearing may remain intact, even when it appears that the client is totally unresponsive to any sort of stimuli. The family member should speak to the client as if she were fully aware.</span>
If wrong: <span style="font-size:12pt">The sense of hearing may remain intact, even when it appears that the client is totally unresponsive to any sort of stimuli. The family member should speak to the client as if she were fully aware.</span>

Q: <span style="font-size:12pt">A hospitalized American Indian client is approaching death. Family members who are standing vigil in the client’s room begin to divide up his possessions among themselves as his symptoms progress. What is the nurse’s most important intervention?</span>
- <span style="font-size:12pt">Ask the family members to step outside the room so the client cannot hear them.</span>
- <span style="font-size:12pt">Tell the family that they are being insensitive and their behavior is inappropriate.</span>
- <span style="font-size:12pt">Recognize that this is a culturally appropriate activity and document it in the chart.</span>
- <span style="font-size:12pt">Report these activities to the client’s physician and the nursing supervisor.</span>
A: <span style="font-size:12pt">Recognize that this is a culturally appropriate activity and document it in the chart.</span>
If right: <span style="font-size:12pt">American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client’s family’s behaviors.</span>
If wrong: <span style="font-size:12pt">American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client’s family’s behaviors.</span>

Q: <span style="font-size:12pt">The client tells the nurse that even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. The client is afraid that she is “losing her mind.” What is the nurse’s best response?</span>
- <span style="font-size:12pt">“Most people move on within a few months. You should see a grief counselor.”</span>
- <span style="font-size:12pt">“Whenever you start to cry, distract yourself from thoughts of your sister.”</span>
- <span style="font-size:12pt">“You should try not to cry. I’m sure your sister is in a better place now.”</span>
- <span style="font-size:12pt">“Your feelings are completely normal and may continue for a long time.”</span>
A: <span style="font-size:12pt">“Your feelings are completely normal and may continue for a long time.”</span>
If right: <span style="font-size:12pt">Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client’s response.</span>
If wrong: <span style="font-size:12pt">Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client’s response.</span>

Q: <span style="font-size:12pt">The health care provider suggests inpatient hospice for a client. The family members are concerned that their loved one will receive only custodial care. What is the nurse’s best response?</span>
- <span style="font-size:12pt">“The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.”</span>
- <span style="font-size:12pt">“Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.”</span>
- <span style="font-size:12pt">“A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.”</span>
- <span style="font-size:12pt">“Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.”</span>
A: <span style="font-size:12pt">“The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.”</span>
If right: <span style="font-size:12pt">Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.</span>
If wrong: <span style="font-size:12pt">Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.</span>

Q: <span style="font-size:12pt">The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take?</span>
- <span style="font-size:12pt">Administer naloxone (Narcan).</span>
- <span style="font-size:12pt">Administer oxygen.</span>
- <span style="font-size:12pt">Assist with intubation.</span>
- <span style="font-size:12pt">Monitor pain level.</span>
A: <span style="font-size:12pt">Administer naloxone (Narcan).</span>
If right: <span style="font-size:12pt">A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client’s oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.</span>
If wrong: <span style="font-size:12pt">A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client’s oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.</span>

Q: <span style="font-size:12pt">The nurse is caring for four clients who are reporting pain. Based on the following assessments and histories, which client’s pain is most likely chronic in nature?</span>
- <span style="font-size:12pt">Foley catheter inserted 30 minutes ago with a heart rate of 100 beats/min</span>
- <span style="font-size:12pt">History of heart disease with a heart rate of 120 beats/min</span>
- <span style="font-size:12pt">History of fibromyalgia with a blood pressure of 110/70 mm Hg</span>
- <span style="font-size:12pt">Hip replacement surgery with a blood pressure of 170/90 mm Hg</span>
A: <span style="font-size:12pt">History of fibromyalgia with a blood pressure of 110/70 mm Hg</span>
If right: <span style="font-size:12pt">The definition of <i>chronic pain</i> involves the length of time the pain is experienced and/or the progressive nature of the problem causing the pain. Both heart disease and fibromyalgia could fit into this category. However, pain of a chronic nature does not call the sympathetic nervous system into play. Therefore, a rise in heart rate and blood pressure is not seen in a client who has chronic pain. The client with fibromyalgia who is having pain is not experiencing the increased blood pressure that would be seen with acute pain.</span>
If wrong: <span style="font-size:12pt">The definition of <i>chronic pain</i> involves the length of time the pain is experienced and/or the progressive nature of the problem causing the pain. Both heart disease and fibromyalgia could fit into this category. However, pain of a chronic nature does not call the sympathetic nervous system into play. Therefore, a rise in heart rate and blood pressure is not seen in a client who has chronic pain. The client with fibromyalgia who is having pain is not experiencing the increased blood pressure that would be seen with acute pain.</span>

Q: <span style="font-size:12pt">The nurse is caring for four clients. Which client assessment is the most indicative of having pain?</span>
- <span style="font-size:12pt">Blood pressure 150/70 mm Hg and sleeping</span>
- <span style="font-size:12pt">Client stating that he is “anxious”</span>
- <span style="font-size:12pt">Heart rate of 105 beats/min and restlessness</span>
- <span style="font-size:12pt">Postoperative client with a neck incision</span>
A: <span style="font-size:12pt">Heart rate of 105 beats/min and restlessness</span>
If right: <span style="font-size:12pt">At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.</span>
If wrong: <span style="font-size:12pt">At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.</span>

Q: <span style="font-size:12pt">The wife is concerned because her terminally ill husband does not want to eat. What is the nurse’s best response?</span>
- <span style="font-size:12pt">“Let him know that food is available if he wants it, but do not insist that he eat.”</span>
- <span style="font-size:12pt">“A feeding tube can be placed in the nose to provide important nutrients.”</span>
- <span style="font-size:12pt">“Force him to eat even if he does not feel hungry, or he will die sooner.”</span>
- <span style="font-size:12pt">“He is getting all the nutrients he needs through his intravenous catheter.”</span>
A: <span style="font-size:12pt">“Let him know that food is available if he wants it, but do not insist that he eat.”</span>
If right: <span style="font-size:12pt">When family members understand that the client is not suffering from hunger and is not “starving to death,” they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.</span>
If wrong: <span style="font-size:12pt">When family members understand that the client is not suffering from hunger and is not “starving to death,” they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.</span>

Q: <span style="font-size:12pt">Which client does the nurse assess first for pain control?</span>
- <span style="font-size:12pt">Older client with chronic rheumatoid arthritis</span>
- <span style="font-size:12pt">Client postoperative day three walking in the hallway</span>
- <span style="font-size:12pt">Sleeping client with an epidural pump</span>
- <span style="font-size:12pt">Quiet client with pancreatic cancer curled up in bed</span>
A: <span style="font-size:12pt">Quiet client with pancreatic cancer curled up in bed</span>
If right: <span style="font-size:12pt">The pain of pancreatic cancer is usually severe. This client should be assessed first because the client’s present behavior may indicate suffering and pain. The client with arthritis has had this condition for a while and may not be experiencing severe pain. The client who is walking in the hallway and the client who is sleeping do not demonstrate nonverbal pain behaviors.</span>
If wrong: <span style="font-size:12pt">The pain of pancreatic cancer is usually severe. This client should be assessed first because the client’s present behavior may indicate suffering and pain. The client with arthritis has had this condition for a while and may not be experiencing severe pain. The client who is walking in the hallway and the client who is sleeping do not demonstrate nonverbal pain behaviors.</span>

Q: <span style="font-size:12pt">Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery?</span>
- <span style="font-size:12pt">“Instruct your visitors to press the button for you when you are sleeping.”</span>
- <span style="font-size:12pt">“Push the button every 15 minutes whether you feel pain at that time or not.”</span>
- <span style="font-size:12pt">“Push the button when you first feel pain instead of waiting until pain is severe.”</span>
- <span style="font-size:12pt">“Try to go as long as you possibly can before you press the button.”</span>
A: <span style="font-size:12pt">“Push the button when you first feel pain instead of waiting until pain is severe.”</span>
If right: <span style="font-size:12pt">Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA.</span>
If wrong: <span style="font-size:12pt">Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA.</span>

Q: <span style="font-size:12pt">Why does the nurse always ask the client his or her pain level after taking routine vital signs?</span>
- <span style="font-size:12pt">To determine whether pain is influencing blood pressure and heart rate</span>
- <span style="font-size:12pt">To determine the need for more frequent vital sign measurement</span>
- <span style="font-size:12pt">To ensure that pain assessment occurs on a regular basis</span>
- <span style="font-size:12pt">To follow McCaffery’s guidelines on pain management</span>
A: <span style="font-size:12pt">To ensure that pain assessment occurs on a regular basis</span>
If right: <span style="font-size:12pt">Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.</span>
If wrong: <span style="font-size:12pt">Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.</span>

Q: <span style="font-size:12pt">When assessing a client who is taking long-term ibuprofen (Motrin) for pain, the nurse finds numerous areas of bruising. What is the nurse’s first action?</span>
- <span style="font-size:12pt">Assess for gastric discomfort.</span>
- <span style="font-size:12pt">Assess for the presence of pain.</span>
- <span style="font-size:12pt">Continue to monitor bruising.</span>
- <span style="font-size:12pt">Place client on falls precaution.</span>
A: <span style="font-size:12pt">Assess for gastric discomfort.</span>
If right: <span style="font-size:12pt">NSAIDs can cause gastrointestinal disturbances and can prevent platelet aggregation, which results in GI bleeding. Therefore, clients should be observed for gastric discomfort or vomiting and bleeding.</span>
If wrong: <span style="font-size:12pt">NSAIDs can cause gastrointestinal disturbances and can prevent platelet aggregation, which results in GI bleeding. Therefore, clients should be observed for gastric discomfort or vomiting and bleeding.</span>

Q: <span style="font-size:12pt">A home care client who is currently on hydromorphone (Dilaudid) for pain management presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the client’s history, the nurse asks which question first?</span>
- <span style="font-size:12pt">“Are you currently in severe pain?”</span>
- <span style="font-size:12pt">“Did you take more Dilaudid than prescribed?”</span>
- <span style="font-size:12pt">“When did you take your last dose of Dilaudid?”</span>
- <span style="font-size:12pt">“When was your last bowel movement?”</span>
A: <span style="font-size:12pt">“When did you take your last dose of Dilaudid?”</span>
If right: <span style="font-size:12pt">Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal syndrome occurs when the client abruptly stops taking the medication. Symptoms include abdominal cramping, nausea, sweating, delirium, and convulsions. Although the other distractors may be asked about as part of the admission assessment, they are not of priority.</span>
If wrong: <span style="font-size:12pt">Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal syndrome occurs when the client abruptly stops taking the medication. Symptoms include abdominal cramping, nausea, sweating, delirium, and convulsions. Although the other distractors may be asked about as part of the admission assessment, they are not of priority.</span>

Q: <span style="font-size:12pt">A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating the care plan. For which common complications does the nurse assess? <i>(Select all that apply.)</i></span>
- <span style="font-size:12pt">Phlebitis</span>
- <span style="font-size:12pt">Pneumothorax</span>
- <span style="font-size:12pt">Thrombophlebitis</span>
- <span style="font-size:12pt">Excessive bleeding</span>
- <span style="font-size:12pt">Extravasation</span>
A: <span style="font-size:12pt">Phlebitis</span>; <span style="font-size:12pt">Thrombophlebitis</span>
If right: <span style="font-size:12pt">Although the complication rate with PICC lines is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.</span>
If wrong: <span style="font-size:12pt">Although the complication rate with PICC lines is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.</span>

Q: A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of 90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this client’s peripheral IV?
- 24
- 22
- 20
- 18
A: 18
If right: The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 18-gauge catheter IV. The 18-gauge catheter allows rapid flow of IV fluids.
If wrong: The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 18-gauge catheter IV. The 18-gauge catheter allows rapid flow of IV fluids.

Q: <span style="font-size:12pt">A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs?</span>
- <span style="font-size:12pt">Dizziness on changing position</span>
- <span style="font-size:12pt">Increased urine output</span>
- <span style="font-size:12pt">Warmth and redness at site</span>
- <span style="font-size:12pt">Low-grade temperature</span>
A: <span style="font-size:12pt">Dizziness on changing position</span>
If right: <span style="font-size:12pt">When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.</span>
If wrong: <span style="font-size:12pt">When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.</span>

Q: <span style="font-size:12pt">A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client’s systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?</span>
- <span style="font-size:12pt">Insert a Foley catheter to monitor urine output closely.</span>
- <span style="font-size:12pt">Ask the client’s family to come to the hospital because death is near.</span>
- <span style="font-size:12pt">Initiate the prescribed dobutamine (Dobutrex) intravenous drip.</span>
- <span style="font-size:12pt">Obtain blood cultures before administering the next dose of antibiotics.</span>
A: <span style="font-size:12pt">Initiate the prescribed dobutamine (Dobutrex) intravenous drip.</span>
If right: <span style="font-size:12pt">The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client’s pulse pressure is decreasing rapidly. The family should be updated appropriately.</span>
If wrong: <span style="font-size:12pt">The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client’s pulse pressure is decreasing rapidly. The family should be updated appropriately.</span>

Q: <span style="font-size:12pt">A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent?</span>
- <span style="font-size:12pt">Chest pain and diaphoresis</span>
- <span style="font-size:12pt">Decreased breath sounds due to chest trauma</span>
- <span style="font-size:12pt">Left arm fracture with palpable radial pulses</span>
- <span style="font-size:12pt">Sore throat and a temperature of 104° F</span>
A: <span style="font-size:12pt">Left arm fracture with palpable radial pulses</span>
If right: <span style="font-size:12pt">A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.</span>
If wrong: <span style="font-size:12pt">A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.</span>

Q: <span style="font-size:12pt">A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support?</span>
- <span style="font-size:12pt">Contact the on-call orthopedic surgeon.</span>
- <span style="font-size:12pt">Don personal protective equipment.</span>
- <span style="font-size:12pt">Notify the Rapid Response Team.</span>
- <span style="font-size:12pt">Obtain a complete history from the paramedic.</span>
A: <span style="font-size:12pt">Don personal protective equipment.</span>
If right: <span style="font-size:12pt">Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in <i>all</i> resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.</span>
If wrong: <span style="font-size:12pt">Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in <i>all</i> resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.</span>

Q: <span style="font-size:12pt">An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first?</span>
- <span style="font-size:12pt">Place the client on a non-rebreather mask.</span>
- <span style="font-size:12pt">Begin bag-valve-mask ventilation.</span>
- <span style="font-size:12pt">Initiate cardiopulmonary resuscitation.</span>
- <span style="font-size:12pt">Prepare for chest tube insertion.</span>
A: <span style="font-size:12pt">Begin bag-valve-mask ventilation.</span>
If right: <span style="font-size:12pt">Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.</span>
If wrong: <span style="font-size:12pt">Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.</span>

Q: <span style="font-size:12pt">The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage?</span>
- <span style="font-size:12pt">Treat clients on a first-come, first-serve basis.</span>
- <span style="font-size:12pt">Identify and treat clients with low acuity first.</span>
- <span style="font-size:12pt">Prioritize clients based on illness severity.</span>
- <span style="font-size:12pt">Determine health needs from a complete assessment.</span>
A: <span style="font-size:12pt">Prioritize clients based on illness severity.</span>
If right: <span style="font-size:12pt">ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the “head of the line.”</span>
If wrong: <span style="font-size:12pt">ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the “head of the line.”</span>

Q: <span style="font-size:12pt">The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client’s shock is caused by sepsis?</span>
- <span style="font-size:12pt">Hypotension</span>
- <span style="font-size:12pt">Pale clammy skin</span>
- <span style="font-size:12pt">Anxiety and confusion</span>
- <span style="font-size:12pt">Oozing of blood at the IV site</span>
A: <span style="font-size:12pt">Oozing of blood at the IV site</span>
If right: <span style="font-size:12pt">The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.</span>
If wrong: <span style="font-size:12pt">The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.</span>

Q: <span style="font-size:12pt">The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?</span>
- <span style="font-size:12pt">“Is your blood pressure higher than usual?”</span>
- <span style="font-size:12pt">“Are you having pain in your throat?”</span>
- <span style="font-size:12pt">“Have you been vomiting?”</span>
- <span style="font-size:12pt">“Are you usually this swollen?”</span>
A: <span style="font-size:12pt">“Are you usually this swollen?”</span>
If right: <span style="font-size:12pt">Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.</span>
If wrong: <span style="font-size:12pt">Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.</span>

Q: <span style="font-size:12pt">The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse?</span>
- <span style="font-size:12pt">Encourage drinking of cool water or sports drinks.</span>
- <span style="font-size:12pt">Sponge the victim with cool water and remove his shirt.</span>
- <span style="font-size:12pt">Administer Tylenol (acetaminophen), 650 mg orally.</span>
- <span style="font-size:12pt">Encourage rest, and reassess in 15 minutes.</span>
A: <span style="font-size:12pt">Sponge the victim with cool water and remove his shirt.</span>
If right: <span style="font-size:12pt">The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the emergency department as quickly as possible. The nurse should take actions to lower his body temperature in the meantime by removing his shirt and sponging his body with cool water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment.</span>
If wrong: <span style="font-size:12pt">The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the emergency department as quickly as possible. The nurse should take actions to lower his body temperature in the meantime by removing his shirt and sponging his body with cool water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment.</span>

Q: <span style="font-size:12pt">An older adult client presents with signs and symptoms related to digoxin toxicity. Which age-related change may have contributed to this problem?</span>
- <span style="font-size:12pt">Increased total body water</span>
- <span style="font-size:12pt">Decreased renal blood flow</span>
- <span style="font-size:12pt">Increased gastrointestinal motility</span>
- <span style="font-size:12pt">Decreased ratio of adipose tissue to lean body mass</span>
A: <span style="font-size:12pt">Decreased renal blood flow</span>
If right: <span style="font-size:12pt">Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to digoxin toxicity.</span>
If wrong: <span style="font-size:12pt">Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to digoxin toxicity.</span>

Q: <span style="font-size:12pt">An older adult client is being discharged from the hospital on several medications. Which intervention best reinforces medication teaching for this client?</span>
- <span style="font-size:12pt">Have the client actively participate in drug administration during hospitalization.</span>
- <span style="font-size:12pt">Include the client’s children in discussions regarding medication administration.</span>
- <span style="font-size:12pt">Give the client a pamphlet with the actions, side effects, and doses of all drugs.</span>
- <span style="font-size:12pt">Make a chart showing which drugs should be taken at specified times during the day.</span>
A: <span style="font-size:12pt">Have the client actively participate in drug administration during hospitalization.</span>
If right: <span style="font-size:12pt">Supervised self-administration of medications allows accurate assessment of the client’s capabilities and hands-on learning opportunities for instruction or reinforcement.</span>
If wrong: <span style="font-size:12pt">Supervised self-administration of medications allows accurate assessment of the client’s capabilities and hands-on learning opportunities for instruction or reinforcement.</span>

Q: <span style="font-size:12pt">An older adult client is in physical restraints. Which intervention by the nurse is the priority?</span>
- <span style="font-size:12pt">Assess the client hourly while keeping the restraints in place.</span>
- <span style="font-size:12pt">Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.</span>
- <span style="font-size:12pt">Assess the client once each shift, releasing the restraints for feeding.</span>
- <span style="font-size:12pt">Assess the client twice each shift while keeping the restraints in place.</span>
A: <span style="font-size:12pt">Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.</span>
If right: <span style="font-size:12pt">The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.</span>
If wrong: <span style="font-size:12pt">The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.</span>

Q: <span style="font-size:12pt">An older adult client is suspected of being neglected by the caregiver. What assessment provides the nurse with the best information about this possibility?</span>
- <span style="font-size:12pt">Inspect skin in the “bathing suit zone” for bruises.</span>
- <span style="font-size:12pt">Assess the client for orientation to person, place, and time.</span>
- <span style="font-size:12pt">Compare the client’s current weight with prior recorded weights.</span>
- <span style="font-size:12pt">Perform orthostatic pulse and blood pressure readings.</span>
A: <span style="font-size:12pt">Compare the client’s current weight with prior recorded weights.</span>
If right: <span style="font-size:12pt">Neglect is often manifested by dehydration, undernutrition, pressure ulcers, or contractures. Injuries raise the suspicion for abuse, whereas disorientation and rapid heart rate/high blood pressure can be the result of disease processes. Noting the client’s weight trend would be a helpful assessment related to this suspicion.</span>
If wrong: <span style="font-size:12pt">Neglect is often manifested by dehydration, undernutrition, pressure ulcers, or contractures. Injuries raise the suspicion for abuse, whereas disorientation and rapid heart rate/high blood pressure can be the result of disease processes. Noting the client’s weight trend would be a helpful assessment related to this suspicion.</span>

Q: <span style="font-size:12pt">An older adult recently had a hysterectomy and has requested some medication for pain. The physician leaves an order for meperidine (Demerol). Which action by the nurse is most appropriate?</span>
- <span style="font-size:12pt">Assess the client’s pain 1 hour after giving the medication.</span>
- <span style="font-size:12pt">Call the physician and request a different pain medication.</span>
- <span style="font-size:12pt">Assess the client’s respiratory rate often after administering the Demerol.</span>
- <span style="font-size:12pt">Ensure that the client does not receive iron supplements at the same time.</span>
A: <span style="font-size:12pt">Call the physician and request a different pain medication.</span>
If right: <span style="font-size:12pt">Meperidine (Demerol) is included among the Beers criteria for potentially inappropriate medication use in older adults. Morphine, codeine, and hydromorphone are acceptable medications for the older adult that the nurse could suggest to the physician. Assessing the client’s pain and monitoring respiratory rate are important interventions for any client receiving narcotic analgesics, but in this case, client safety is best ensured by not administering inappropriate drugs. Iron supplements can be administered without regard to Demerol.</span>
If wrong: <span style="font-size:12pt">Meperidine (Demerol) is included among the Beers criteria for potentially inappropriate medication use in older adults. Morphine, codeine, and hydromorphone are acceptable medications for the older adult that the nurse could suggest to the physician. Assessing the client’s pain and monitoring respiratory rate are important interventions for any client receiving narcotic analgesics, but in this case, client safety is best ensured by not administering inappropriate drugs. Iron supplements can be administered without regard to Demerol.</span>

Q: <span style="font-size:12pt">A client has just had a central venous access line inserted. What is the nurse’s next action?</span>
- <span style="font-size:12pt">Beginning the prescribed infusion as soon as possible</span>
- <span style="font-size:12pt">Confirming placement of the catheter by x-ray</span>
- <span style="font-size:12pt">Having the infusion team start the IV therapy</span>
- <span style="font-size:12pt">Confirming that solutions are appropriate for the central line</span>
A: <span style="font-size:12pt">Confirming placement of the catheter by x-ray</span>
If right: <span style="font-size:12pt">A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.</span>
If wrong: <span style="font-size:12pt">A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.</span>

Q: <span style="font-size:12pt">A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes priority?</span>
- <span style="font-size:12pt">Verifying the client’s identity</span>
- <span style="font-size:12pt">Ensuring that the blood bank has enough blood</span>
- <span style="font-size:12pt">Establishing a peripheral IV site</span>
- <span style="font-size:12pt">Feeding the client before starting the blood</span>
A: <span style="font-size:12pt">Verifying the client’s identity</span>
If right: <span style="font-size:12pt">Blood transfusion reactions can be devastating and can be prevented in large measure by positive client identification. This is accomplished by two professionals using two different client identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action, and transfusions can be given without regard to food and drink.</span>
If wrong: <span style="font-size:12pt">Blood transfusion reactions can be devastating and can be prevented in large measure by positive client identification. This is accomplished by two professionals using two different client identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action, and transfusions can be given without regard to food and drink.</span>

Q: <span style="font-size:12pt">In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority?</span>
- <span style="font-size:12pt">Applying continuous heat</span>
- <span style="font-size:12pt">Continuing to monitor site</span>
- <span style="font-size:12pt">Elevating the extremity</span>
- <span style="font-size:12pt">Removing the catheter</span>
A: <span style="font-size:12pt">Removing the catheter</span>
If right: <span style="font-size:12pt">The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.</span>
If wrong: <span style="font-size:12pt">The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.</span>

Q: <span style="font-size:12pt">The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to the new nurse?</span>
- <span style="font-size:12pt">“Apply topical anesthetic cream to the area after discontinuing the system.”</span>
- <span style="font-size:12pt">“Be aware of a rebound effect when discontinuing the system.”</span>
- <span style="font-size:12pt">“Be sure to flush the system with saline after removing the Huber needle.”</span>
- <span style="font-size:12pt">“Place pressure over the site to prevent bleeding.”</span>
A: <span style="font-size:12pt">“Be aware of a rebound effect when discontinuing the system.”</span>
If right: <span style="font-size:12pt">Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing.</span>
If wrong: <span style="font-size:12pt">Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing.</span>

Q: <span style="font-size:12pt">The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin. Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse use to draw up and administer the heparin?<br><img width="530" height="110" align="bottom" alt="ot002-1.jpg" src="ppg/examview/Chapter_15_Iggy/00001_res/ot002-1.jpg" border="0"><img width="539" height="152" align="bottom" alt="ot002-2.jpg" src="ppg/examview/Chapter_15_Iggy/00001_res/ot002-2.jpg" border="0"><img width="522" height="109" align="bottom" alt="ot002-3.jpg" src="ppg/examview/Chapter_15_Iggy/00001_res/ot002-3.jpg" border="0"><img width="525" height="123" align="bottom" alt="ot002-4.jpg" src="ppg/examview/Chapter_15_Iggy/00001_res/ot002-4.jpg" border="0"></span>
Feedback: D [the 10-mL syringe] Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC line.

Q: The charge nurse on the critical care respiratory unit is evaluating the arterial blood gas (ABG) values of several clients.  Which client would require an immediate intervention by the charge nurse?
- The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24.
- The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26.
- The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23.
- The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.
A: The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23.
If right: Answer: C Cognitive Level: Analysis The client with COPD has abnormal values with respiratory acidosis, but these are to be expected in a client with COPD, you would not see this client first. The client with ARDS would be expected to have a low arterial oxygen level; therefore, the nurse would not assess this client first. In the client with reactive airway disease, the AGB shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature. The last client has normal ABGs and does not need to be seen first.
If wrong: Answer: C Cognitive Level: Analysis The client with COPD has abnormal values with respiratory acidosis, but these are to be expected in a client with COPD, you would not see this client first. The client with ARDS would be expected to have a low arterial oxygen level; therefore, the nurse would not assess this client first. In the client with reactive airway disease, the AGB shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature. The last client has normal ABGs and does not need to be seen first.

Q: The nurse is reviewing the arterial blood gas results (ABG) of a client with pneumonia.  The results are:  pH 7.34, PaCO2 50, HCO3 24, PaO2 87.  Which intervention should the nurse implement first?
- Have the client turn, cough, and deep breathe.
- Place the client on oxygene via non-rebreather.
- Check the client's pulse oximeter reading.
- Notifiy the HCP of the results.
A: Have the client turn, cough, and deep breathe.
If right: Answer: A Cognitive Level: Application These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. The PaO2 level is within normal limits, 80-100. Administering oxygen would not be the first intervention. The nurse knows the arterial blood gas oxygen level, which is an accurate test. The pulse oximeter would only provide an approximate level. The nurse can intervene in this case without notifying the health care provider first.
If wrong: Answer: A Cognitive Level: Application These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. The PaO2 level is within normal limits, 80-100. Administering oxygen would not be the first intervention. The nurse knows the arterial blood gas oxygen level, which is an accurate test. The pulse oximeter would only provide an approximate level. The nurse can intervene in this case without notifying the health care provider first.

Q: The client is diagnosed with gastroenteritis.  Which laboratory value warrants immediate intervention by the nurse?
- A serum sodium level of 152 mEq/L.
- An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- A serum potassium of 4.8 mEq/L.
- A stool sample that is positive for fecal leukocytes.
A: A serum sodium level of 152 mEq/L.
If right: Answer: A Cognitive Level: Analysis The normal serum sodium level is 135-145 mEq/L; this sodium level is elevated, indicating the client is dehydrated, which warrants intervention by the nurse. The ABG results are normal so the nurse does not need to intervene. The normal serum potassium level is 3.5-5.5 mEq/L; therefore, this lab value does not warrant intervention by the nurse. A stool specimen showing fecal leukocytes would support the diagnosis of gastroenteritis and not warrant immediate intervention by the nurse.
If wrong: Answer: A Cognitive Level: Analysis The normal serum sodium level is 135-145 mEq/L; this sodium level is elevated, indicating the client is dehydrated, which warrants intervention by the nurse. The ABG results are normal so the nurse does not need to intervene. The normal serum potassium level is 3.5-5.5 mEq/L; therefore, this lab value does not warrant intervention by the nurse. A stool specimen showing fecal leukocytes would support the diagnosis of gastroenteritis and not warrant immediate intervention by the nurse.

Q: A client who has been diagnosed with acute renal failure has an intake of 2,000 mL and a urine output of 200 mL for the past 24 hours.  Which assessment by the nurse is most important?
- Palpate peripheral pulses.
- Auscultate breath sounds.
- Check urine specific gravity.
- Monitor blood urea nitrogen and creatinine.
A: Auscultate breath sounds.
If right: Answer: B Cognitive Level: Application An assessment of the client's breath sounds is most important. This client is experiencing fluid volume excess, which can cause pulmonary edema and heart failure. Peripheral pulses may be bounding, but this finding would not be as important as assessing for signs of pulmonary edema. Urine specific gravity may be increased, but this finding would not be as important as assessing for signs of pulmonary edema. Blood urea nitrogen and creatinine levels may be increased, but these findings would not be as important as assessing for signs of pulmonary edema.
If wrong: Answer: B Cognitive Level: Application An assessment of the client's breath sounds is most important. This client is experiencing fluid volume excess, which can cause pulmonary edema and heart failure. Peripheral pulses may be bounding, but this finding would not be as important as assessing for signs of pulmonary edema. Urine specific gravity may be increased, but this finding would not be as important as assessing for signs of pulmonary edema. Blood urea nitrogen and creatinine levels may be increased, but these findings would not be as important as assessing for signs of pulmonary edema.

Q: An older adult client is admitted to the hospital with a history of intractable vomiting for 3 days.  During the admission interview, the nurse notes that the client is confused.  Which fluid, electrolyte, and acid-base imbalances are most likely affecting the client? Select all that apply.
- Hyponatremia
- Hypernatremia
- Respiratory acidosis
- Metabolic alkalosis
- Fluid volume excess
- Fluid volume deficit
A: Hyponatremia; Metabolic alkalosis; Fluid volume deficit
If right: Answer: A, D, F Cognitive Level: Application The client is most likely experiencing hyponatremia, metabolic alkalosis, and fluid volume deficit. Persistent vomiting can lead to dehydration and hyponatremia because both sodium and water are lost when vomiting. Vomiting also causes an acid deficit through loss of stomach acids that may result in metabolic alkalosis.
If wrong: Answer: A, D, F Cognitive Level: Application The client is most likely experiencing hyponatremia, metabolic alkalosis, and fluid volume deficit. Persistent vomiting can lead to dehydration and hyponatremia because both sodium and water are lost when vomiting. Vomiting also causes an acid deficit through loss of stomach acids that may result in metabolic alkalosis.

Q: <span style="font-size:12pt">An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation?</span>
- <span style="font-size:12pt">Triage the client to determine the urgency of care.</span>
- <span style="font-size:12pt">Clearly communicate client data to the unit nurse.</span>
- <span style="font-size:12pt">Evaluate the need for ongoing medical treatment.</span>
- <span style="font-size:12pt">Perform a thorough assessment of the client.</span>
A: <span style="font-size:12pt">Clearly communicate client data to the unit nurse.</span>
If right: <span style="font-size:12pt">The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client’s ED experience.</span>
If wrong: <span style="font-size:12pt">The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client’s ED experience.</span>

Q: The nurse assesses a newly admitted client and finds that the client has hyperactive deep tendon reflexes.  Which potential electrolyte imbalance should the nurse suspect?
- Hypokalemia
- Hypercalcemia
- Hypernatrema
- Hypomagnesemia
A: Hypomagnesemia
If right: Answer: D Cognitive Level: Application The nurse should suspect hypomagnesemia in a client with increased DTRs. Serum magnesium levels less than 1.6 mg/dL (hypomagnesemia) increase nerve cell membrane excitability, causing the cells to depolarize spontaneously, which results in hyperactive DTRs. Hypokalemia and hypercalcemia results in hypoactive DTRs and Hypernateremia is not usually associates with abnormalities in DTRs.
If wrong: Answer: D Cognitive Level: Application The nurse should suspect hypomagnesemia in a client with increased DTRs. Serum magnesium levels less than 1.6 mg/dL (hypomagnesemia) increase nerve cell membrane excitability, causing the cells to depolarize spontaneously, which results in hyperactive DTRs. Hypokalemia and hypercalcemia results in hypoactive DTRs and Hypernateremia is not usually associates with abnormalities in DTRs.

Q: A nurse reviews the laboratory report of an adult client who is taking spironlactone (Aldactone) for congestive heart failure (CHF).  Which of the following conditions would the nurse expect if the client were experiencing the most common complication of taking this medication?
- Hypokalemia
- Hyperkalemia
- Hypernatremia
- Hyponatremia
A: Hyperkalemia
If right: Answer: B Cognitive level: Analysis Spironlactone (Aldactone) is a potassium sparing diuretic. The most common complication of taking this medication is hyperkalemia.
If wrong: Answer: B Cognitive level: Analysis Spironlactone (Aldactone) is a potassium sparing diuretic. The most common complication of taking this medication is hyperkalemia.

Q: A nurse in the emergency department is planning care for a client who is experiencing ethanol intoxication.  Which acid-base imbalances should the nurse anticipate when planning care for this client?  Select all that apply.
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
A: Metabolic acidosis; Respiratory acidosis
If right: Answer: A, C Cognitive Level: Application The nurse should anticipate that the client will experience metabolic acidosis and possible respiratory acidosis because the client has ingested excessive amounts of alcohol, which is an acid. Substance that cause acidosis when ingested include ethanol, methyl alcohol, and acetylsalicylic acid (aspirin). Ethanol toxicity can cause muscle weakness that results in respirator depression, placing the client at risk for respiratory acidosis as well as metabolic acidosis.
If wrong: Answer: A, C Cognitive Level: Application The nurse should anticipate that the client will experience metabolic acidosis and possible respiratory acidosis because the client has ingested excessive amounts of alcohol, which is an acid. Substance that cause acidosis when ingested include ethanol, methyl alcohol, and acetylsalicylic acid (aspirin). Ethanol toxicity can cause muscle weakness that results in respirator depression, placing the client at risk for respiratory acidosis as well as metabolic acidosis.

Q: A nurse is caring for a client who has developed acute respiratory acidosis.  The nruse reviews the client's STAT laboratory values.  Which electrolyte value should the nurse be most concerned with?
- Calcium
- Sodium
- Magnesium
- Potassium
A: Potassium
If right: Answer: D Cognitive Level: Application Although the nurse should review all the laboratory values, the nurse should be most concerned with the client's potassium level. The serum potassium level is often high in the presence of acidosis, as the body attempts to maintain neutrality during buffering. In acidosis, hydrogen ions increase and move into the intracellular fluid (ICF). To keep the ICF neutral, an equal number of potassium ions move out of the ICF and into the extracellular fluid, causing relative hyperkalemia.
If wrong: Answer: D Cognitive Level: Application Although the nurse should review all the laboratory values, the nurse should be most concerned with the client's potassium level. The serum potassium level is often high in the presence of acidosis, as the body attempts to maintain neutrality during buffering. In acidosis, hydrogen ions increase and move into the intracellular fluid (ICF). To keep the ICF neutral, an equal number of potassium ions move out of the ICF and into the extracellular fluid, causing relative hyperkalemia.

Q: A nurse analyzes a client's arterial blood gas (ABG) values. The client's serum pH is 7.42, PaCO2 is 30mm Hg, and HCO3 is 18 mEq/L.  Which acid-base imbalance should th nurse associate with these ABG values?
- Partially compensated metabolic acidosis
- Fully compensated respiratory acidosis
- Partially compensated metabolic alkalosis
- Fully compensated respiratory alkalosis
A: Fully compensated respiratory alkalosis
If right: Answer: D Cognitive Level: Analysis The nurse should associate fully compensated respiratory alkalosis with these ABG values. The pH of 7.42 is within the normal range of 7.35-7.45, indicating full compensation. The pH is on the upper (more alkalotic) end of the normal reference range, and both carbon dioxide and bicarbonate levels are decreased. A decreased carbon dioxide level would cause the blood to become alkalotic, but the decreased bicarbonate level is pulling the pH down within the normal range, indicating that the kidneys are excreting bicarbonate to compensate for and imbalance that is respiratory in origin.
If wrong: Answer: D Cognitive Level: Analysis The nurse should associate fully compensated respiratory alkalosis with these ABG values. The pH of 7.42 is within the normal range of 7.35-7.45, indicating full compensation. The pH is on the upper (more alkalotic) end of the normal reference range, and both carbon dioxide and bicarbonate levels are decreased. A decreased carbon dioxide level would cause the blood to become alkalotic, but the decreased bicarbonate level is pulling the pH down within the normal range, indicating that the kidneys are excreting bicarbonate to compensate for and imbalance that is respiratory in origin.

Q: <span style="font-size:12pt">A client with colon cancer is discharged to home with morphine for pain management. He is having episodes of nausea and vomiting. Which route of morphine administration would be most advantageous to use?</span>
- <span style="font-size:12pt">Oral</span>
- <span style="font-size:12pt">Rectal</span>
- <span style="font-size:12pt">Intravenous</span>
- <span style="font-size:12pt">Intramuscular</span>
A: <span style="font-size:12pt">Rectal</span>
If right: <span style="font-size:12pt">Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at home. Oral agents are the preferred route of analgesia in many cases. However, because of his nausea and vomiting, this client does not have the functional GI system needed for good absorption of oral agents. Intramuscular agents are not recommended for cancer pain. Intravenous agents are recommended when oral and rectal routes fail to provide pain control.</span>
If wrong: <span style="font-size:12pt">Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at home. Oral agents are the preferred route of analgesia in many cases. However, because of his nausea and vomiting, this client does not have the functional GI system needed for good absorption of oral agents. Intramuscular agents are not recommended for cancer pain. Intravenous agents are recommended when oral and rectal routes fail to provide pain control.</span>

Q: <span style="font-size:12pt">The nurse is caring for four clients. Which client assessment is the most indicative of having pain?</span>
- <span style="font-size:12pt">Blood pressure 150/70 mm Hg and sleeping</span>
- <span style="font-size:12pt">Client stating that he is “anxious”</span>
- <span style="font-size:12pt">Heart rate of 105 beats/min and restlessness</span>
- <span style="font-size:12pt">Postoperative client with a neck incision</span>
A: <span style="font-size:12pt">Heart rate of 105 beats/min and restlessness</span>
If right: <span style="font-size:12pt">At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.</span>
If wrong: <span style="font-size:12pt">At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.</span>

Q: <span style="font-size:12pt">What statement indicates that the client understands teaching about neutropenia?</span>
- <span style="font-size:12pt">“I need to use a soft toothbrush.”</span>
- <span style="font-size:12pt">“I have to wear a mask at all times.”</span>
- <span style="font-size:12pt">“My grandchildren may get an infection from me.”</span>
- <span style="font-size:12pt">“I will call my doctor if I have an increase in temperature.”</span>
A: <span style="font-size:12pt">“I will call my doctor if I have an increase in temperature.”</span>
If right: <span style="font-size:12pt">Bone marrow suppression leads to neutropenia and increases the client’s risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.</span>
If wrong: <span style="font-size:12pt">Bone marrow suppression leads to neutropenia and increases the client’s risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.</span>

Q: <span style="font-size:12pt">A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment is necessary. What is the nurse’s best response?</span>
- <span style="font-size:12pt">“Your cancer is widespread and requires more than the usual amount of radiation treatment.”</span>
- <span style="font-size:12pt">“Giving larger doses of radiation for a shorter period of time does not produce better effects and has worse side effects.”</span>
- <span style="font-size:12pt">“Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period.”</span>
- <span style="font-size:12pt">“It is less likely that your hair will fall out or that you will become anemic if radiation is given in this manner.”</span>
A: <span style="font-size:12pt">“Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period.”</span>
If right: <span style="font-size:12pt">Because of varying responses of all cancer cells within a given tumor, small doses of radiation are given on a daily basis for a set period of time. This method allows multiple opportunities to destroy cancer cells while minimizing damage to normal tissues.</span>
If wrong: <span style="font-size:12pt">Because of varying responses of all cancer cells within a given tumor, small doses of radiation are given on a daily basis for a set period of time. This method allows multiple opportunities to destroy cancer cells while minimizing damage to normal tissues.</span>

Q: <span style="font-size:12pt">A client’s spouse reports that the last time the client received lorazepam (Ativan) before receiving chemotherapy, the client was extremely drowsy and didn’t remember the trip home. Which is the nurse’s best action?</span>
- <span style="font-size:12pt">Hold the dose of lorazepam for this round of chemotherapy.</span>
- <span style="font-size:12pt">Explain that this is a normal response to the drug.</span>
- <span style="font-size:12pt">Perform a Mini-Mental State Examination.</span>
- <span style="font-size:12pt">Document the response in the client’s chart.</span>
A: <span style="font-size:12pt">Explain that this is a normal response to the drug.</span>
If right: <span style="font-size:12pt">Lorazepam, a benzodiazepine, induces sedation and amnesia, in addition to having antiemetic effects. Many clients have little if any memory about events occurring within a few hours after receiving lorazepam. This is an expected side effect and does not denote any permanent reduced cognition in the client. Both the client and the spouse should be aware of this effect so that the client is not at risk for injury. Driving, cooking, or operating mechanical equipment should not be performed until the drug’s effects have worn off.</span>
If wrong: <span style="font-size:12pt">Lorazepam, a benzodiazepine, induces sedation and amnesia, in addition to having antiemetic effects. Many clients have little if any memory about events occurring within a few hours after receiving lorazepam. This is an expected side effect and does not denote any permanent reduced cognition in the client. Both the client and the spouse should be aware of this effect so that the client is not at risk for injury. Driving, cooking, or operating mechanical equipment should not be performed until the drug’s effects have worn off.</span>

Q: <span style="font-size:12pt">A client is being treated at home for vancomycin-resistant <i>Enterococcus</i> (VRE). The client and the family are worried about spreading the infection. Which action by the nurse is best?</span>
- <span style="font-size:12pt">Instruct the client to use a separate bathroom.</span>
- <span style="font-size:12pt">Encourage the family to stay 3 feet away from the client.</span>
- <span style="font-size:12pt">Tell the client to cough into tissues and dispose of them immediately.</span>
- <span style="font-size:12pt">Teach the family ways to increase their immune system functioning.</span>
A: <span style="font-size:12pt">Instruct the client to use a separate bathroom.</span>
If right: <span style="font-size:12pt">VRE can live on surfaces for days or even weeks. Inanimate objects such as toilet seats or door handles can easily become contaminated and spread infection. The other actions are not necessary.</span>
If wrong: <span style="font-size:12pt">VRE can live on surfaces for days or even weeks. Inanimate objects such as toilet seats or door handles can easily become contaminated and spread infection. The other actions are not necessary.</span>

Q: <span style="font-size:12pt">A client’s white blood cell (WBC) count value is 10,000 cells/mm<sup>3</sup>. The nurse reviews the differential. Which counts or percentages is the nurse sure to report to the provider?</span>
- <span style="font-size:12pt">Eosinophils, 200/mm<sup>3</sup></span>
- <span style="font-size:12pt">A left shift in the white count</span>
- <span style="font-size:12pt">Segmented neutrophils, 6000/mm<sup>3</sup></span>
- <span style="font-size:12pt">Basophils 100/mm<sup>3</sup></span>
A: <span style="font-size:12pt">A left shift in the white count</span>
If right: <span style="font-size:12pt">A left shift in the WBC count indicates that the client is experiencing a continuing infection and that the client’s bone marrow cannot produce the required neutrophils, so it is now releasing immature neutrophils into the blood. The eosinophil count, the segmented neutrophil count, and the basophil count are all within normal ranges.</span>
If wrong: <span style="font-size:12pt">A left shift in the WBC count indicates that the client is experiencing a continuing infection and that the client’s bone marrow cannot produce the required neutrophils, so it is now releasing immature neutrophils into the blood. The eosinophil count, the segmented neutrophil count, and the basophil count are all within normal ranges.</span>

Q: <span style="font-size:12pt">The client’s family members are concerned that the client should have a urinary catheter placed because of her decreasing urinary output. What is the hospice nurse’s best response?</span>
- <span style="font-size:12pt">“A Foley catheter is inserted only if she is taking medications that affect output.”</span>
- <span style="font-size:12pt">“I will insert a Foley catheter if her urinary output drops below 500 mL/day.”</span>
- <span style="font-size:12pt">“A Foley catheter will be inserted if her bladder becomes distended.”</span>
- <span style="font-size:12pt">“I will insert a Foley catheter if she becomes incontinent of urine.”</span>
A: <span style="font-size:12pt">“A Foley catheter will be inserted if her bladder becomes distended.”</span>
If right: <span style="font-size:12pt">Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended bladder, and would be more comfortable not moving. The other statements are not appropriate uses for an indwelling catheter in a hospice setting.</span>
If wrong: <span style="font-size:12pt">Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended bladder, and would be more comfortable not moving. The other statements are not appropriate uses for an indwelling catheter in a hospice setting.</span>

Q: <span style="font-size:12pt">Which behavior exhibited by an older adult client alerts the nurse to the possibility that the client is experiencing delirium?</span>
- <span style="font-size:12pt">Becoming confused within 24 hours after hospital admission</span>
- <span style="font-size:12pt">Displaying a cheerful attitude despite a poor prognosis</span>
- <span style="font-size:12pt">Becoming withdrawn and sleeping most of the day</span>
- <span style="font-size:12pt">Beginning to use slurred speech and losing coordination</span>
A: <span style="font-size:12pt">Becoming confused within 24 hours after hospital admission</span>
If right: <span style="font-size:12pt">Delirium is characterized by acute confusion that is usually short term. Delirium can result from placement in unfamiliar surroundings, such as being hospitalized. Depression is characterized by an increase in sleep and lack of social contact. Slurred speech may indicate a stroke.</span>
If wrong: <span style="font-size:12pt">Delirium is characterized by acute confusion that is usually short term. Delirium can result from placement in unfamiliar surroundings, such as being hospitalized. Depression is characterized by an increase in sleep and lack of social contact. Slurred speech may indicate a stroke.</span>

Q: <span style="font-size:12pt">The nurse is providing community education for clients at risk for dehydration. One client states, “We are not at risk because we live in a hot and dry climate.” What is the nurse’s best response?</span>
- <span style="font-size:12pt">“You are still at risk but not as high a risk as those who live in hot and humid climates.”</span>
- <span style="font-size:12pt">“Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water.”</span>
- <span style="font-size:12pt">“In a hot and dry environment, the body can lose an increased amount of water without your knowledge.”</span>
- <span style="font-size:12pt">“Even though you are not at risk, you should drink adequate fluids when you exercise.”</span>
A: <span style="font-size:12pt">“In a hot and dry environment, the body can lose an increased amount of water without your knowledge.”</span>
If right: <span style="font-size:12pt">Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate.</span>
If wrong: <span style="font-size:12pt">Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate.</span>

Q: <span style="font-size:12pt">The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question?</span>
- <span style="font-size:12pt">Enoxaparin (Lovenox) 40 mg subcutaneous twice daily</span>
- <span style="font-size:12pt">Transfusion of 2 units of fresh frozen plasma</span>
- <span style="font-size:12pt">Regular insulin intravenous drip per protocol</span>
- <span style="font-size:12pt">Cefazolin (Ancef) 1 g IV every 6 hours</span>
A: <span style="font-size:12pt">Enoxaparin (Lovenox) 40 mg subcutaneous twice daily</span>
If right: <span style="font-size:12pt">Therapy during the second (late) phase of septic shock is aimed at enhancing the blood’s ability to clot. Enoxaparin would increase the client’s risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client’s blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.</span>
If wrong: <span style="font-size:12pt">Therapy during the second (late) phase of septic shock is aimed at enhancing the blood’s ability to clot. Enoxaparin would increase the client’s risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client’s blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.</span>

Q: <span style="font-size:12pt">The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?</span>
- <span style="font-size:12pt">“Is your blood pressure higher than usual?”</span>
- <span style="font-size:12pt">“Are you having pain in your throat?”</span>
- <span style="font-size:12pt">“Have you been vomiting?”</span>
- <span style="font-size:12pt">“Are you usually this swollen?”</span>
A: <span style="font-size:12pt">“Are you usually this swollen?”</span>
If right: <span style="font-size:12pt">Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.</span>
If wrong: <span style="font-size:12pt">Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.</span>

Q: <span style="font-size:12pt">The nurse is assessing a client who has septic shock. The following assessment data were collected:<br></span><div style="font-size:2pt"></div><table cellpadding="0" cellspacing="0" width="68%" border="1"><tr valign="top"><td> </td><td><div style="text-align:center"><b><span style="font-size:12pt">Baseline Data</span></b></div></td><td><div style="text-align:center"><b><span style="font-size:12pt">Today’s Data</span></b></div></td></tr><tr valign="top"><td><span style="font-size:12pt">Heart rate</span></td><td><span style="font-size:12pt">75 beats/min</span></td><td><span style="font-size:12pt">98 beats/min</span></td></tr><tr valign="top"><td><span style="font-size:12pt">Blood pressure</span></td><td><span style="font-size:12pt">125/65 mm Hg</span></td><td><span style="font-size:12pt">128/75 mm Hg</span></td></tr><tr valign="top"><td><span style="font-size:12pt">Respiratory rate</span></td><td><span style="font-size:12pt">12 breaths/min</span></td><td><span style="font-size:12pt">18 breaths/min</span></td></tr><tr valign="top"><td><span style="font-size:12pt">Urinary output</span></td><td><span style="font-size:12pt">40 mL/hr</span></td><td><span style="font-size:12pt">40 mL/hr</span></td></tr><tr height="0" style="border:none"><td width="32%"></td><td width="35%"></td><td width="33%"></td></tr></table><span style="font-size:12pt">The nurse correlates these findings with which stage of shock?</span>
- <span style="font-size:12pt">Early</span>
- <span style="font-size:12pt">Compensatory</span>
- <span style="font-size:12pt">Intermediate</span>
- <span style="font-size:12pt">Refractory</span>
A: <span style="font-size:12pt">Early</span>
If right: <span style="font-size:12pt">An increase in heart and respiratory rates (heart rate first) from the client’s baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.</span>
If wrong: <span style="font-size:12pt">An increase in heart and respiratory rates (heart rate first) from the client’s baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.</span>

Q: <span style="font-size:12pt">The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock?</span>
- <span style="font-size:12pt">15-year-old adolescent who plays high school basketball</span>
- <span style="font-size:12pt">24-year-old computer specialist who has bulimia</span>
- <span style="font-size:12pt">48-year-old truck driver who has a 40-pack-year history of smoking</span>
- <span style="font-size:12pt">62-year-old business executive who travels frequently</span>
A: <span style="font-size:12pt">24-year-old computer specialist who has bulimia</span>
If right: <span style="font-size:12pt">Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock.</span>
If wrong: <span style="font-size:12pt">Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock.</span>

Q: <span style="font-size:12pt">The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this client’s teaching? <i>(Select all that apply.)</i></span>
- <span style="font-size:12pt">“Wear a facemask at all times.”</span>
- <span style="font-size:12pt">“Take your temperature once a day.”</span>
- <span style="font-size:12pt">“Drink only bottled water.”</span>
- <span style="font-size:12pt">“Avoid any contact with pets.”</span>
- <span style="font-size:12pt">“Wash dishes with hot sudsy water.”</span>
- <span style="font-size:12pt">“Rinse your toothbrush in liquid laundry bleach.”</span>
A: <span style="font-size:12pt">“Take your temperature once a day.”</span>; <span style="font-size:12pt">“Wash dishes with hot sudsy water.”</span>; <span style="font-size:12pt">“Rinse your toothbrush in liquid laundry bleach.”</span>
If right: <span style="font-size:12pt">Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes.</span>
If wrong: <span style="font-size:12pt">Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes.</span>