1. CHAPTER 1
Managed care organizations are insurers that carefully plan and closely supervise the
distribution of healthcare services. What is one of the goals of managed care?
A) Preventing illness through screening and promotion of health activities
B) Improving training of healthcare professionals
C) Eliminating health disparities between segments of the population
D) Providing hospice or home hospice care
Ans: A
Feedback:
Preventing illness through screening and promotion of health activities is one of the
goals of managed care. Improved training of healthcare professionals is the priority for
international health and not the goal of managed care. Eliminating health disparities
between the segments of population is a goal of Healthy People 2020. Providing hospice
or home hospice care is only for terminally ill clients.
2. In an effort to cut costs, hospitals have instituted many changes. Which of these
cost-cutting factors is most likely to jeopardize the quality of care?
A) Using unlicensed assistive personnel
B) Increasing numbers of clients in hospitals
C) Not devoting enough time to the client
D) The rise of medical care costs in healthcare systems
Ans: A
Feedback:
Hospitals are using unlicensed assistive personnel to perform some duties practical and
registered nurses once provided. Many are concerned that the use of unlicensed assistive
personnel will jeopardize the quality of care. Increasing numbers of clients in hospitals,
not devoting enough time to the client, or the rise of medical costs are less likely to
jeopardize the quality of care.
3. Since losing his right leg years ago, Mr. Smith and his wife have formed a community
walking group to raise money for the homeless in his area. Which of the following has
contributed to him being viewed as “healthy”?
A) The client is married and is moving on.
B) The client is experiencing high quality of life within the limits of the physical
condition.
C) The client is facing various states of health and illness.
D) The client is physiologically and psychologically stable.
Ans: B
Feedback:
Clients adapt physically, emotionally, and socially, enabling them to maintain comfort,
stability, and self-expression. Clients with chronic illness can achieve a high level of
wellness and experience high quality of life. Marriage is an aspect of quality of life but
does not define the quality of the client's life. All clients experience various states of
health and illness.
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4. A 17-year-old client is having protected sex one to two times a week in a monogamous
relationship. What is the client participating in?
A) Health promotion
B) Health maintenance
C) Illness prevention
D) Wellness
Ans: B
Feedback:
Protecting one's current level of health by practicing safe sex to prevent illness is an
example of a health maintenance activity. Health promotion strategies are used to
enhance health, such as eating a diet high in fiber. Illness prevention includes
identifying risk factors such as hypertension. Wellness is the balance of total well-being.
5. A client complaining of bloody urine has scheduled an appointment with a family
practitioner. What type of care is the client receiving?
A) Tertiary
B) Secondary
C) Skilled nursing care
D) Primary
Ans: D
Feedback:
The first provider that clients contact about a health need provides primary care; this
person is typically a family practitioner or nurse practitioner. Secondary care includes
referrals to facilities for additional testing. Tertiary care focuses on more complex
medical and surgical intervention. Skilled nursing care occurs in facilities or units that
offer prolonged health maintenance or rehabilitative services.
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6. The hospital is having a problem with healthcare-associated infections. A committee has
been established to study the problem and make recommendations. The nurse working
on the committee knows that this work addresses what?
A) Inpatient quality indicators
B) Prevention quality indicators
C) National Patient Safety Goals
D) Patient safety indicators
Ans: C
Feedback:
The Joint Commission has established National Patient Safety Goals that are updated
annually. These safety goals have changed how patients are identified and prevent
adverse effects. Some of the 2012 goals include reducing the risk of
healthcare-associated infections. Patient safety indicators reflect the quality of care in
hospitals but focus on potentially avoidable complications. Prevention indicators
identify hospital admissions that could be avoided through high-quality outpatient care.
Inpatient indicators reflect quality of care inside the hospital.
7. After hip surgery, a client is admitted to the rehabilitation hospital. What type of care is
the client receiving?
A) Secondary
B) Tertiary
C) Rehabilitation
D) Primary
Ans: B
Feedback:
Hospitals where specialized technology is available provide tertiary care. Primary care
is the initial contact that a client has, such as an appointment with a family practitioner.
Secondary care includes referrals for additional testing. Rehabilitation is aimed at
restoring a person to his or her fullest ability.
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8. An older man has been sick for 3 weeks but will not seek medical help even though he
is able to get to the doctor's office. The client does not know what his insurance will
cover. The client has many medical bills from treatments not covered and does not want
to be faced with more. Why is this client waiting to obtain medical treatment?
A) Cost
B) Language
C) Accessibility
D) Culture
Ans: A
Feedback:
Many groups, such as ethnic minorities and older adults, are underserved; many do not
seek early services because they cannot afford to pay for them. Accessibility is not an
issue because the client is able to get to the office. No cultural or language barrier is
mentioned.
9. The Healthy People 2020 initiative targets the improvement of health for all. In addition
to eliminating health disparities, what are the broad goals of this plan?
A) Increasing technological innovations
B) Preventing treatable problems
C) Applying a systematic approach to health improvement
D) Increasing the quality and length of a healthy life
Ans: D
Feedback:
Two broad goals of the Healthy People 2020 initiative are to increase quality and years
of healthy life and eliminate health disparities. Healthy People 2020 initiatives will help
with treatable problems but will not prevent problems. The initiative does not apply a
systematic approach to health improvement or increase technological innovations.
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10. What method for financing healthcare is based on the ability to keep clients healthy and
out of the hospital through periodic screening, health education, and preventive
services?
A) Managed care
B) Preferred provider organization
C) Health maintenance organization
D) Point-of-service organization
Ans: C
Feedback:
Health maintenance organizations strive to keep their costs low and members out of the
hospital through periodic screenings, health education, and preventive services.
Managed care organizations are insurers who carefully plan and closely supervise the
distribution of healthcare services. Preferred provider organizations are a community
network of providers who are willing to discount their fees for service in exchange for a
steady stream of referral customers. Point-of-service organizations involve a network of
providers; clients select a primary care physician within the group who then serves as
the gatekeeper for other healthcare services.
11. The LPN is leading a cardiac rehabilitation support group. How can the nurse best
demonstrate meeting the clients need holistically?
A) Lead an exercise, show a video about healthy lifestyle changes, and invite a
spiritual leader to talk with the group.
B) Have the clients share various healthy low-cholesterol recipes and participate in a
cooking class.
C) Have the clients discuss ways to relieve stress and practice stress reduction.
D) Demonstrate low-impact aerobic exercise to the group and bring in a lecturer on
Tai Chi.
Ans: A
Feedback:
Nurses practice from the perspective of holism, which is viewing a person's health as a
state balance between body, mind, and spirit. Option A addresses all aspects of holism
in caring for clients. Options B, C, and D address only one aspect of this level of care.
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12. A client is brought into the emergency department by the rescue squad after
involvement in a motorcycle accident with a severe spinal cord injury. What type of
illness does the LPN view this event?
A) Terminal
B) Acute
C) Chronic
D) Catastrophic
Ans: D
Feedback:
Illness refers to a state of being sick and can be viewed as catastrophic or a sudden,
traumatic illness, which has occurred with this client. The client has suffered a traumatic
accident with serious injury and would be classified as catastrophic. This event is not
chronic, terminal, or acute.
13. A client with chronic obstructive pulmonary disease visits a local long-term care facility
once a week to lead a bingo game for the residents. How does the LPN determine that
this client is achieving a high level of wellness?
A) The client enjoys the activity that she provides to the clients.
B) The client finds satisfaction in socialization with the residents.
C) The client is achieving a high quality of life within the limits of her illness.
D) The client needs to feel a part of a group setting.
Ans: C
Feedback:
Clients with chronic illness can achieve a high level of wellness if they can experience a
high quality of life within the limits of that illness. This client would be considered
healthy because she is engaged in a personal and social activity weekly. Although the
client may enjoy the activity, find satisfaction in socialization, or need to feel a part of a
group, the larger scope of wellness is option C.
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14. The LPN is providing a program at the local YMCA about stress-reduction techniques
combined with a 1-mile walk around the indoor track once a week. What does this type
of program address for the community?
A) Health promotion
B) Health maintenance
C) Illness prevention
D) Early detection of illness
Ans: A
Feedback:
Health promotion refers to engaging in strategies to enhance health such as eating a diet
high in grains and complex carbohydrates, exercising regularly, balancing work with
leisure activities, and practicing stress-reduction techniques. Illness prevention involves
identifying risk factors such as a family history of hypertension or diabetes and reducing
the effects of risk factors on one's health. Early detection uses screening diagnostic tests
and procedures to identify a disease process earlier, so that treatment may be initiated
earlier and be more effective. Health maintenance refers to protecting one's current level
of health by preventing illness or deterioration, such as by complying with medication
regimens, being screened for diseases such as breast and colon cancers, or practicing
safe sex.
15. The LPN is collecting data at the clinic from a new client who is being seen for an
employee physical. The client informs the nurse that both parents have a history of high
blood pressure and his father had a stroke at age 52 years. The nurse discusses diet and
exercise programs that may benefit the client. What is the nurse displaying with this
information?
A) Early detection
B) Health maintenance
C) Health promotion
D) Illness prevention
Ans: D
Feedback:
Illness prevention involves identifying risk factors such as family history of
hypertension or diabetes and reducing the effects of risk factors on one's health. Early
detection uses screening diagnostic tests and procedures to identify a disease process
earlier, so that treatment may be initiated earlier and be more effective. Health
maintenance refers to protecting one's current level of health by preventing illness or
deterioration, such as by complying with medication regimens, being screened for
diseases such as breast and colon cancers, or practicing safe sex. Health promotion
refers to engaging in strategies to enhance health such as eating a diet high in grains and
complex carbohydrates, exercising regularly, balancing work with leisure activities, and
practicing stress-reduction techniques.
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16. The LPN informs the secretary that a client is expected to come in for lab work. The
secretary inquires about why the nurse refers to the individual as a client. What is the
best response by the nurse?
A) “We should refer to everyone as a client. They pay for our service.”
B) “That's how the physician wants us to refer to them.”
C) “Using the term client implies that they are an active partner in nursing care.”
D) “Using the term client is more respectful that using the term patient.”
Ans: C
Feedback:
A client is an active partner in nursing care, and the person receiving healthcare services
should no longer play a passive, ill role. The use of the term client reflects the attitude of
personal responsibility for health. Options A, B, and D do not address the reason for the
term used.
17. The LPN is making a referral to physical therapy for a client who has had a hip
replacement and is going to be discharged in 2 days. The nurse understands that having
physical therapy included in the care of the client includes them in what discipline?
A) Part of the healthcare team
B) A discipline unto themselves
C) Part of the administrative team
D) The same discipline as the prescribing physician only
Ans: A
Feedback:
The healthcare team consists of specially trained personnel who work together to help
clients meet their healthcare needs. The team includes physicians, nurses, psychologists,
pharmacists, dietitians, social workers, respiratory and physical therapists, occupational
therapists, nursing assistants, technicians, and insurance company staff. Because
physical therapists are part of the healthcare team, options B, C, and D would be
incorrect.
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18. The client is referred from the physician to a cardiologist for a cardiac catheterization to
determine if the client has coronary artery disease. What type of care does the nurse
understand that this is?
A) Primary care
B) Secondary care
C) Tertiary care
D) Acute care
Ans: B
Feedback:
Secondary care includes referrals to facilities for additional testing such as cardiac
catheterization, consultation, and diagnosis as well as emergency and acute care
interventions. This client falls into this category due to the referral to the cardiologist for
the cardiac catheterization. The client does not fall into the acute care category. Primary
care would include being seen by the client's primary physician. Tertiary care focuses
more on complex medical and surgical interventions, cancer care, rehabilitative
services, long-term care such as burn care, and palliative and hospice care.
19. A client with terminal cancer is being referred to hospice services to assist with care of
the client and the family in the home environment. What type of care does the nurse
determine this is?
A) Primary care
B) Secondary care
C) Tertiary care
D) Acute care
Ans: C
Feedback:
Tertiary care focuses more on complex medical and surgical interventions, cancer care,
rehabilitative services, long-term care such as burn care, and palliative and hospice care.
This patient is terminally ill and being referred for hospice service. Secondary care
includes referrals to facilities for additional testing such as cardiac catheterization,
consultation, and diagnosis as well as emergency and acute care interventions. The
client does not fall into the acute care category. Primary care would include being seen
by the client's primary physician.
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20. A client comes to the clinic with the complaint that he has been ill for several weeks but
do not have insurance and have delayed care. What does the LPN understand about the
overall healthcare reform goals that will address issues such as this client?
A) The goal of healthcare reform is to provide care to women, infants, and children.
B) The goal of healthcare reform is to provide more healthcare programs to address
illness.
C) The goal of healthcare reform is to provide quality healthcare for those that can
afford it.
D) The goal of healthcare reform is to provide affordable healthcare to more citizens.
Ans: D
Feedback:
The overall goal of healthcare reform is to provide affordable healthcare to more U.S.
citizens. Other goals are to reduce the insurance companies' control of healthcare and to
provide more assistance to senior citizens on fixed incomes. The other answers address
other individual programs but not the broader terms of the healthcare initiative.
21. A 72-year-old client who is hospitalized will be going on anticoagulant therapy and will
require home healthcare nurses to visit once weekly to draw blood for coagulation
studies. What coverage does the client have that will cover this service?
A) Medicaid
B) Medicare Part A
C) Medicare Part B
D) Medicare Part C
Ans: B
Feedback:
Medicare covers individuals who are 65 years of age or older, permanently disabled
workers of any age with specific disabilities, and persons with end-stage renal disease.
Medicare Part A covers hospital care, skilled care, hospice, and home health services.
Medicare Part B covers medically necessary services such as physician services that are
not covered under Part A. Medicare Part C is the Medicare Advantage Plan and includes
Parts A and B. Medicaid coverage is coverage for indigent patients that are unable to
afford healthcare and qualify financially.
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22. A 65-year-old client is prescribed multiple medications for diabetes, hypertension, and
angina and is going to the pharmacy to have the prescriptions filled. What coverage will
the client use to assist with financial coverage of the medication?
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
Ans: D
Feedback:
Medicare Part D is Medicare Prescription Drug Coverage and helps to cover and
possibly reduce prescription drug costs and protect against catastrophic drug expenses.
Medicare Part A covers hospital care, skilled care, hospice, and home health services.
Medicare Part B covers medically necessary services such as physician services that are
not covered under Part A. Medicare Part C is the Medicare Advantage Plan and includes
Parts A and B.
23. A client informs the nurse that she is a single parent with four children and cannot
afford to pay for medical insurance for her and her family. What coverage does the
nurse understand this client and her family may be eligible for?
A) Medicare
B) Medigap insurance
C) Prospective payment system
D) Medicaid
Ans: D
Feedback:
Medicaid is a federally funded, state-run program that provides medical assistance for
individuals with limited incomes and resources. Qualifications vary from state to state,
but, typically, clients qualify if they have children and a limited income. Medicare
covers individuals who are 65 years of age or older, permanently disabled workers of
any age with specific disabilities, and persons with end-stage renal disease. Prospective
payment system is a method of reimbursement in which healthcare providers receive
payment for services based on a predetermined, fixed rate. Medigap insurance policies
are for people that have adequate resources to cover copayments and deductibles.
Page 11
24. A client is a member of a group insurance plan in which he pays a preset, fixed fee for
healthcare services. What type of insurance plan does the nurse understand the client to
have?
A) A preferred provider organization (PPO)
B) A health maintenance organization (HMO)
C) Medicare
D) Medicaid
Ans: B
Feedback:
An HMO is a group insurance plan in which participants pay a preset, fixed fee in
exchange for healthcare services. The fee is not based on the number of services
provided but rather is projected to the number of participants and expected services. A
PPO operates on the principle that competition can control costs. Acting as agents for
health insurance companies, PPOs create a community network of providers who are
willing to discount their fees for service in exchange for a steady stream of referred
customers. Medicare is for people that are age 65 years and older or disabled. Medicaid
is coverage for those clients who are unable to afford healthcare.
25. An HMO client obtained a second opinion regarding a diagnosis of colon cancer. There
was no authorization obtained for this second opinion from the client or primary care
provider. What is the consequence of this action?
A) The client will be responsible for the entire bill for the second opinion.
B) The client will still receive full coverage.
C) The client will be dropped from the HMO for breaking the rules.
D) The client will be fined by the HMO for not using the authorization process.
Ans: A
Feedback:
Members of an HMO must receive authorization for secondary care, such as second
opinions from specialists or diagnostic testing. If members obtain unauthorized care,
they are responsible for the entire bill. In this way, HMOs serve as gatekeepers for
healthcare services. The member will not be fined or dropped from the program but will
not receive coverage for the service rendered from the second opinion.
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26. What does the nurse understand is the focus of healthcare when a client receives
services from a health maintenance organization (HMO)?
A) Avoiding coverage for needed services
B) Health promotion and maintenance
C) To offer discounted services to all patients
D) High-quality service and contain cost
Ans: B
Feedback:
If the HMO does not require much high-cost care, providers make money; if members
use many high-cost resources, providers lose money. This method of financing provides
the strongest incentives for limiting use of expensive services and focusing healthcare
on health maintenance and promotion. If services such as diagnostic testing are required,
the HMO will cover this and not avoid payment. Services are not discounted for
patient's that are nonmembers or members. The goals of a physician hospital
organization (PHO) are to maintain high-quality service and contain costs while
fostering group contracts, collaboration, and capitation.
27. The LPN has been asked to assist in gathering data regarding the incidence of falls in
the hospital as part of a project that is geared toward identifying avoidable contributing
factors and their effects. What type of quality indicators (QI) is this considered?
A) Prevention QI
B) Inpatient QI
C) Patient safety QI
D) Pediatric QI
Ans: C
Feedback:
Patient safety QIs reflect quality of care within hospitals but focus on potentially
avoidable complications and adverse effects. Prevention QIs identify hospital
admissions that could be avoided through high-quality outpatient care. Inpatient QIs
reflect quality of care inside hospitals, including inpatient mortality for medical
conditions and surgical events.
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28. A client undergoing a surgical procedure at the hospital died related to complications
during the procedure. The LPN is required to collect data about the event so that a cause
can be determined. What type of quality indicators would be used in this incident?
A) Prevention QIs
B) Inpatient QIs
C) Patient safety QIs
D) Pediatric QIs
Ans: B
Feedback:
Inpatient QIs reflect quality of care inside hospitals, including inpatient mortality for
medical conditions and surgical procedures. Prevention QIs identify hospital admissions
that could be avoided through high-quality outpatient care. Patient safety QIs also
reflect quality of care within hospitals but focus on potentially avoidable complications
and adverse events. Pediatric QIs reflect quality of care inside hospitals and identify
potentially avoidable hospitalization among children.
29. The LPN is working with a team of nurses in order to develop protocols for managing
care of clients who are having peritoneal dialysis on their unit. What type of care
mapping would the nurse use for the development of these standards?
A) Nursing care plan
B) Standing orders
C) Recipe for care
D) Clinical pathways
Ans: D
Feedback:
Protocols (also known as guidelines or standards) for managing care have been
developed. Multidisciplinary teams use clinical pathways or care mapping for specific
diagnoses or procedures, which standardize important aspects of care such as diagnostic
workups, nursing care, education, physical therapy, and discharge planning across the
estimated length of stay. A nursing care plan is individualized to meet the needs of each
client and is not standardized. There is no “recipe” for care that will meet the needs of
clients. Standing orders reflect a physician's order that is standardized for patients with a
specific diagnosis or procedure.
Page 14
30. The LPN is assisting with the development of a program to administer flu shots to a
group of senior citizens. What type of prevention does this program reflect?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Prevalence
Ans: A
Feedback:
Primary prevention is prevention of the development of disease in a susceptible or
potentially susceptible population and includes health promotion and immunization.
Secondary prevention is the early diagnosis and treatment to shorten duration and
severity of an illness, reduce contagion, and limit complications. Tertiary prevention is
healthcare to limit the degree of disability or promote rehabilitation in chronic,
irreversible diseases. Prevalence is the number of cases of a disease in a specific
population during a specific period.
31. The LPN working in the clinic has had several incidence of positive chlamydia cultures
return in women with pelvic pain. The nurse understands that early diagnosis and
treatment are essential measures in which to reduce contagion and limit the
complications related to this infection. What type of prevention will the nurse use when
these infections are treated?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Prevalence
Ans: B
Feedback:
Secondary prevention is the early diagnosis and treatment to shorten duration and
severity of an illness, reduce contagion, and limit complications. Tertiary prevention is
healthcare to limit the degree of disability or promote rehabilitation in chronic,
irreversible diseases. Prevalence is the number of cases of a disease in a specific
population during a specific period. Primary prevention is prevention of the
development of disease in a susceptible or potentially susceptible population and
includes health promotion and immunization.
Page 15
32. The LPN is working for a physician who participates in an HMO and will be assisting
with the billing. What type of information regarding capitation does the nurse need to
understand?
A) Fees are not based on the number of services provided but rather are projected to
the number of participants and expected services.
B) Fees are based on the number of services that the primary care provider bills for.
C) The HMO makes money based on the degree of illness and number of diagnostic
tests that are done.
D) The fees that are charged are different even with the same diagnosis.
Ans: A
Feedback:
With an HMO, the fee is not based on the number of services provided but rather is
projected to the number of participants and expected services. This type of financial
management is referred to as capitation, which refers to the actual head or person count.
Option A is incorrect because HMO is based on the number of participants and expected
services. The HMO makes money by keeping people healthy and out of the hospital.
The fees are the same regardless of the actual service or frequency of care provided.
33. An LPN has applied for a position in the hospital emergency department and is told that
the facility only hires RNs and unlicensed assistive personnel (UAPs) in the emergency
department. What concern does the LPN have with the practice of hiring UAPs in place
of LPNs?
A) LPNs will be phased out of the healthcare field altogether when more UAPs are
hired.
B) UAPs are performing some of the duties that practical nurses typically provide
and may jeopardize the quality of care.
C) UAPs will replace nurses because they deliver a better quality of care.
D) State boards of nursing will begin to credential UAPs.
Ans: B
Feedback:
Changes in the healthcare industry have also affected employment for healthcare
workers. Hospitals employ UAPs to perform some duties that practical and registered
nurses once provided. Many are concerned that the use of UAPs will jeopardize the
quality of care. There is no evidence to indicate that LPNs will be phased out of the
healthcare system or will replace nurses. State boards of nursing cannot credential an
unlicensed person that does not go through a formal education program.
Page 16
34. What statement by the LPN shows an understanding of the ultimate goal of Healthy
People 2020?
A) “The ultimate goal is that they will find a cure for diabetes.”
B) “The ultimate goal is that they provide an overall action plan to improve health
and quality of life.”
C) “The ultimate goal is that everyone be within a normal weight.”
D) “The ultimate goal is that everyone will exercise once daily.”
Ans: B
Feedback:
The Healthy People 2020 campaign provides an overall action plan to improve the
health and quality of life for people living the United States. The U.S. Department of
Health and Human Services identified the four overarching health goals: Attain high
quality, longer lives free of preventable disease, disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the health of all groups. Create
social and physical environments that promote good health for all. Promote quality of
life, healthy development, and healthy behaviors across all life stages. Health People
2020 is not focused on an individual disease process, a “normal” weight, or exercise for
the individual as the overall goal.
35. The LPN is aware of the various changes in the healthcare field. What important factor
remains the same in this time of change?
A) Nurses must provide safe, high-quality, cost-effective care to individuals,
families, and communities.
B) Nurses must inform clients that they will have to use facilities that are within their
service area.
C) Clients must become actively involved in the process of standardizing care.
D) Nurses will have to work in unsafe conditions in order to provide care to clients.
Ans: A
Feedback:
In the midst of these dramatic changes and challenges, nurses must continue to provide
safe, high-quality, cost-effective care to individuals, families, and communities. It is
also imperative that nurses distinguish and communicate to clients the various choices
that the clients may make about their healthcare. Clients have a choice as to location of
care providers and are not limited to local facilities. Clients are not involved in
standardizing care; this is a healthcare provider function. Nurses will not have to work
in unsafe conditions in order to provide care to clients.
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1. CHAPTER 2
Which of the following describes the role of the nurse as defined by Florence
Nightingale?
A) Helping people to carry out activities that contribute to health and recovery
B) Putting the patient in the best condition for nature to act upon him or her
C) Diagnosing and treating human responses to actual or potential health problems
D) Promoting a caring relationship that facilitates health and healing
Ans: B
Feedback:
Florence Nightingale (1859) described the role of the nurse as putting “the patient in the
best condition for nature to act upon him.” Virginia Henderson envisioned the nurse's
role as helping people (sick or well) to carry out activities that contribute to health,
recovery, or a peaceful death. The American Nurses Association (ANA) traditionally
defined nursing as “the diagnosis and treatment of human responses to actual or
potential health problems.” In response to an increased emphasis on the science of care,
the ANA now acknowledges “promotion of a caring relationship that facilitates health
and healing” as one of the four essential features of contemporary nursing practice.
2. Which setting has been the traditional site for the nursing work force?
A) Dialysis units
B) Inpatient units
C) Same-day surgery units
D) Clinics
Ans: B
Feedback:
Although hospitals include all levels of outpatient areas (e.g., dialysis units, clinics,
same-day surgery units, related diagnostic departments), inpatient units have been the
traditional site for much of the nursing work force.
3. Which type of care is used for clients with terminal illness who have a life expectancy of
less than 6 months?
A) Hospice care
B) Ambulatory care
C) Skilled nursing care
D) Intermediate care
Ans: A
Feedback:
Hospices provide care for clients with terminal illness whose life expectancy is less than
6 months. Ambulatory care is also called outpatient care. Skilled nursing care facilities
provide skilled nursing and rehabilitative care to people who have the potential to regain
function but need skilled observation and nursing care during an acute illness.
Intermediate care facilities are nursing homes that provide custodial care for people who
cannot care for themselves because of mental or physical disabilities.
Page 1
4. Freestanding apartments are an example of which type of alternative healthcare setting?
A) Skilled nursing care
B) Assisted living
C) Congregate housing
D) Boarding homes
Ans: C
Feedback:
Congregate housing provides independent living or minimal assistance for seniors or
disabled adults. Skilled nursing care facilities provide skilled nursing and rehabilitative
care to people who have the potential to regain function but need skilled observation and
nursing care during an acute illness. Assisted living facilities provide care to residents
who need assistance with up to three activities of daily living. Boarding homes are
usually small homes with individual rooms where residents pay for room and board and
minimal nursing services.
5. In which setting is total care often practiced?
A) Assisted living
B) Intensive care units
C) Boarding homes
D) Congregate nursing
Ans: B
Feedback:
Total care is often practiced in intensive care units where nurses are assigned one or two
clients. Assisted living facilities provide care to residents who need assistance with up to
three activities of daily living. Boarding homes are usually small homes with individual
rooms where residents pay for room and board and minimal nursing services.
Congregate housing provides independent living or minimal assistance for seniors or
disabled adults.
6. Which of the following describes the goal of alternative care facilities?
A) An RN and one or more assistive personnel care for a group of patients.
B) An RN assumes all care for a small group of patients.
C) There is 24-hour accountability by an RN.
D) The facility provides the least restrictive living arrangement.
Ans: D
Feedback:
The goal of alternative care facilities is to provide the least restrictive living
arrangement while maintaining safety and quality. Patient-focused care uses an RN
partnered with one or more assistive personnel to care for a group of clients. Total care
refers to assignments in which a nurse assumes all the care for a small group of clients.
In primary nursing, an RN assumes 24-hour accountability for the client's care and has
total responsibility for the nursing care of assigned clients during his or her shift.
Page 2
7. Which nursing theorist stated that clients are open systems in constant interaction with
their environment?
A) Florence Nightingale
B) Virginia Henderson
C) Imogene King
D) Dorothea Orem
Ans: C
Feedback:
Imogene King stated that clients are open systems in constant interaction with their
environment. Florence Nightingale described the role of the nurse as putting “the patient
in the best condition for nature to act upon him.” Virginia Henderson envisioned the
nurse's role as helping people (sick or well) to carry out activities contributing to health,
recovery, or a peaceful death that they would do for themselves if they had the
necessary strength, will, or knowledge. Dorothea Orem was a proponent of the self-care
deficit theory.
8. Veterans' hospitals are an example of which type of ownership?
A) For-profit
B) Government-owned
C) Proprietary
D) Nonprofit
Ans: B
Feedback:
Veterans' hospitals are an example of government-owned healthcare institutions.
For-profit agencies (proprietary) are owned and operated by corporate groups with
investors and stockholders. Nonprofit institutions include universities and religious
organizations.
9. A religious organization is an example of this type of ownership?
A) Government-owned
B) Proprietary agency
C) Nonprofit agency
D) Public facility
Ans: C
Feedback:
Nonprofit institutions include universities and religious organizations. Veterans'
hospitals are an example of government-owned or public healthcare institutions, which
receive at least some tax support. For-profit agencies (proprietary) are owned and
operated by corporate groups with investors and stockholders.
Page 3
10. Which type of length of stay includes emergency department visits?
A) Long-term care
B) Acute care
C) Short stay
D) In-and-out care
Ans: D
Feedback:
An example of in-and-out care is an emergency department visit. Long-term care
provides care to residents for the remainder of their lives. Acute care occurs in hospitals
where clients stay more than 24 hours but less than 30 days. Short stay provides care to
clients who suffer from acute conditions or need treatments that entail less than 24 hours
of care and monitoring.
11. A student nurse asks the nursing instructor, “What will my role as a nurse encompass
after I graduate?” What is the best response by the nursing instructor?
A) “You will take care of clients who are ill in a hospital or long-term care facility.”
B) “You will care for individuals and families and play a role in health education,
illness prevention, and promotion.”
C) “You will care for a variety of clients of all ages when they are ill.”
D) “It will all depend on where you want to work when you graduate. Nurses do
different things in healthcare.”
Ans: B
Feedback:
Nursing is concerned with caring for individuals, families, or groups. Nurses not only
care for clients when they are ill but also play a significant role in health education,
illness prevention, and promotion. Nurses attend to client needs related to hygiene;
activity; diet; the environment; medical treatment; and physical, emotional, and spiritual
comfort. Answer A only identifies a small portion of nursing and does not recognize
health promotion, prevention, or education. Answer C and D are very narrow views of
nursing and doesn't answer the question that the student is asking.
Page 4
12. The LPN is caring for clients at the hospital's medical unit. What role does the
LPN/LVN have in the care of clients on this unit?
A) The LPN/LVN may provide care to clients who have a well-defined, common
problem.
B) The LPN/LVN may manage and coordinate the care of a group of clients.
C) The LPN/LVN has a high level of competency in assessment skills.
D) The LPN/LVN encourages clients and family members to develop self-care skills.
Ans: A
Feedback:
The LPN/LVN provides care to clients under the direction of a registered nurse (RN),
advanced practice nurse (APRN), or physician in a structured healthcare setting.
LPN/LVNs care for clients with well-defined, common problems that often require a
high level of technical competency and expertise. The other answers are all roles that an
RN would have.
13. An LPN says to an RN, “I don't understand why I get paid less, yet we do the same
thing here at work.” What role does the RN have in the healthcare setting that the LPN
does not?
A) The RN only cares for clients with well-defined, common problems.
B) The RN's role is more complex and involves management and coordination of all
the care provided to a group of clients.
C) The RN is responsible for everything that the LPN does in the healthcare setting.
D) The RN is the only provider that cares for clients with common problems that
require a high level of technical competency and expertise.
Ans: B
Feedback:
The RN's role is more complex, involving the management and coordination of all the
care provided to a group of clients. LPN/LVNs care for clients with well-defined,
common problems that often require a high level of technical competency and expertise.
LPNs are responsible for their own actions and must work within their scope of practice.
Page 5
14. The charge nurse is making assignments for a group of clients on a medical unit. When
reviewing the acuity of the clients, the charge nurse assigns the RN to the clients with
higher acuity levels. Why would the charge nurse assign the RN to the patient's with a
higher acuity?
A) LPNs do not understand how to care for clients with complex disorders.
B) Assigning an LPN would allow them to provide care out of their scope of
practice.
C) Higher acuity clients request the services of an RN versus other care providers.
D) A higher acuity client requires a greater need for highly skilled care.
Ans: D
Feedback:
Generally, higher acuity requires a greater need for highly skilled care. Clients with
complicated or high-risk surgery, massive trauma, or critical illness will be cared for in
an acute care hospital, where a high level of professional, skilled, and technological care
is available. RNs are instrumental in caring for these clients. LPNs may understand how
to care for clients with complex disorders, but RNs are instrumental in the client care.
There are no guidelines about practicing for LPNs and the acuity of clients. Clients
generally do not request care by a specific provider.
15. A client who is receiving respiratory support with a tracheostomy and mechanical
ventilation after a stroke is being discharged from the acute care facility. Family
members state that they will not be able to care for the client at home to provide the care
that is required. What type of care may this client be a candidate for after discharge?
A) Long-term acute care
B) Subacute care
C) Intermediate care facility
D) Rehabilitation care
Ans: A
Feedback:
Clients who require ventilator support or who have other conditions that are potentially
unstable but do not have rapid changes may receive care in a long-term acute care
facility. Subacute care refers to care that is more intense than traditional long-term care
but less intense than acute inpatient care. Intermediate care facilities (ICFs) are nursing
homes that provide custodial care for people who cannot care for themselves because of
mental or physical disabilities. Rehabilitation centers provide physical and occupational
therapy to clients and families to help individuals regain as much independence with
ADLs as possible.
Page 6
16. A client is going to be in a subacute care unit for approximately 30 days. The client will
require frequent assessments and periodic review of the client's progress. What role will
the registered nurse have in the care of this client?
A) The RN will provide direct care for the client.
B) The RN will ensure that the client eats 100% of the meals.
C) The RN will order the various treatments for the client.
D) The RN will coordinate the client's care.
Ans: D
Feedback:
RNs coordinate clients' care, and LPN/LVNs provide and oversee care provided by
unlicensed assistive personnel (UAPs). The RN does not generally provide the direct
care, and this would include overseeing meals. It is beyond the scope of practice for
RNs to order treatments and medications.
17. An older adult client is being transferred to another facility in order to continue physical
therapy after having a total right hip replacement. What type of facility will provide
skilled nursing and rehabilitative care for this patient who will go home after the
rehabilitation?
A) Acute care facility
B) Long-term acute care
C) Skilled nursing care
D) Intermediate care facility
Ans: C
Feedback:
Skilled nursing care facilities provide skilled nursing and rehabilitative care to people
who have the potential to regain function but need skilled observation and nursing care
during an acute illness. Acute care facilities are for clients who have a higher level of
acuity. Long-term acute care are for clients who require long-term wound care of
ventilator support or who have other conditions that are potentially unstable but do not
have rapid changes. Intermediate care facilities provide custodial care for people who
cannot care for themselves because of mental or physical disabilities.
Page 7
18. An LPN just received her license to practice and applied for a position at a skilled
nursing care facility. While being interviewed, the LPN asks what her role will be at the
facility. What is the best answer by the interviewer?
A) “You will be organizing and coordinating the care of the clients.”
B) “You will be participating in the care of the clients.”
C) “You will be in charge of a unit and have 24-hour accountability.”
D) “You will be responsible for developing and implementing a plan of care for the
clients.”
Ans: B
Feedback:
An RN must be in charge of client's care, although other healthcare providers,
particularly LPN/LVNs, participate in their care. The other answers are all under the
scope of practice of an RN.
19. A client who has mental disabilities has recently lost his remaining parent and is unable
to care for himself at home. What facility would best meet the needs of this client?
A) Acute care facility
B) Rehabilitation care
C) Intermediate care facility
D) Ambulatory care
Ans: C
Feedback:
Intermediate care facilities (ICFs) are nursing homes that provide custodial care for
people who cannot care for themselves because of mental or physical disabilities.
Clients must meet specific criteria related to an inability to meet their own activities of
daily living (ADL). Rehabilitation centers provide physical and occupational therapy to
clients and families to help individuals regain as much independence with ADLs as
possible. Acute care facilities care for clients with a higher acuity level. Ambulatory
care is also referred to as outpatient care and is a short stay.
Page 8
20. A client experienced a stroke approximately 2 weeks previously and has residual left
side hemiparesis. What facility would best meet the needs of this client in order to help
regain independence with activities of daily living?
A) Rehabilitation care
B) Hospice care
C) Ambulatory care
D) Acute care
Ans: A
Feedback:
Rehabilitation care provides physical and occupational therapy to clients and families to
help individuals regain as much independence with ADLs as possible. Hospices provide
care for clients diagnosed with a terminal illness whose life expectancy is fewer than 6
months. Ambulatory care is also a short-term outpatient care. Acute care facilities are
facilities that provide care to clients of higher acuity.
21. A client has end-stage chronic obstructive pulmonary disease (COPD) and is terminally
ill. The family wants the client to spend her last days in a facility that will be able to
keep the patient comfortable and control her severe dyspnea. What facility will meet the
needs of the client and family?
A) Rehabilitation care
B) Hospice care
C) Intermediate care facilities
D) Ambulatory care
Ans: B
Feedback:
Hospice provides care for clients diagnosed with a terminal illness whose life
expectancy is fewer than 6 months. Hospices allow terminally ill clients to live as fully
as possible while managing pain, discomfort, and other symptoms. Rehabilitation
centers provide physical and occupational therapy to clients and families to help
individuals regain as much independence with ADLs as possible. Intermediate care
facilities (ICFs) are nursing homes that provide custodial care for people who cannot
care for themselves because of mental or physical disabilities. Ambulatory care is also
outpatient care.
Page 9
22. Home health nurses will be caring for a debilitated client in the home. The client will be
discharged from an acute care facility to the care of family members. The client will
require twice daily wound care for a large sacral decubitus ulcer. What will be the goal
of the home health nurses in the care of this client?
A) To have the client admitted to a long-term care facility if the ulcer does not heal in
a timely manner
B) To have client come to the home care agency twice daily for dressing changes
C) To continue to see the patient twice daily for dressing changes until the wound
heals
D) To encourage family members to develop self-care skills and perform dressing
changes
Ans: D
Feedback:
The RN encourages clients and family members to develop self-care skills, with support
from community resources. The home health nurse's goal is to allow the client to be
cared for in their home and not in a long-term care facility if that is not what the client
wishes. The client's condition does not enable self-care. The goal for the family will be
to perform dressing changes and the nurse will continue to monitor the condition of the
wound.
23. A client is living in congregate housing and informs the LPN at the clinic that they do
not like living there. When the nurse asks why they are unhappy with current living
arrangements, the client states, “It is a nice place but I am unable to do anything because
I hardly have money for my medicines or food.” What is an issue related to congregate
housing?
A) Residents may find that congregate housing is unaffordable.
B) Residents may not have any other resources to purchase extra services or goods.
C) Residents are not assured of appropriate housing and may be evicted at any time.
D) Residents must be financially able to participate in outside activities.
Ans: B
Feedback:
Congregate housing is affordable, but residents may not have any other resources to
purchase extra services or goods. They are assured of appropriate housing but may lack
the resources, ability, or opportunity to participate in outside activities.
Page 10
24. A client who is mentally disabled is working at an adult activity center. The client is
unable to live independently, and the family member they are living with can no longer
assist with supervised care. What option for living arrangements would be ideal for this
person?
A) Congregate housing
B) Boarding home
C) Long-term acute care facility
D) Acute care facility
Ans: B
Feedback:
Boarding homes usually are small homes with individual rooms where residents pay for
room and board and minimal nursing services. Residents often share rooms, have a
common dining area for all meals, and also oversee employment for disabled adults and
provide a stable environment for those who cannot live independently. Congregate
housing provides independent living for seniors or disabled adults who need minimal to
no assistance. Long-term care facilities are for clients who require long-term wound
care or ventilator support or who have other conditions that are potentially unstable but
do not have rapid changes. Acute care facilities are for those clients who are of high
illness acuity.
25. A client is unable to care for her needs and requires assistance with activities of daily
living. The son calls the clinic and informs the LPN that he wants his mother to be able
to remain in her home but must work and is unable to care for her 24 hours per day.
What options can the LPN suggest for the care of his mother?
A) Employ private duty nurses to care for the parent.
B) He must admit his mother to a nursing home.
C) He will have to quit his job and stay home to care for her.
D) Take her to an adult day care center.
Ans: A
Feedback:
A modern version of the case method is private duty nurse where care is provided in the
home and many household duties are performed as well. The son does not have to admit
his parent to the nursing home if he chooses not to, and he will not have to quit his job if
he can have a nurse come into the home. Adult day care would not assist with after-hour
care.
Page 11
26. The LPN has been assigned to a medical floor and to do all of the dressing changes and
other treatments. The RN will make the rounds with the physicians, transcribe orders,
and administer all of the IV medications. Another LPN will administer medications.
What type of nursing is this group providing?
A) Team nursing
B) Total care
C) Functional nursing
D) Primary nursing
Ans: C
Feedback:
Functional nursing is a task-oriented method, and distinct duties are assigned to specific
personnel. Total care refers to assignments in which a nurse assumes all the care for a
small group of clients. In team nursing, teams made up of an RN team leader, other
RNs, LPN/LVNs, and nursing assistants provide care to a group of clients. Primary
nursing is when the RN assumes 24-hour accountability for the client's care and has
total responsibility for the nursing care of assigned clients during his or her shift.
27. The LPN is part of a group of nurses that has an RN team leader as well as another LPN
and two nursing assistants who will be providing care to a group of clients. What type of
nursing method is this considered?
A) Functional nursing
B) Total care
C) Case method
D) Team nursing
Ans: D
Feedback:
Team nursing is composed of an RN team leader, other RNs, LPN/LVNs, and nursing
assistants who provide care to a group of clients. Functional nursing is a task-oriented
method where everyone in the group is assigned to specific tasks. Case method is the
same as private duty nursing. Total care refers to assignments in which a nurse assumes
all the care for a small group of clients.
Page 12
28. The RN is assuming all of the care for a small group of clients, and an LPN is assigned
to another group of clients with a lower acuity. What type of nursing is this considered?
A) Total care
B) Team nursing
C) Functional nursing
D) Primary nursing
Ans: A
Feedback:
Total care refers to assignments in which a nurse assumes all the care for a small group
of clients. Team nursing are teams made up of an RN team leader, other RNs,
LPN/LVNs, and nursing assistants, and they provide care to a group of clients.
Functional nursing is a task-oriented method of nursing. Primary nursing is when an RN
assumes 24-hour accountability for the client's care and has total responsibility for the
nursing care of assigned clients during his or her shift.
29. An RN has been assigned to care for three clients on the medical unit and will assume
24-hour accountability for those clients' care. When the nurse goes off duty, the plan of
care will be continued by a secondary nurse. What type of nursing model is this
considered?
A) Team nursing
B) Case method
C) Functional nursing
D) Primary nursing
Ans: D
Feedback:
In primary nursing, the RN assumes 24-hour accountability for the client's care and has
total responsibility for the nursing care of assigned clients during his or her shift. Team
nursing is made up of an RN team leader, other RNs, LPN/LVNs, and nursing assistants
who provide care to a group of clients. The case method is the same as a private duty
nurse. In functional nursing, distinct duties are assigned to specific personnel.
Page 13
30. The nurse manager of a telemetry unit is considering changing from a team model of
nursing to a primary nursing model. When considering this decision, what advantage
does the manager understand the primary nursing model brings to nursing care?
A) The RN will partner with one or more assistive personnel to care for a group of
clients.
B) Caregivers see to all their clients' needs, thus providing holistic and
comprehensive care.
C) Tasks are divided, and clients see several people during the shift.
D) The RN will be the team leader and direct the care that is provided by all of the
other personnel.
Ans: B
Feedback:
In primary nursing, an RN assumes 24-hour accountability for the client's care and has
total responsibility. An advantage is that the client has a caregiver who sees to all of his
or her needs and who provides holistic and comprehensive care. Option A refers to a
patient-care focused model. Option C refers to a total care model, and option D is a team
approach.
31. A hospital unit has been using a functional nursing model for delivery of care for
several years. The manager has been discussing with the staff the idea of a change to
total care because functional nursing has some disadvantages to the clients. What
disadvantage is the manager referring to?
A) It is expensive because it only uses RNs.
B) Some nurses work harder than others to provide care.
C) It fragments care and is confusing for the clients.
D) Nurses are accountable for the client's care 24 hours per day.
Ans: C
Feedback:
Although efficient, functional nursing fragments care and is confusing for clients.
Primary nursing is expensive because it uses RNs only. Nurses are designated certain
tasks if functional nursing is employed, so the care is divided. Nurses are accountable
for client care in a primary nursing model.
Page 14
32. A client is admitted to an acute care facility after having a stroke. The client will require
a variety of healthcare services throughout the hospital stay as well as coordination of
care prior to discharge. What referral would be a priority for overseeing the client's
care?
A) Case management
B) Physical therapy
C) Occupational therapy
D) Dietary services
Ans: A
Feedback:
The person responsible for overseeing the client's care, usually an RN with a bachelor's
or master's degree or another highly experienced health professional, is called the case
manager. Physical therapy, occupational therapy, and dietary services are all important
care disciplines but do not encompass all of the client's needs.
33. A client in an acute care facility is assigned a case manager to oversee and coordinate
care. What important function does a case manager have?
A) Provide early, thorough discharge planning.
B) Make sure the client is administered medications.
C) Provide care to the client who is terminally ill and has less than 6 months to live.
D) Make home visits to see that the patient is taken care of after discharge.
Ans: A
Feedback:
An important function of case managers is to provide early, thorough discharge
planning. The case manager is not responsible for the administration of medications.
Hospice care provides care to the client who is terminally ill. The case manager
oversees the care of the clients while they are hospitalized. Referrals to community
agencies and home healthcare will be made for home visits.
34. A client arrives at the physician's clinic in order to receive care for a cough and fever.
What type of healthcare institute classification is this client attending?
A) Short stay
B) Acute care
C) Long-term care
D) In-and-out care
Ans: D
Feedback:
Contact with the client is measured in minutes versus hours. Typical examples are office
visits, emergency department visits, and therapy sessions with in-and-out care. Short
stays provides care to clients who suffer from acute conditions or need treatments that
require fewer than 24 hours of care and monitoring. Long-term care provides care to
residents for the remainder of their lives. Acute care traditionally occurs in hospitals
where clients stay more than 24 hours.
Page 15
35. A client will be discharged from an acute care facility but will require home health
services to assess the need for assistive devices to aid in activities of daily living and
identify issues related to fine motor movements and muscle retraining after a stroke.
What referral will home health services make?
A) Physical therapy
B) Homemakers
C) Occupational therapy
D) Speech therapy
Ans: C
Feedback:
Occupational therapy will assess the need for assistive devices to aid in activities of
daily living and identify issues related to fine motor movements and muscle retraining.
Physical therapy will assess the client's mobility after orthopedic surgery, injury, or
stroke. Homemaker services will clean, do laundry, and shop for groceries. Speech
therapy will provide rehabilitation to clients with speech or swallowing disorders.
Page 16
1. Chapter 3
Which of the following is a true statement about critical thinking in nursing?
A) It involves purposeful, outcome-directed thinking.
B) It shows trends and patterns in client status.
C) It makes judgments based on conjecture.
D) It supplies validation for reimbursement.
Ans: A
Feedback:
In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical
thinking makes judgments based on evidence rather than conjecture. Providing a
foundation for evaluation and quality improvement and showing trends and patterns in
client status are functions served by documentation.
2. Which of the following is involved in the implementation step of the nursing process?
A) Selecting nursing interventions
B) Documenting nursing care and client responses
C) Documenting the plan of care
D) Identifying measurable outcomes
Ans: B
Feedback:
The implementation step in the nursing process involves documenting nursing care and
client responses. Planning involves selecting nursing interventions, documenting the
plan of care, and identifying measurable outcomes.
3. Which of the following is an important element of implementation?
A) Client database
B) Critical thinking
C) Nursing orders
D) Documentation
Ans: D
Feedback:
An important element of implementation is documentation. The client database includes
all the information obtained from the medical and nursing history. Physical examination
and diagnostic studies are not an important element of implementation. Critical thinking
is intentional, contemplative, and outcome-directed thinking. Developing good critical
thinking skills will make nurses more efficient and effective at resolving situations
necessitating multiple interventions. Nursing orders are specific nursing directions so
that all healthcare team members understand what to do for the client; therefore, they
are not an important element of implementation.
Page 1
4. Which of the following pieces of information is included in the client database?
A) Nursing care
B) Diagnostic studies
C) Plan of care
D) Collaborative problems
Ans: B
Feedback:
The client database includes all the information obtained from the medical and nursing
history, physical examination, and diagnostic studies. The client database does not
include nursing care, plan of care, or collaborative problems.
5. Which type of nursing diagnosis statement begins with the stem readiness for enhanced
and does not include related factors or supporting data?
A) Health promotion
B) Syndrome
C) Risk
D) Actual
Ans: A
Feedback:
Health promotion nursing diagnoses reflect clinical judgment of a client's motivation
and behavior to increase well-being and enhance health-seeking behaviors. Risk nursing
diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired
Skin Integrity related to inactivity. Actual nursing diagnoses identify existing problems.
Syndrome diagnoses describe specific diagnoses that occur as a group and are best
addressed as a group of collective interventions.
6. Which of the following is the highest level of human need according to Maslow (1968)?
A) Physiologic
B) Love and belonging
C) Esteem and self-esteem
D) Self-actualization
Ans: D
Feedback:
The highest level need is self-actualization. The first level of need is physiological
needs. Love and belonging are third-level needs. Esteem and self-esteem are
fourth-level needs.
Page 2
7. Which phase of the nursing process enables the nurse to compare the actual outcomes
with the expected outcomes?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Ans: D
Feedback:
Evaluation is assessment and review of the quality and suitability of the care given and
the client's responses to that care. Assessment is careful observation and evaluation of a
client's health status. Planning involves setting priorities, defining expected (desired)
outcomes (goals), determining specific nursing interventions, and recording the plan of
care. Implementation means carrying out the written plan of care; performing
interventions; monitoring the client's status; and assessing and reassessing the client
before, during, and after treatments.
8. Which of the following is a true statement about critical thinking according to
Alfaro-LeFevre (2010)?
A) It makes judgments based on conjecture.
B) It is based on the medical model.
C) It considers only the client's needs.
D) It is guided by professional standards and codes of ethics.
Ans: D
Feedback:
Critical thinking is guided by professional standards and codes of ethics. It is based on
principles of the nursing process and scientific methods. Critical thinking makes
judgments based on evidence rather than conjecture. It considers client, family, and
community needs.
9. Which type of nursing diagnosis has a goal to increase well-being and enhance specific
health behaviors?
A) Health promotion
B) Risk
C) Wellness
D) Actual
Ans: A
Feedback:
Health promotion nursing diagnoses look for ways to enhance health. Risk nursing
diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired
Skin Integrity related to inactivity. In wellness diagnoses, the diagnostic statement
begins with the stem readiness for enhanced and does not include related factors or
supporting data. Actual nursing diagnoses identify existing problems.
Page 3
10. Which of the following identify a diagnosis associated with a cluster of other diagnoses?
A) Risk nursing diagnoses
B) Actual nursing diagnoses
C) Syndrome diagnoses
D) Health promotion nursing diagnoses
Ans: C
Feedback:
Syndrome diagnoses identify a diagnosis associated with a cluster of other diagnoses,
such as Disuse Syndrome. Risk nursing diagnoses identify potential problems and use
the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity. Health
promotion nursing diagnoses reflect clinical judgment of a client's motivation and
behavior to increase well-being and enhance health-seeking behaviors. Actual nursing
diagnoses identify existing problems.
11. The LPN states to an RN, “I don't know why we have to follow a care plan. No one
even uses it, and it just means more paperwork. What's the purpose?” What is the best
response by the RN?
A) “I agree with you, and we should talk to the manager about eliminating them from
our required paperwork.”
B) “I think it is something we have always done, and we have to continue to use
them.”
C) “It helps to provide a systematic method for us to plan and implement care so that
we achieve positive outcomes.”
D) “Physicians use our care plans in order to see what we are doing for the clients.”
Ans: C
Feedback:
The purpose of the nursing process is to provide a systematic method for nurses to plan
and implement client care to achieve desired outcomes. “Without learning principles of
critical thinking and nursing process, it's like using a calculator without understanding
what is means to add, subtract, multiply, or divide” and is why the process should be
complete with the paperwork. The other two answers are vague and offer no explanation
for the importance of the process.
12. A client is admitted to the hospital for control of diabetes mellitus. When does the LPN
understand the nursing process begins?
A) When the client enters the healthcare system
B) Prior to the client being discharged
C) After the RN initiates the plan of care
D) When the physician writes the first order for care
Ans: A
Feedback:
The nursing process begins when a client enters the healthcare system. The other three
options are incorrect.
Page 4
13. The RN is obtaining a health history and performing a physical assessment for a client
who is admitted to the hospital with complaints of chest pain. What part of the nursing
process does the LPN understand the RN is performing?
A) Planning
B) Implementation
C) Evaluation
D) Assessment
Ans: D
Feedback:
Assessment is the careful observation and evaluation of a client's health status. The
nurse collects information to determine abnormal function and risk factors that
contribute to health problems as well as client strengths. Planning is establishing the
outcomes and actions that will help achieve the overall goals. Implementation is putting
the plan into action. Evaluation is determining the client's responses to the care
provided.
14. The RN develops an outcome standard of “client will ambulate with an assistive device
60 feet with assistance twice a day” for a patient who had a hip replacement. What part
of the nursing process is involved with this outcome statement?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Ans: B
Feedback:
Establishing the outcomes and actions will help the client achieve the overall goals of
care. Assessment is the careful observation and evaluation of a client's health status by
the collection of data. Implementation is putting the plan into action, and evaluation is
determining the client's responses to the care provided.
Page 5
15. A client has been admitted to the hospital with a large sacral pressure ulcer. The
physician orders the wound care protocol to be performed twice a day. What would be a
statement on the plan of care that would address the implementation phase of the
nursing process for this patient?
A) A 6 cm × 4 cm wound with malodorous, yellow exudate
B) The client's wound will heal by 1 cm by the end of 5 days.
C) The client's wound has healed by 0.5 cm on day 3 of wound care.
D) Turn the client every 2 hours.
Ans: D
Feedback:
Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal
and prevent another formation of a wound. Option A is the assessment phase of the
nursing process. Option B is the planning phase of the nursing process, and option C is
the evaluation phase of the nursing process.
16. The LPN plays a vital role in the development of a nursing diagnosis for a client. What
role does the LPN have?
A) Report information that suggests actual or potential health problems.
B) Examine and analyze the client database to formulate nursing diagnosis.
C) Inform the physician about the specific development of the nursing diagnosis.
D) Evaluate the effectiveness of the nursing diagnosis and how it pertains to the data
collected.
Ans: A
Feedback:
As in other phases of the nursing process, the nurse's role depends on his or her level of
practice. LPN/LVNs report information that suggests actual or potential health
problems. RNs examine and analyze the client database to formulate a nursing
diagnosis. The physician is generally not involved in the nursing process and care
planning of the client. The RNs role is to evaluate the effectiveness or resolving of the
nursing diagnosis.
Page 6
17. The RN is attempting to formulate a nursing diagnosis for a client but does not find
where the problem fits into a North American Nursing Diagnosis Association
(NANDA)–approved diagnosis. What is the best option for the nurse?
A) Gather other data so that it will fit into a NANDA approved diagnosis.
B) The nurse will have to forgo applying a nursing diagnosis.
C) Pick a NANDA-approved diagnosis as long as it somewhat fits.
D) Use his or her own terminology.
Ans: D
Feedback:
If a client's problem does not fit into any of the NANDA-approved diagnoses, the nurse
can use her or his own terminology. The nurse is not able to forgo, pick any diagnosis as
long as it comes close to fitting, or try gathering new data so that a diagnosis will be
chosen.
18. The nurse gathers data for a client who has dehydration and formulates a nursing
diagnosis of Fluid Volume Deficit related to diarrhea and vomiting as evidenced by
poor skin turgor, lethargy, and altered fluid and electrolyte balance. What type of
nursing diagnosis is identified with this client?
A) Risk nursing diagnosis
B) Syndrome diagnosis
C) Health promotion nursing diagnosis
D) Actual nursing diagnosis
Ans: D
Feedback:
Actual nursing diagnoses identify existing problems, such as Urinary Retention or
Anxiety. Health promotion nursing diagnoses reflect clinical judgment of a client's
motivation and behavior to increase well-being and enhance health-seeking behaviors.
Syndrome diagnoses describe diagnoses that occur as a group and are best addressed as
a group with collective interventions. Risk nursing diagnoses identify potential
problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to
inactivity.
Page 7
19. The nurse is developing a care plan for a client who has had a stroke and is unable to
assist with care at this time. Which problem would the nurse deem a top priority?
A) Risk for development of a pressure ulcer
B) Risk for Injury
C) Ineffective Breathing Pattern
D) Social Isolation
Ans: C
Feedback:
Nurses must rank any problem that poses a threat to physiologic functioning first. For
example, nursing diagnoses such as Ineffective Breathing Pattern and Deficient Fluid
Volume demand the nurse's attention more than other diagnoses because these situations
may be life threatening. The other diagnoses are second level and higher. This relates to
Maslow's hierarchy.
20. In order to establish specific and realistic outcomes so that the client does not become
frustrated in trying to achieve them, who should be involved in establishing these
outcomes?
A) The client and family
B) The physician
C) The certified nursing assistant (CNA)
D) Case management
Ans: A
Feedback:
The nurse includes the client and family in establishing outcomes. Outcomes are
specific and realistic, so the client can attain them and not become frustrated, and
measurable, so the nurse can reliably determine to what extent the client is meeting the
goals. The physician, CNA, and case management do not play a role in the development
of nursing outcomes.
21. The nurse is prioritizing the care of a client who has diagnoses of uncontrolled diabetes
and may have the left foot amputated related to a nonhealing ulcer. What need would
the nurse place at the lowest level while prioritizing this client's care?
A) Physiologic needs
B) Safety and security needs
C) Love and belonging needs
D) Self-actualization needs
Ans: D
Feedback:
Self-actualization needs are the fifth and last level. Physiologic needs are the first level,
safety and security needs are the second level, and love and belonging needs are the
third level.
Page 8
22. The nurse has developed a plan of care for a client who is having a surgical procedure
and is at risk for the development of pneumonia. The nurse devises the outcome
statement to read: “The client will have clear lungs by the third postoperative day.” On
the third postoperative day, the patient has left lower lobe crackles and infiltrates on the
chest x-ray. What conclusion does the nurse reach for this client?
A) The outcome is achieved, the problem is solved, and the nursing orders are
discontinued.
B) The outcome is not met, but progress is being made, and the plan of care is
continued or revised with minor change.
C) The outcome is not achieved, and the plan requires critical reevaluation and major
revision.
D) The outcome will be reassessed in 2 more days.
Ans: C
Feedback:
The client has not achieved the outcome and in fact has developed pneumonia. The plan
will require critical reevaluation, and new outcomes will be required to assist with
resolving the pneumonia. The other evaluation criteria are not correct for this particular
client's condition.
23. The nursing student says to the instructor, “I always hear about critical thinking and
how to develop it. How will this benefit me as a nurse?” What is the best response by
the instructor?
A) “If you have critical thinking skills, you won't make mistakes.”
B) “You will never make it through nursing school without those skills.”
C) “Without good critical thinking skills, you won't be able to make a decision.”
D) “Acquiring critical thinking skills will help you become more efficient and
effective at resolving problems.”
Ans: D
Feedback:
Developing good critical thinking skills will make nurses more efficient and effective at
resolving problems. This careful, deliberate, outcome-directed thinking has predictable
features that nurses can practice and learn. Having critical thinking skills does not mean
that mistakes won't be made but can be learned from. Options B and C are
nontherapeutic responses to the student.
Page 9
24. The nurse is developing a concept care map for a client with multiple medical problems.
What would the nurse take as the first step in developing and using a concept care map?
A) Assessment
B) Assessment/Diagnosis
C) Diagnosis/Planning
D) Planning/Implementation
Ans: A
Feedback:
The first step in developing and using a concept care map involves identifying the
primary reasons for a client's admission to a health care facility. The second step is the
assessment/diagnosis, the third step is diagnosis/planning, and the fourth step is
planning/implementation.
25. The student nurse is developing a concept care map for her client with multiple
sclerosis. In what phase does the student determine the relationship among the nursing
diagnoses and begin to see the client holistically?
A) Assessment
B) Assessment/diagnosis
C) Diagnosis/Planning
D) Planning/Implementation
Ans: C
Feedback:
In diagnosis/planning, the nurse determines relationships among nursing diagnoses. It
provides a means to “see” the client holistically. Assessment is the beginning phase
where the nurse begins collecting the data. In assessment/diagnosis, the diagnoses are
being formed and the relationships are not clear at this point. Planning/implementation
cannot begin until the relationship is formed.
26. The nurse understands that one of the characteristics of critical thinking is flexibility.
What can the nurse do to achieve this characteristic?
A) Listen to new ideas and other viewpoints.
B) Modify priorities and adapt to change.
C) Accept that answers may not come easily.
D) Foresee probable outcomes.
Ans: B
Feedback:
In order to demonstrate flexibility, the nurse must be able to modify previous priorities
as well as adapt to change. Listening to new ideas and other viewpoints is an example of
being open minded. Accepting that answers may not come easily is an example of
perseverance, and being able to foresee probable outcomes is an example of the ability
to weigh advantages and disadvantages before making decisions.
Page 10
27. A new graduate nurse is assigned six clients to care for on a medical unit. Without
asking anyone for help, by the end of the shift, the nurse is visibly upset and states, “I
can't do this anymore.” What characteristic of critical thinking has this nurse not
developed?
A) Show confidence
B) Aware of their own limitations
C) Humble
D) Willing to persevere
Ans: B
Feedback:
The new graduate has not developed the awareness of limitation and does not know
when to ask for help. Showing confidence is being aware of their strengths and
capabilities. Being humble is not having to know everything all of the time.
Perseverance is accepting that answers may not come easily.
28. The LPN is assisting with the admission of a client scheduled for surgery the next day.
What role does the LPN have in the planning phase of the nursing process?
A) Gathers more extensive biopsychosocial data
B) Draws conclusions, uses judgment, and makes diagnosis
C) Establishes priorities, sets short- and long-term goals
D) Contributes to the development of care plans
Ans: D
Feedback:
The role of the LPN allows for the contribution of the development of care plans. The
other answers are within the scope of practice of an RN.
29. The RN has developed the plan of care for a client and shares the plan with the LPN.
What can the LPN provide in the implementation phase for this client? Select all that
apply.
A) Basic therapeutic and preventive nursing measures
B) Manages client care such as delegation
C) Provides client and family teaching
D) Records and exchanges information with healthcare team
Ans: A, C
Feedback:
The role of the LPN in the implementation phase is to provide basic therapeutic and
preventive nursing measures, provide client education, and record information. The
other answers are within the scope of practice of an RN.
Page 11
30. A client has a nursing diagnosis of Risk for Impaired Skin Integrity related to prescribed
bed rest and decreased sensation and mobility of the lower extremities. What type of
nursing diagnosis is this classified as?
A) Actual diagnosis
B) Health promotion diagnosis
C) Risk diagnosis
D) Syndrome diagnosis
Ans: C
Feedback:
The client does not have an actual problem but is at risk for the development of
impaired skin integrity due to the bed rest. The client does not have a syndrome nor is
this a promotion of health.
31. The LPN is collecting data so that the RN may develop the plan of care for the client.
What is the importance of accurate gathering of baseline data?
A) The physician will be able to make a diagnosis.
B) A comparison for future signs and symptoms
C) The RN will be able to make the assignments based on the baseline data.
D) The RN will know what type of medication the client will receive.
Ans: B
Feedback:
The client database includes all the information obtained from the medical and nursing
history, physical examination, and diagnostic studies. Baseline data serve as a
comparison for future signs and symptoms and provide a reference for determining if a
client's health is improving. The physician does not use the care plan for his diagnosis.
32. A client being cared for by the healthcare team has a large open abdominal wound after
having a surgical procedure. The wound had to be reopened due to the development of
infection and is left to heal with packing and dressing changes twice daily. What would
be an appropriate measurable short-term outcome for this client?
A) The wound will heal before the client is discharged.
B) The client will change his own dressing twice a day.
C) The client will have no fever and no purulent discharge in 3 days.
D) Dressing changes will be done twice a day using aseptic technique.
Ans: C
Feedback:
The client having no fever or purulent discharge in 3 days is a realistic measurable goal.
The wound is large and will not heal within the time frame of discharge. It is unrealistic
to have an outcome that the client will be able to change his own dressing after a
surgical procedure. Dressing changes twice a day is a nursing intervention.
Page 12
33. The RN determines the interventions for a client with pneumonia and writes them in the
written plan as nursing orders. What would be an appropriate nursing order for this
client?
A) Force fluids.
B) Offer the client 100 mL of fluid every hour while awake.
C) Offer fluids prn.
D) Give adequate amounts of fluid throughout the day.
Ans: B
Feedback:
Nursing orders are specific nursing directions so that all healthcare team members
understand exactly what to do for the client. Different people are likely to interpret a
vague nursing order such as “Encourage fluids” differently, resulting in inconsistent
care. The other answers are not specific and are open to different interpretations.
Forcing a patient to do anything is not therapeutic or ethical for nurses.
34. A client is being admitted to the medical floor, and the RN is too busy to do the full
assessment. The RN delegates the LPN to care for the patient until the RN can see the
patient. What function is within the scope of practice for the LPN?
A) The LPN can gather the data.
B) The LPN can draw conclusions and use judgment to make a diagnosis.
C) The LPN can establish priorities.
D) The LPN can manage the client's care.
Ans: A
Feedback:
The role of the LPN in the nursing process for assessment is to gather data, perform
assessment, and identify the client's strengths. The other answers are within the RN
scope of practice.
35. The nurse has developed a nursing diagnosis of Risk for Complications (RC) of
Thrombophlebitis for a client. This is a problem that will be monitored and managed by
the nurse using physician-prescribed and nursing-prescribed interventions. What type of
nursing problem is this considered?
A) Syndrome diagnosis
B) Collaborative problem
C) Actual diagnosis
D) Risk diagnosis
Ans: B
Feedback:
A collaborative problem is monitored and managed by the nurse using
physician-prescribed and nursing-prescribed interventions. This client does not have a
syndrome or an actual problem with thrombophlebitis. The difference between the risk
diagnosis and the collaborative is the medical diagnosis that is in the diagnostic
statement.
Page 13
Page 14
1. Chapter 4
Which of the following should the nurse use during an admission interview?
A) Give the client suggestions for the answers and avoid making eye contact during
the interview.
B) Allow the client ample time to answer each question and maintain eye contact.
C) Set a time limit to answer each question and proceed to the next question if the
client fails to do so.
D) Provide the client with a self-help guide to look for answers and maintain eye
contact occasionally.
Ans: B
Feedback:
The nurse should give the client ample time to answer each question and maintain eye
contact to facilitate the interview. Giving the client suggestions for answers and
avoiding eye contact during the interview might make the client uncomfortable. Giving
the client a time limit to answer each question and proceeding to the next question if the
client fails to do so might make the client anxious. Giving the client a self-help guide
may hinder interaction between the nurse and the client.
2. Which of the following is important to do at the end of an interview with the client?
A) Call the client's family members to give them information.
B) Call the physician to discuss findings and establish a plan of care.
C) Conduct a physical examination immediately after the interview.
D) Summarize the information and thank the client for cooperating.
Ans: D
Feedback:
A nurse should end an interview with the client by summarizing what occurred and
thanking the client for cooperating. The nurse should not discuss the information
obtained through the interview with the client's family. It may not be necessary to call
the doctor for further consultation or to conduct a physical examination immediately
after the interview.
3. Which portion of the interview determines how well the client can perform activities of
daily living (ADLs)?
A) Cultural history
B) Functional assessment
C) Chief complaint
D) Psychosocial history
Ans: B
Feedback:
A functional assessment determines how well the client can perform ADLs. The
psychosocial history and cultural history include the client's age, occupation, religious
affiliation, cultural background, and health beliefs. The chief complaint is the current
reason the client is seeking care.
Page 1
4. When asking questions about the client's marital status, the nurse is gathering
information about which of the following?
A) Present illness
B) Functional assessment
C) Chief complaint
D) Psychosocial history
Ans: D
Feedback:
The psychosocial history and cultural history include the client's age, occupation,
religious affiliation, cultural background, health beliefs, marital status, and home and
working environments. When gathering information about the history of the present
illness, the nurse asks the client to describe all present problems, including the onset,
frequency, and duration of symptoms. A functional assessment determines how well the
client can perform activities of daily living. The chief complaint is the current reason the
client is seeking care.
5. Which assessment technique involves a systematic observation of the client?
A) Auscultation
B) Inspection
C) Palpation
D) Percussion
Ans: B
Feedback:
Inspection is the systematic and thorough observation of the client and specific areas of
the body. Auscultation involves listening with a stethoscope for normal and abnormal
sounds generated by organs and structures such as the heart, lungs, and intestines.
Palpation is assessing the characteristics of an organ or body part by touching and
feeling it with the hands or fingertips. Percussion is tapping a portion of the body to
determine whether there is tenderness or to elicit sounds that vary according to the
density of underlying structures.
6. Which of the following are statements the client makes about how he or she feels?
A) Objective data
B) Cultural data
C) Cognitive data
D) Subjective data
Ans: D
Feedback:
Subjective data are statements the client makes about what he or she feels. Objective
data are facts obtained through observation, physical examination, and diagnostic
testing. Cultural data include cultural background and health beliefs.
Page 2
7. The nurse is completing a physical examination on a client complaining of abdominal
pain. Which of the following are facts obtained during the physical examination?
A) Symptoms
B) Objective data
C) Subjective data
D) Complaints
Ans: B
Feedback:
Objective data are facts obtained through observation, physical examination, and
diagnostic testing. Feelings related to subjective data are symptoms. Subjective data are
statements the client makes about what he or she feels. Complaints are reasons the client
is seeking care.
8. Questions about current and past use of prescription medications would probably be part
of which of the following?
A) The client's past health history
B) The client's history of present illness
C) The client's chief complaint
D) The functional assessment
Ans: A
Feedback:
The client's past health history includes identifying childhood diseases and prior
hospitalizations. History of present illness is gathered when the nurse asks the client to
describe all present problems, including the onset, frequency, and duration of
symptoms. A chief complaint is the current reason the client is seeking care. A
functional assessment determines how well the client can perform activities of daily
living.
9. The nurse identifies jaundice in an assigned client. Which assessment technique is the
nurse using?
A) Inspection
B) Palpation
C) Auscultation
D) Percussion
Ans: A
Feedback:
Inspection is the systematic and thorough observation of the client and specific areas of
the body. Palpation is assessing the characteristics of an organ or body part by touching
and feeling it with the hands or fingertips. Auscultation involves listening with a
stethoscope for normal and abnormal sounds generated by organs and structures such as
the heart, lungs, and intestines. Percussion is tapping a portion of the body to determine
whether there is tenderness or to elicit sounds that vary according to the density of
underlying structures.
Page 3
10. The nurse is preparing to interview a client. Which of the following is a variable
involved in determining the length of the interview?
A) Financial status
B) Mental state
C) Social status
D) Relationships
Ans: B
Feedback:
The length of the interview depends on variables such as the severity of the client's
condition, level of discomfort, ability to cooperate, age, and mental state. Financial
status, social status, and relationships are not variables involved in determining the
length of the interview.
11. The nurse is admitting a client to the medical unit with a diagnosis of chronic
obstructive pulmonary disease (COPD). When should the nurse perform the assessment
of the client?
A) When the client is admitted to the healthcare system
B) Prior to the client receiving the first dose of medication
C) After the physician has made their first visit to examine the client
D) Within 24 hours of the initial admission interview
Ans: A
Feedback:
The nurse first assesses the client when he or she is admitted to the healthcare system.
The other answers will delay the assessment and can delay appropriate care and
treatment.
12. The nurse provides a comprehensive initial assessment on a newly admitted client. What
is the benefit to establishing this database from the client?
A) It will help determine what unit the patient needs to be admitted to.
B) It will inform the healthcare team about what medications are best for the client.
C) It will give the healthcare team all of the information about the client.
D) It will be a yardstick for measuring effectiveness of care.
Ans: D
Feedback:
Findings from this comprehensive initial assessment establish a database that gives all
team members relevant client information and become a yardstick for measuring
effectiveness of care. The physician will make the determination about what unit the
patient will require according to the acuity of care. The physician will determine what
medications are best for the client. The information obtained will not be conclusive, and
further assessment of the client's condition and information will be obtained during the
hospital stay.
Page 4
13. The client is being interviewed by the nurse and is asked what symptoms they have had
to bring them to the clinic. Which of the following data collected is considered
subjective?
A) Blood pressure of 110/60 mm Hg
B) Client states, “My chest feels tight.”
C) Bowel sounds present in 4 quadrants
D) Client's skin is warm and dry.
Ans: B
Feedback:
Subjective data are statements the client makes about what he or she feels. The other
data are objective because they are facts that are obtained through observation.
14. The client arrives at the clinic and informs the nurse that he is “coughing, having a sore
throat, and have been running a fever for 2 days.” What are these feelings of discomfort
called?
A) Signs
B) Objective data
C) Symptoms
D) Clinical signs
Ans: C
Feedback:
When the client tells the nurse about nausea, pain, fear, bloating, or other feelings of
discomfort, he or she is providing subjective data. These feelings of discomfort are
classed as symptoms. Signs are objective data that is abnormal, and objective data is
what the nurses obtain through observation, physical examination, and diagnostic
testing. Clinical signs are the same as signs.
15. The nurse is caring for a patient who has been admitted to the hospital with abdominal
pain and is suspected to have appendicitis. What data obtained is considered objective
data?
A) Bowel sounds hypoactive in the right lower quadrant
B) Complaints of pain when right lower quadrant palpated
C) Client states that the pain began 3 hours ago.
D) Client states they are nauseated.
Ans: A
Feedback:
Objective data are facts obtained through observation, physical examination, and
diagnostic testing. When the nurse assesses blood pressure or heart rate or examines
results from urinalysis, he or she obtains objective data. The other answers are examples
of subjective data.
Page 5
16. The nurse is assessing a patient and determines that the vital signs are not within normal
range for the patient. With the results of the objective data being abnormal, what does
the nurse document these findings as?
A) Symptoms
B) Subjective data
C) Physical assessment
D) Signs
Ans: D
Feedback:
When objective data are abnormal, they are called signs. Symptoms refer to feelings of
discomfort felt by the client. Subjective data is what the client states to the nurse.
Physical assessment is a general term used regarding the assessment of the patient.
17. A client is arriving at the clinic for the first time. The nurse provides an introduction and
establishes an initial rapport with the client. What phase of the interview process is this?
A) Introductory phase
B) Working phase
C) Summary phase
D) Closing phase
Ans: A
Feedback:
The introductory phase establishes initial rapport with the client and family members
and informs the client about the nurse's need to ask questions and gather information.
When making introductions, the nurse should address the client by his or her surname.
The working phase is the second part of the process, and the summary and closing phase
is the last.
18. The nurse is conducting an interview with a client at the hospital. The client has a
roommate in the room. Where would the optimal place for this interview to take place?
A) In the waiting area
B) In the client's room
C) In a private treatment room
D) At the nurse's station
Ans: C
Feedback:
A private setting for the interview is essential to eliminate interruptions and maintain the
client's confidentiality. The nurse should explain that information obtained during the
interview helps with planning care. He or she should tell the client that all information is
kept confidential, although all members of the healthcare team share the data. The other
responses are not private, and information may be overheard.
Page 6
19. A client is being seen at the clinic for the first time, and the nurse asks the client about
what brought them to the clinic today as well as the past medical history. What part of
the interview process does this represent?
A) Introductory phase
B) Working phase
C) Summary phase
D) Closing phase
Ans: B
Feedback:
During the working phase, the nurse asks the client questions to gather data for the
client database. The introductory phase involves the beginning introductions as well as
establishing rapport. The summary or closing phase is at the end of the interview.
20. A client will be admitted to the hospital to have a surgical procedure in the morning.
The nurse is aware that the client is hearing impaired and is planning the care as well as
how to communicate with the client. What solution for communication could the nurse
use?
A) Use a whiteboard or paper and pencil so that the client will clearly understand
what is being asked.
B) See if the client can lip-read so communication will be clear.
C) Tell the client he must bring an interpreter with him to the hospital to stay.
D) Speak in a loud voice so that the client may hear some of what is said.
Ans: A
Feedback:
Using the whiteboard or paper and pencil will allow a clear communication between the
nurse and the client without room for misinterpretation of questions. Lipreading is not
always convenient if the client or nurse is facing away from one another and can be
misinterpreted. The client is under no obligation to have an interpreter with them at all
times. Speaking loudly can be a HIPAA violation and is not an effective means of
communication.
Page 7
21. The nurse is having difficulty with the working phase of the interview process with a
client who is not maintaining eye contact or responding openly to questions that are
being asked. What question can the nurse ask that could require more discussion?
A) “Are you married?”
B) “Can you tell me more about what brought you to the hospital?”
C) “How many children do you have?”
D) “Do you work outside of the home?”
Ans: B
Feedback:
Questions are best phrased as open-ended questions that require discussion. “Can you
tell me more about what brought you to the hospital?” requires more than just a yes or
no answer. The other answers are closed-ended questions and only require a yes or no
response.
22. The nurse has received a client in the emergency department that is very short of breath.
The nurse only wants to ask closed questions to decrease the workload on the client.
What would be an example of a question for the nurse to ask?
A) “Can you tell me about the precipitating factors that lead you to come to the
hospital?”
B) “What did you do when the shortness of breath began?”
C) “Do you use oxygen at home?”
D) “Can you give me a history of previous medical problems?”
Ans: C
Feedback:
“Do you use oxygen at home?” is a closed-ended question that only requires a yes or no
answer. The other questions require more than a yes or no response.
23. The client comes to the clinic and says to the nurse, “I am coming in today to see the
doctor because I started having diarrhea 2 days ago and am going six to eight times per
day.” How would the nurse document this statement?
A) Concern: Client is afraid he is going to be dehydrated from the amount of diarrhea
he is having.
B) Problem: Client is having diarrhea at least six to eight times per day.
C) The client is having diarrhea and wants to see the physician.
D) Chief complaint: “Diarrhea began 2 days ago and having six to eight stools per
day.”
Ans: D
Feedback:
The chief complaint is the current reason the client is seeking care. “Concern” is not a
relevant response and is not what the client stated. “The client is having diarrhea and
wants to see the physician” is vague and does not give enough information. “Problem:
Client is having diarrhea” is not appropriate, not informative documentation.
Page 8
24. The nurse at the clinic asks the client about what brought him in to see the physician
today. What is the purpose of asking the client about his primary health concern?
A) To discover what the client perceives as the health problem that needs treatment
B) To triage the patient and determine if he really need to see the physician today
C) To determine if the insurance company will pay for the visit
D) To see if a prescription can be called in without having to see the physician
Ans: A
Feedback:
The purpose of asking the client about his or her primary health concern is to discover
what the client perceives as the health problem that needs treatment. Recording
information in the client's own words is best. The nurse cannot determine if the client
should see the physician today and if the client should not be denied treatment based on
the insurance companies willingness to pay. The client can opt to pay for the visit
themselves. Physicians do not generally give prescriptions any longer without seeing the
clients.
25. The nurse is interviewing a client whose chief complaint is abdominal pain. What
information requested by the nurse is part of a focus assessment?
A) “Have you had any problems with your breathing lately?”
B) “How long have you had this pain, and what does the pain feel like? Can you rate
the pain on a scale of 0 to 10?”
C) “Do you smoke? If so, how many packs per day do you smoke?”
D) “Have you had any swelling in your feet or ankles?
Ans: B
Feedback:
Asking for more detailed information about one body system or problem is called a
focus assessment because it adds depth to the original data. For example, a client may
reveal that he or she has experienced abdominal pain for the past several weeks. Further
questioning then addresses what causes the pain, how long it lasts, what the quality of
the pain is, and what makes it better or worse. The other answers relate to questions that
do not have anything to do with the patient's chief complaint.
Page 9
26. The nurse is performing a functional assessment for a client who has had a mild stroke
and will be discharged in 2 days from the hospital. What question would be important to
ask when conducting this assessment?
A) “Do you have enough money to pay for the medications that you will be taking at
home?”
B) “Do you have friends that will come and visit and take you out to socialize?”
C) “You have an appointment to see the physician in 1 week. How will you obtain
transportation to come to the office?”
D) “Do you understand that your medication can cause bleeding tendencies?”
Ans: C
Feedback:
A functional assessment determines how well the client can manage activities of daily
living (ADLs). ADLs include self-care activities, such as walking moderate distances,
bathing, and toileting, and instrumental activities, such as preparing meals, obtaining
transportation, and dialing the phone. This assessment component is particularly
important when assessing older adults or physically challenged clients of any age. The
other answers do not pertain to ADLs.
27. The nurse is interviewing a client who is being placed on medication for the treatment
of depression. What question would be essential for the nurse to ask the client to avoid
complications related to drug therapy?
A) “Are you presently taking an herbal preparation for the treatment of depression?”
B) “Do you have enough money or insurance coverage to pay for this medication?”
C) “How many times have you been treated for depression?”
D) “Will you be seeing a counselor or therapist?
Ans: A
Feedback:
The nurse identifies any current and past use of prescription and nonprescription drugs
or herbal products. He or she asks about the client's use of alcohol and tobacco because
these drugs can create or contribute to other health problems. If the client is using herbal
preparations for the treatment of depression, this can cause complications with the
medication that the physician is prescribing. The other questions do not relate to the past
or present prescription and nonprescription drug use.
Page 10
28. The nurse is ending an interview with a client who has been admitted to the hospital for
pneumonia. What statement made by the nurse would be an effective way to end the
interview?
A) “I appreciate your cooperation and understand that your symptoms have been
getting worse for 2 days.”
B) “I will refer any questions you have to the physician.”
C) “How long do you think you will be in the hospital for pneumonia?”
D) “Let me show you where your call bell, television controls, and bathroom are.”
Ans: A
Feedback:
An effective way of ending the interview is to summarize what occurred and thank the
client for cooperating. Referring questions to the physician without attempting to answer
any is not an effective means of communication and does not end the summary phase
adequately, and the client has not been thanked for cooperating. Option C is not a
summarization nor has the client been thanked. Option D relates to the orientation of the
client's room.
29. The nurse has closed the interview with the client and observes that the client appears to
have something else to say. What statement made by the nurse can provide an
opportunity for the client to express concerns and ask questions?
A) “Use your call bell if you need anything.”
B) “I don't know what else I could tell you, this about covers all of it.”
C) “Well that is all I have for you. Let me know if you need anything.”
D) “Do you have any questions or concerns that we have not discussed?”
Ans: D
Feedback:
Asking the client if he or she needs more information provides an opportunity for the
client to express concerns and ask questions. Option A does not allow the client to ask
questions and is not specific for questions or concerns. “I don't know what else I could
tell you” inhibits the client from asking the nurse anything further as well as “Well that
is all I have for you.”
Page 11
30. The RN is precepting an LPN who is new to the medical unit. The RN begins to assess a
newly admitted client to the unit and is demonstrating an assessment technique that is
used that assesses each body system separately. What type of assessment method is the
RN using?
A) Systems method
B) Head-to-toe method
C) Inspection
D) Focused assessment
Ans: A
Feedback:
The systems method approaches the examination by assessing each body system
separately. The head-to-toe method of assessment begins at the top of the body and
progresses downward. Sometimes, healthcare providers use parts of both methods.
Inspection is the systematic and thorough observation of the client and specific areas of
the body. A focused assessment concentrates on the area of the body that is the chief
complaint.
31. What type of assessment is the nurse performing when beginning the assessment at the
head and progressing down to the lower extremities?
A) Focused assessment
B) Head-to-toe assessment
C) Total body assessment
D) Systems method
Ans: B
Feedback:
A head-to-toe assessment begins at the top of the body and progresses downward. A
focused assessment focuses on a part of the body that is the primary site of problem
such as a respiratory assessment for a cough. The total body assessment has no direction
for an assessment and can be done in any order. A systems method approaches the
examination by assessing each body system separately.
Page 12
32. A client comes to the clinic for someone to “check a mole” that is changing color and
getting larger. The nurse asks the client to remove the shirt so that the mole may be
observed. What part of the assessment is this considered?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Ans: A
Feedback:
Inspection is the systematic and thorough observation of the client and specific areas of
the body. Palpation is assessing the characteristics of an organ or body part by touching
and feeling it with the hands or fingertips. Percussion is tapping a portion of the body to
determine if there is any tenderness or to elicit sounds that vary according to the density
of underlying structures. Auscultation means listening with a stethoscope for normal and
abnormal sounds.
33. The LPN observes the RN performing an assessment of the abdomen. The RN is lightly
touching the patient's abdomen and feeling it with the hands and fingertips. What
assessment techniques is the LPN aware that the RN is using?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Ans: B
Feedback:
Palpation is assessing the characteristics of an organ or body part by touching and
feeling it with the hands or fingertips. Inspection is the systematic and thorough
observation of the client and specific areas of the body. Percussion is a tapping of a
portion of the body to determine if there is tenderness or to elicit sounds that vary
according to the density of underlying structures. Auscultation means listening with a
stethoscope for normal and abnormal sounds.
Page 13
34. The LPN is transferring a medical client to the intensive care unit and is met by the RN.
The RN is listening with the stethoscope to determine how much fluid the client may
have in the lungs. What type of assessment technique is the RN performing?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Ans: D
Feedback:
Auscultation means listening with a stethoscope for normal and abnormal sounds
generated by organs and structures such as the heart, lungs, intestines, and major
arteries. Inspection is the visual observation of the client and specific structures.
Palpation is the touching of the patient with the fingertips or hands. Percussion is
tapping a portion of the body to determine if there is tenderness or to elicit sounds that
vary according to the density of underlying structures.
35. The nurse is caring for an older adult client who has recently been admitted and is
performing a physical assessment. What test can the nurse perform to obtain a baseline
cognitive function?
A) Mini-Cog
B) Neurovascular assessment
C) Cardiovascular assessment
D) Pupillary response
Ans: A
Feedback:
When performing a physical assessment for an older client, ascertain a baseline
cognitive function level at onset of interview. The Mini-Cog is a quick and simple
four-question method. The other answers are not specific assessment techniques in order
to assess cognitive function.
Page 14
1. Chapter 5
Which of the following is an example of statutory law?
A) Permission for care
B) Consent for minor client
C) Nurse practice act
D) Inferring consent
Ans: C
Feedback:
Statutory law is a law that any local, state, or federal legislative body enacts. An
example of statutory law is the nurse practice act in each state. Clients sign a general
permission for care and treatment on hospitalization. The parent or guardian should
provide consent if the client is a minor to protect healthcare workers from being charged
with battery. In an emergency, healthcare providers can infer consent.
2. Which of the following is a component of the nurse practice acts of various states?
A) Breaches of duty owed by one person to another
B) Determining the grounds for disciplinary action
C) Expected action based on moral or legal obligations
D) Injury due to the failure to act
Ans: B
Feedback:
Nurse practice acts define nursing practice and set standards for nurses in each state.
Each state has its own nurse practice act, but one of the common components is the
grounds for disciplinary action. Tort law is the body of law that governs breaches of
duty owed by one person to another. A duty is an expected action that is based on moral
or legal obligations. A tort is an injury that occurred because of another person's
intentional or unintentional actions or failure to act.
3. Which of the following is a measure taken to protect healthcare workers from being
charged with battery?
A) The client's signed release is obtained for presentations.
B) The nurse uses initials instead of names in written reports.
C) Clients sign a written consent before undergoing any kind of procedure.
D) The nurse draws bedside curtains while giving personal care.
Ans: C
Feedback:
To protect healthcare workers from being charged with battery, clients sign a general
permission for care and treatment at the time of hospitalization. They also sign a written
consent before undergoing special tests, procedures, or surgery. Obtaining a signed
release for recognizable photographs for publications, using initials or code numbers
instead of names in written reports or research papers, and drawing bedside curtains
when giving personal care are essential for protecting a client's privacy.
Page 1
4. Which of the following statements is applicable when a competent client wants to leave
a hospital or long-term care facility before being discharged by the physician?
A) Physical or chemical restraints are used to detain the client.
B) The nurse applies restraints based on a current medical order.
C) The nurse determines whether the client's safety or the safety of others is at risk.
D) The client signs a form releasing the healthcare facility from its responsibility.
Ans: D
Feedback:
A nurse should not detain a competent client who wants to leave a hospital or long-term
care facility before being discharged by the physician. If a client wants to leave the
facility against medical advice, the client should sign a form that releases the healthcare
facility from its responsibility. Mentally impaired, confused, or disoriented clients may
be restrained if their safety or the safety of others is at risk. This does not apply to a
competent client.
5. Which of the following statements regarding the statute of limitations is correct?
A) It is applicable only in the case of a minor.
B) There is no designated time for a person to file a lawsuit.
C) The designated time is typically calculated from the time the incident occurred.
D) It provides legal immunity to rescuers who provide first aid in the case of an
emergency.
Ans: C
Feedback:
A statute of limitations is the designated time for a person to file a lawsuit. The time is
typically calculated from the time the incident occurred. If the injured party is a minor,
the statute of limitations sometimes does not commence until the victim reaches
adulthood. Good Samaritan laws ensure legal immunity for rescuers who provide first
aid in the case of an emergency to accident victims.
6. Which of the following is stated in a living will?
A) Legal consent regarding healthcare
B) Designation of another person as healthcare proxy
C) Wishes regarding healthcare if terminally ill
D) Medical orders for end-of-life instructions
Ans: C
Feedback:
A living will is a document that states a client's wishes regarding healthcare if he or she
is terminally ill. It is not necessarily a legal consent. A client may designate another
person to be the medical durable power of attorney or healthcare proxy.
Do-not-resuscitate orders contain written medical orders for end-of-life instructions.
Page 2
7. Which of the following is a true statement with regard to laws?
A) They deal with right and wrong.
B) They are written rules for conduct and actions.
C) They consider beliefs about morals and values.
D) They do not have a formal enforcement system.
Ans: B
Feedback:
Laws are written rules for conduct and actions. Ethical standards dictate the rightness or
wrongness of human behavior. Ethics are moral principles and values. Laws do have a
formal enforcement system.
8. Which type of law concerns offenses that violate the public's welfare?
A) Statutory law
B) Common law
C) Administrative law
D) Criminal law
Ans: D
Feedback:
Criminal law concerns offenses that violate the public's welfare. Statutory law is law
that any local, state, or federal legislative body enacts. Common is based on earlier court
decisions, judgment, and decrees. Administrative law means that regulatory agencies
enforce the rules and regulations that concern health, welfare, and safety of federal and
state citizens.
9. Allowing unauthorized people to observe a client during treatment is an example of
which of the following?
A) False imprisonment
B) Invasion of privacy
C) Battery
D) Assault
Ans: B
Feedback:
The right to privacy means that people have the right to expect that they and their
property will be left alone. False imprisonment occurs when healthcare workers
physically or chemically restrain a person from leaving a healthcare institution. Battery
is actual physical contact with another person without that person's consent. Assault is
an act that involves a threat or attempt to do bodily harm.
Page 3
10. Which of the following is a true statement about a living will?
A) It states the client's wishes regarding healthcare if terminally ill.
B) It specifies information regarding nontreatment only.
C) It is legal consent.
D) It is a type of financial attainment.
Ans: A
Feedback:
A living will states the client's wishes regarding healthcare if terminally ill. It does not
specify information regarding nontreatment only, it is not a legal consent, and it is not a
type of financial attainment.
11. The nurse understands that laws and ethics are made in order to maintain order and
harmony within society. What is the difference between laws and ethics?
A) Laws are written rules for conduct and actions, and ethics are moral principles and
values that guide our behavior.
B) Laws are written to protect society from unsavory people, and ethics are rules for
appropriate behavior.
C) Laws are written to ensure appropriate behavior and ethics are to conduct actions.
D) Ethics determine how a client is to be treated, and laws are forms of punishment.
Ans: A
Feedback:
Laws are written rules for conduct and actions and ensure the protection of rights, and
ethics are moral principles and values that guide the behavior of honorable people.
Ethical standards dictate the rightness or wrongness of human behavior. The other
answers do not address this as clearly.
Page 4
12. The nursing student asks the instructor why it is important for them to know about the
law and ethics when they will be taking care of client's physical and psychosocial needs
and not be practicing law. What is the best response by the instructor?
A) “You will need to understand these things if you are ever sued.”
B) “This is part of the curriculum, so we have to cover this material.”
C) “You will probably never encounter any difficulty, but it is good to know just in
case it happens.”
D) “You will need to have a basic understanding of laws and ethics because it may
affect your practice.”
Ans: D
Feedback:
The healthcare delivery system affects and is affected by societal beliefs, values, and
laws. Nurses today require a basic understanding of laws and ethics that may affect their
practice. Issues related to competence, safety, and optimal care; protecting client's
rights; and practicing according to professional standards of care are of most concern to
nurses. Being sued is not the only issue that a nurse may face in her practice and does
not cover the ethical portion of practice. The answer regarding the curriculum does not
answer the question and demeans the importance of the topic.
13. The LPN has been fired from her job at the nursing home and reported to the state board
of nursing for giving medication to a client without a physician's order. The LPN states
that she was not aware that this was a violation of scope of practice. What is the LPN's
responsibility regarding knowing how to practice within their scope?
A) The nurse should call the state board and ask for a list of what she can and cannot
do.
B) The nurse should access her state nurse practice act to determine the set standard
for nurses in her state.
C) The nurse should ask an RN what their scope of practice is.
D) The nurse should ask another LPN what she can and cannot do.
Ans: B
Feedback:
Nurse practice acts define nursing practice and set standards for nurses in each state.
These legal statues regulate the practice of nursing to protect the health and safety of
citizens. Although each state has its own nurse practice act, they all share common
components. The LPN should have accessed this information directly from the board
website or asked for a written nurse practice act from the state of practice. The nurse
practice act does not designate what specific tasks the nurse can and cannot perform.
The LPN should not ask others who may not have the answers.
Page 5
14. The LPN is working in a perioperative setting, and formalin is being used in an
unvented room that could result in a health hazard to the other staff as well as client's.
The nurse is aware that the Occupational Safety and Health Administration (OSHA) is
an agency that will fine the hospital for this type of infraction. What type of law does
the LPN understand empowers OSHA to regulate for the health, welfare, and safety of
federal and state citizens?
A) Common law
B) Civil law
C) Criminal law
D) Administrative law
Ans: D
Feedback:
Statutory law empowers regulatory agencies to create and carry out the laws. These
federal and regulatory agencies practice administrative law, the rules and regulations
that concern the health, welfare, and safety of federal and state citizens. For example,
OSHA is the federal agency that develops the rules and regulations governing
workplace safety. Common law is based on earlier court decisions, judgments, and
decrees. Civil law applies to disputes that arise between individual citizens. Criminal
law concerns offenses that violate the public's welfare.
15. The nurse overhears a certified nursing assistant (CNA) tell an older adult client loudly,
“If you don't get in that bed, I will throw you in there and tie you down so that you don't
get up again!” What type of intentional tort does the nurse understand that the CNA has
committed?
A) Assault
B) Battery
C) False imprisonment
D) Invasion of privacy
Ans: A
Feedback:
Assault is an act that involves a threat or attempt to do bodily harm. Types of assault
include physical intimidation, verbal remarks, or gestures that lead the client to believe
that force or injury may be forthcoming. Battery is actual physical contact with another
person without that person's consent. False imprisonment occurs when healthcare
workers physically or chemically restrain an individual from leaving a healthcare
institution.
Page 6
16. The nurse is caring for an alert and oriented client in the hospital. The client is unhappy
with the care he is receiving and state he is leaving and don't care if he sees the
physician ever again. The nurse brings the client a sedative and tells the client that it is
for his blood pressure to prevent the client from leaving the facility. What type of
intentional tort is this nurse guilty of?
A) Assault
B) Battery
C) False imprisonment
D) Invasion of privacy
Ans: C
Feedback:
False imprisonment occurs when healthcare workers physically or chemically restrain
an individual from leaving a healthcare institution. A nurse cannot detain a competent
client who wishes to leave a hospital or long-term care facility before being discharged
by the physician. The client may sign an against medical advice form that releases the
hospital from liability. Assault is an act that involves a threat or attempt to do bodily
harm. Battery is actual physical contact with another person without that person's
consent. Invasion of privacy means the failure of the right to expect that the clients and
their property will be left alone.
17. The LPN was assisting a client with a bath, and some of the bathwater spilled on the
floor. The nurse assisted the client back to the bed and left the room, forgetting to clean
the spill. The client got out of the bed to use the bedside commode and slipped on the
water and fractured her hip. What type of unintentional tort may the client sue the nurse
for?
A) Battery
B) Negligence
C) Assault
D) False imprisonment
Ans: B
Feedback:
Negligence describes the failure to act as a reasonable person would have acted in a
similar situation. If harm results from the action, a person may sue that individual for
negligence. The nurse was negligent in not cleaning up the spill and caused the client
harm. Battery, assault, and false imprisonments are all intentional torts.
Page 7
18. The LPN has the responsibility to take the vital signs for a client who had a surgical
procedure earlier that day. The blood pressure results were 78/42 mm Hg from a
previous 132/74 mm Hg. The LPN documented the results without reporting them to the
RN in charge. The client developed shock and died 3 hours later. What type of
unintentional tort may the nurse be sued for?
A) Defamation
B) Battery
C) Assault
D) Malpractice
Ans: D
Feedback:
The law defines malpractice as professional negligence. It refers to harm that result from
a licensed person's actions or lack of action. A jury must determine if the responsible
person's conduct deviated from the standard expected of others with similar education
and experience. All other answers are intentional torts.
19. An LPN is at a community softball game observing the game when the person sitting
next to her, clutches his chest and falls to the ground. The nurse begins cardiopulmonary
resuscitation (CPR), and in the process, one of the ribs cracked. The client is taken by
rescue squad to the hospital and survives a heart attack. What may protect the nurse
from this outcome?
A) The state board of nursing
B) Statute of limitations
C) Good Samaritan law
D) Assumption of risk
Ans: C
Feedback:
Many states have enacted Good Samaritan laws, which provide legal immunity for
rescuers who provide first aid to accident victims in an emergency. The law defines an
emergency as one occurring outside a hospital, not in an emergency department. Statute
of limitations is the designated time in which a person can file a lawsuit. Assumption of
risk is if a client is forewarned of a potential hazard to his or her safety and chooses to
ignore the warning; the court may hold the client responsible. The state board of nursing
would not be involved unless the nurse was reported for negligent or care outside of the
scope of practice.
Page 8
20. The LPN administered a medication to a client complaining of pain. When checking the
armband and the medication administration record, there were no allergies listed. The
client then informs the nurse that he told the admitting nurse that he was allergic to that
medication. What documentation on the incident form would be the best option?
A) “Medication is administered to client by mouth; states he has an allergy to the
medication and causes hives.”
B) “The admitting nurse failed to document that the client has an allergy to the
medication.”
C) “The client states he is allergic to the medication, but I really don't think so. I
didn't see any hives.”
D) “I should have asked the RN if the client is allergic to any medication.”
Ans: A
Feedback:
Healthcare workers complete incident reports when they make or discover errors or
when an event occurs that results in harm. The first option is concise and to the point
without any accusation. In answer B, the LPN is accusing the admitting nurse of failure
to document. Answer C is using judgment and placing blame on the client. Answer D
places the blame on herself.
21. The nurse is preparing a client for a colonoscopy at the hospital. Who does the nurse
understand is responsible for obtaining the informed consent from this client?
A) The nurse
B) The physician
C) The anesthesiologist
D) The physician's office nurse
Ans: B
Feedback:
The physician obtains the informed consent and must inform the client of the
description of the procedure, potential benefits, material risk involved, acceptable
alternatives available, expected outcome, and consequences if the procedure is not done.
Because the physician has the responsibility, the other answers are incorrect.
Page 9
22. A client has designated her daughter as a person to make healthcare decisions for the
client if he is not able to do so. What type of advance directive is this considered?
A) Power of attorney
B) Do-not-resuscitate order (DNR)
C) Living will
D) Durable power of attorney (DPOA) for healthcare
Ans: D
Feedback:
A client may designate another person to be the DPOA for healthcare or healthcare
proxy. This person has the authority to make healthcare decisions for the client if he or
she is no longer competent or able to make these decisions. A general power of attorney
does not give that designated person the ability to make healthcare decision. In DNR
order, the client wishes to have no resuscitative action taken if he or she experiences a
cardiac or respiratory arrest. A living will is a document that states a client's wishes
regarding healthcare if he or she is terminally ill.
23. A client who has been diagnosed with terminal cancer states that he wants no further
treatment and also informs the physician that he does not want any resuscitative action
taken if he experiences a cardiac or respiratory arrest. What type of order does the nurse
anticipate the physician will write?
A) A do-not-resuscitate order
B) Intubation and mechanical ventilation only if respiratory arrest occurs
C) Emergency medications only
D) Do everything except resuscitate
Ans: A
Feedback:
The DNR order is written when the client wishes to have no resuscitative action taken if
he or she experiences a cardiac or respiratory arrest. The other answers are resuscitative
measures that are against the client's wishes.
Page 10
24. The nurse has a client who is confused and disrupting the unit by screaming obscenities
and making a lot of noise. The client has been medicated as ordered but is not
responding to the sedation. The other clients on the unit are agitated and complaining.
The nurse makes the decision to move the client to a location further down the hall
where fewer clients are. What theory of ethics is the nurse demonstrating?
A) Utilitarianism
B) Deontology
C) The idea of rights
D) Obligation of duty
Ans: A
Feedback:
Utilitarianism is an outcome-oriented approach for decision making. There are two
important principles: “the greatest good for the greatest number” and “the end justifies
the means.” Deontology argues that consequences are not the only important
consideration in ethical dilemmas. Answers C and D are not theories.
25. The nurse considers that she has strong professional values and uses ethical values to
make decisions about care. What four characteristics are shared between these concepts?
Select all that apply.
A) They are consistent.
B) Take priority over other values
C) Concern the treatment of others
D) Are well thought out
E) Treat all clients the same regardless of illness
Ans: A, B, C, D
Feedback:
Values are the beliefs that individuals find most meaningful. People value many
different ideas, and not all ideas are ethical. Ethical values are rules or principles a
person uses to make decision about right and wrong. They share four characteristics:
Ethical values are consistent, take priority over other values, concern the treatment of
others, and are well thought out. Treating the clients the same is not part of the shared
values.
Page 11
26. The nurse is caring for a client who has been intubated and on a mechanical ventilator
and has been restrained with soft wrist restraints. The client no longer requires the
restraints, so the nurse removes them. What type of ethical decision making does the
nurse display?
A) Fidelity
B) Autonomy
C) Beneficence
D) Nonmaleficence
Ans: C
Feedback:
Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse
has a duty to remove wrist restraints whenever possible (removing a harm) and to help
the client regain independence (promoting and doing good). Fidelity is the duty to
maintain commitments of professional obligations and responsibilities. Autonomy refers
to a client's right to self-determination or the freedom to make choices without
opposition. Nonmaleficence is the duty to do no harm to the client.
27. The nurse is to administer a potassium supplement to the client. The nurse does not
check the potassium level prior to administering the medication and later finds that the
potassium level was at a critical high. What principle has this nurse violated?
A) Beneficence
B) Nonmaleficence
C) Autonomy
D) Fidelity
Ans: B
Feedback:
Nonmaleficence is the duty to do no harm to the client. For instance, if a nurse fails to
check an order for an unusually high dose of insulin and administers it, he or she has
violated the principle of nonmaleficence. Beneficence is the duty to do good for the
clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints
whenever possible (removing a harm) and to help the client regain independence
(promoting and doing good). Fidelity is the duty to maintain commitments of
professional obligations and responsibilities. Autonomy refers to a client's right to
self-determination or the freedom to make choices without opposition.
Page 12
28. The nurse is administering a medication to a client for the treatment of his constipation.
The client states that he prefers not to take the medication today. The nurse respects the
client's right and informs him if he needs it later, just let the nurse know. What
professional value is the nurse displaying?
A) Beneficence
B) Nonmaleficence
C) Autonomy
D) Fidelity
Ans: C
Feedback:
Autonomy refers to a client's right to self-determination or the freedom to make choices
without opposition. Nonmaleficence is the duty to do no harm to the client. If a nurse
fails to check an order for an unusually high dose of insulin and administers it, he or she
has violated the principle of nonmaleficence. Beneficence is the duty to do good for the
clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints
whenever possible (removing a harm) and to help the client regain independence
(promoting and doing good). Fidelity is the duty to maintain commitments of
professional obligations and responsibilities.
29. A client who has end-stage chronic obstructive pulmonary disease (COPD) asks the
nurse, “Am I going to be getting better? Is there a cure?” What is the best response by
the nurse that demonstrates the professional value, veracity?
A) “Everything will be fine.”
B) “Did someone tell you that there is a cure for this?”
C) “You don't need to worry about that; just get better.”
D) “Although there is no cure for this disease, we will keep you as comfortable as
possible.”
Ans: D
Feedback:
The professional value of veracity is the duty to tell the truth. The nurse must provide
factual information to the client so that he or she may exercise autonomy. The other
answers given are nontherapeutic responses that do not answer the client's question.
Page 13
30. The nurse is assigned to care for a client who is admitted to the medical unit with an
infection after having an abortion. The nurse is uncomfortable caring for this client
because the religious beliefs of the nurse are very firm on the issue of abortion. What
first step can the nurse make in order to solve the ethical dilemma?
A) Evaluate the decision in terms of effects and results.
B) Make the decision and follow through on it.
C) List all possible options for solving the dilemma.
D) Obtain as much information as possible to understand the situation.
Ans: D
Feedback:
The first step in the ethical dilemma decision-making process is to obtain as much
information as possible to understand the situation. Evaluating the decision in terms of
effects and results is the fifth step in the process. Making the decision and following
through is the fourth step of the process, and listing all possible options is the second
step in the process.
31. The nurse is caring for a client in the intensive care unit that is on life support measures.
The family members are opposed in their decision to take the client off of life support.
What option does the nurse discuss with the nurse manager?
A) Ask the family to go out of the unit and make a decision that is final.
B) Contact the ethics committee for their input.
C) Have the physician inform the family that they are not responsible for the
decision.
D) Taking the client off of life support when the family is not present.
Ans: B
Feedback:
The ethics committee may be called on to act as an advocate for clients who no longer
are mentally capable of making their own decisions. Ethics committees are a valuable
resource for reviewing difficult cases and helping ensure a careful and unbiased
decision. The nurse is not practicing within the scope of practice by taking the client off
of life support. The nurse does not mandate to the physician decisions that should be
made. It is nontherapeutic for the nurse to ask the family to go out and make a decision.
Page 14
32. The nurse is concerned that she will be sued for a possible act of malpractice. What
essential elements of malpractice must be present for this to occur? Select all that apply.
A) Harm to an individual
B) Duty of a professional toward an individual
C) Breach of duty by the professional
D) Poor rapport built with the client
E) Cause of harm is the breach of duty
Ans: A, B, C, E
Feedback:
The essential elements of malpractice must include harm to the individual, duty of a
professional toward an individual, breach of duty by the professional, and cause of harm
is the breach of duty. Not building a rapport can contribute to a possible malpractice suit
but is not an essential element.
33. A client jumped out of a window on the second floor of the hospital and sustained a
spinal cord injury that resulted in the inability to have upper and lower extremity
sensation. What type of documentation by the nurse would be appropriate in this
situation?
A) “The client must have been depressed and wanted to commit suicide.”
B) “I saw the client get ready to jump and was unable to get to him fast enough.”
C) “Client observed standing on the window ledge; asked client to come down and
proceeded to enter the room, and client jumped through the glass.”
D) “The previous shift should have notified the physician that the patient was
suicidal.”
Ans: C
Feedback:
The documentation for answer C was objective, accurate, and concise. The other
choices were judgmental, subjective, and vague.
34. The nurse is assigned to a group of clients on the medical floor. A visitor tells the nurse
that their neighbor is a client at the hospital and doesn't know what is wrong. The nurse
goes to the chart and proceeds to inform the visitor about the client's diagnosis. What
type of violation has the nurse committed? Choose the best answer.
A) HIPAA violation
B) Trust violation
C) Hospital policy violation
D) Violation of the code of ethics
Ans: A
Feedback:
The client has the right to request restrictions and confidential communications
concerning protected health information, which is an overview of the major client
protections provided by HIPAA. Although a violation of trust and hospital policy, it is
first and foremost a violation of HIPAA.
Page 15
35. The nurse finds that she must choose between two undesirable alternatives involving a
client that she is caring for. The client wants to be told about his prognosis, and the
family member does not want the client to know. What type of situation does the nurse
understand she is in?
A) Ethical dilemma
B) Bioethical dilemma
C) Value dilemma
D) Personal dilemma
Ans: A
Feedback:
An ethical dilemma is a situation in which an individual must choose between two
undesirable alternatives, and it often involves examining rights and obligations of
particular individuals. A bioethical dilemma is an ethical question surrounding life and
death questions and concerns regarding quality of life as it relates to advanced
technology. Values are ideals and beliefs that are held by an individual or group. This
does not relate to a personal dilemma because it does not affect the nurse.
Page 16
1. Chapter 6
Which of the following roles of a nurse is an example of legitimate power?
A) Director of nursing
B) Team leader making assignments
C) Head nurse scheduling vacations
D) Shift supervisor
Ans: A
Feedback:
Legitimate power is power by virtue of the management position. Director of nursing is
an example of legitimate power. Team leader making assignments is an example of
reward power. Head nurse scheduling vacations is an example of coercive power. Shift
supervisor is an example of referent power.
2. Which of the following is the perceived advantage of autocratic leadership styles?
A) Staff members are invested in management's goals.
B) Decisions are made without any input from staff.
C) Communication is limited to memos.
D) Decisions may not occur on time.
Ans: B
Feedback:
In autocratic leadership style, the lines of authority and policies are clear, and
communication is directive and flows downward. In addition, decisions are made
quickly, and staff members are not invested in management's goals.
3. A licensed practical nurse (LPN) has delegated a task to unlicensed assistive personnel
(UAP). Who is accountable for evaluating the results of the tasks?
A) Physician
B) Shift supervisor
C) UAP
D) LPN
Ans: D
Feedback:
An LPN or licensed vocational nurse (LVN) who delegates tasks to a UAP is
accountable for evaluating the results of the tasks. The UAP is responsible for
performing the actual task. The physician or shift supervisor is not accountable for
evaluating the results of the tasks.
Page 1
4. According to Ellis and Hartley (2011), which type of leadership involves the least
amount of structure and control?
A) Autocratic
B) Laissez-faire
C) Democratic
D) Multicratic
Ans: B
Feedback:
Laissez-faire leadership involves the least structure and control. Autocratic leadership
entails strong control by the manager over the work group. Democratic leadership
involves more participation in decision making by the work group. Multicratic
leadership allows a leader to determine which approach is best for a particular
circumstance.
5. A nurse manager who denies vacation time to an employee who failed to meet
expectations is exhibiting what type of power?
A) Legitimate
B) Coercive
C) Reward
D) Referent
Ans: B
Feedback:
Coercive power is the ability to threaten or punish someone who fails to meet
expectations. Legitimate power is obtained through a designated position. Reward
power occurs when a person attains power through the ability to grant favors or rewards.
Referent power is the power a person has because of his or her association with other
who are powerful.
6. A nurse manager typically exhibits which type of power when using education and work
experience?
A) Referent
B) Legitimate
C) Coercive
D) Expert
Ans: D
Feedback:
Expert power results from knowledge, expertise, or experience in a particular area.
Referent power concerns the power a person has because of his or her association with
other who are powerful. Legitimate power is obtained through a designated position.
Coercive power is the ability to threaten or punish someone who fails to meet
expectations.
Page 2
7. Which of the following is an advantage of democratic leadership?
A) Tasks are accomplished without staff input.
B) Leaders see themselves as coworkers.
C) Quick decision making occurs.
D) Managers provide support and freedom for employees.
Ans: B
Feedback:
Democratic leadership involves more participation in decision making by the work
group. Leaders with this style often see themselves as coworkers. Autocratic leadership
allows little input from staff for decisions. In laissez-faire leadership, the manager
leaves the work group to set goals, make decisions, and take responsibility for their own
management.
8. Which of the following would not be considered one of the five rights of delegation?
A) Educational level
B) Task
C) Circumstances
D) Person
Ans: A
Feedback:
The NCSBN (1997) identified the five rights of delegation: right task, right
circumstances, right person, right direction/communication, and right
supervision/evaluation.
9. Which of the following would be considered an indirect activity that may be delegated
to unlicensed assistive personnel?
A) Delivering meal trays
B) Obtaining vital signs
C) Ambulation
D) Specimen collection
Ans: A
Feedback:
Indirect activities are focused on environmental tasks, such as cleaning equipment,
emptying trash or soiled linen receptacles, and delivering meal trays. Direct activities
are those that help clients meet basic needs, including vital signs, weights, specimen
collection, and ambulation.
Page 3
10. The leader is making all the decisions for the group. Which type of leadership is being
exhibited?
A) Autocratic
B) Democratic
C) Laissez-faire
D) Multicratic
Ans: A
Feedback:
Autocratic leadership entails strong control by the manager over the work group.
Democratic leadership involves more participation in decision making by the work
group. Laissez-faire leadership involves the least structure and control. Multicratic
leadership allows a leader to determine which approach is best for a particular
circumstance.
11. The nurse at a long-term care facility is receiving an admission to a skilled medical unit
with a full census. Which nursing situation is the best example of a nurse demonstrating
appropriate management skills in the care of the client?
A) The nurse is arranging the room to best accommodate the client's medical
equipment.
B) The nurse is obtaining the needed paperwork to begin the admission process.
C) The nurse is delegating patient orientation to the room while obtaining contact
information from the family.
D) The nurse is obtaining a urinary collection hat for the toilet.
Ans: C
Feedback:
Management of clients, especially on a busy unit, is best accomplished by delegation of
appropriate tasks. A manager must use resources in an efficient and effective manner to
accomplish a goal. The manager sees the big picture and determines appropriate actions.
Page 4
12. Which of the following statements best demonstrates a combination of leadership and
management skills when teaching a client with uncontrolled diabetes?
A) “While you have agreed to check your blood sugar every morning, it is also
important to recognize the overall effect on your body system.”
B) “Once you have the lancet in the device, hold it against the finger and press the
button.” You are doing a good job.
C) “Because Thanksgiving is next week, evaluate the amount of simple sugars in the
desserts and eat those in moderation.”
D) “I will notify your physician of your blood glucose reading and request a referral
for a dietician to improve your knowledge of calorie controlled diets.”
Ans: A
Feedback:
In many ways, leadership and management skills are interrelated. Option A uses
management skills of instructing on obtaining blood sugars every morning and
leadership skills of looking at the overall picture of the disease process within the
system. Option B provides instruction on a procedure. Option C instructs on managing
dietary habits. Option D does not include using management and leadership in teaching
a client.
13. The nurse is caring for pediatric clients on an oncology unit. The unit is experiencing a
renovation, and the nurse manager is requesting suggestions for placement of the nurse's
station with the goal of close pediatric client access. Which type of leadership style is
the nurse manager employing?
A) Political leadership style
B) Democratic leadership style
C) Laissez-faire leadership style
D) Authoritarian leadership style
Ans: B
Feedback:
When a manager uses the democratic leadership style, the manager welcomes
participation in decision making with a goal of consensus and teamwork. Option A and
D are not leadership styles. Option C is a leadership style that involves little structure
and guidance.
Page 5
14. During which client–nurse interaction would the nurse most appropriately use the
autocratic leadership style?
A) The nurse is assisting the client to the bathroom when wound dehiscence occurs.
B) The nurse is presenting meal options to a resistant diabetic client.
C) The nurse is instructing on how to obtain blood glucose readings.
D) The nurse is preparing discharge instructions per physician's order.
Ans: A
Feedback:
During an emergency, such as when a wound dehiscence occurs, an autocratic
leadership style with one person in tight control of the situation is best. At this time, the
focus is on accomplishing the tasks of patient safety, wound care, and physician
notification. All of the other interactions would best be managed with a therapeutic
nurse patient interaction.
15. A mother of a 10-year-old newly diagnosed diabetic client expresses concern that her
child will not follow through with the diabetic regimen. The nurse suggests developing a
calendar of daily requirements with a weekly prize for completing. The mother is
exerting which type of power to obtain the desired result?
A) Coercive power
B) Expert power
C) Parental power
D) Reward power
Ans: D
Feedback:
Reward power is using rewards and favors to obtain a particular action. In this case, the
mother rewards the child when the child completes the prescribed diabetic regimen.
Coercive power is used when using a threat or punishment to meet expectations. Expert
power results from the respected knowledge in a particular situation. Parental power
many times falls under expert power.
Page 6
16. The manager of the surgical unit is presenting the benefits of a new computer
documentation system on reducing the nurse's time documenting, thus increasing the
time to care for clients at the bedside. Increasing nurse excitement in the changes within
the system is a form of which type of power?
A) Referent power
B) Motivational power
C) Legitimate power
D) Authoritarian power
Ans: B
Feedback:
Motivational power refers to the ability to create enthusiasm for a collaborative project
or achievement of a common goal. Referent power relates to being in or associating
with someone who is in the position of power. Legitimate power is afforded to the
management position but is not the best answer for this question scenario. Option D
relates to leadership styles.
17. The LPN is caring for a full nursing assignment and delegates specific duties to the
certified nursing assistant (CNA). Which nursing action is best to assess the competency
of the CNA to complete the assignment?
A) Ask the client if the assignments were completed
B) View the paperwork related to the assignments for completion
C) Ask the CNA exactly how the assignments were completed
D) Observe the CNA during completion of the assignments
Ans: D
Feedback:
Observing the CNA, especially during the first time that the CNA is independent, is the
best way to ensure the knowledge and competency of the CNA (a component of
supervision). If the CNA performs the assignment correctly, the task can be routinely
delegated with usual follow-up. Asking clients, viewing paperwork, and asking the
CNA provides information on the task but is not the best choice for assessing.
Page 7
18. The LPN is assigning clients on a rehabilitation unit. Which of the following nursing
actions should the LPN complete prior to assigning any delegated task?
A) Complete nursing report
B) Review physician notes
C) Assess the clients
D) Obtain feedback from the CNA
Ans: C
Feedback:
Assessing the client prior to delegation assures the right person, task, and circumstance.
The licensed nurse should assess the appropriateness of assignment to meet the skills of
the person being delegated to. Completing nursing report provides information about the
client, which the assessment phase confirms. Reviewing physician notes provides
updated information regarding medical orders. Obtaining feedback on the assignment
from CNA provides information on skill level.
19. The registered nurse (RN) delegates management of the client vital signs to the LPN
while the client is receiving blood products. Which of the following RN actions is
essential in completing the “right circumstance” right of delegation?
A) The RN initiates the transfusion and remains with the client during initial vital
signs.
B) The RN supervises the LPN obtaining vital signs and discusses signs of a
transfusion reaction.
C) The RN obtains the LPN scope of practice and determines the ability to manage
client.
D) The RN discusses the specific tasks to delegate and asks for any questions.
Ans: A
Feedback:
To complete the “right circumstance” right, the RN must determine that the client is not
having any transfusion reaction and that the client's vitals are stable. Option B and C
represents “right tasks” because the RN validates the scope of practice and supervises
the competent completion of tasks. Option D represents right communication.
Page 8
20. Staff is assembling for shift assignments. Which of the following nursing actions
identifies the manager's responsibility on the clinical unit?
A) The manager assesses the clients on the clinical unit and updates the physician.
B) The manager assures that adequate care is given by the staff and assesses the flow
of activities on the clinical unit.
C) The manager removes the physician orders from the chart and notes completion.
D) The manager attends facility meetings and plans the goals of the healthcare
facility.
Ans: B, D
Feedback:
The key feature of the manager's position is the individual responsibility and
accountability for the accomplishment of tasks on the clinical unit. Option B accounts
for the care of the clients and flow of the clinical unit. Options A and C are task
oriented, and, although the manager may assist staff, it is not the focus of the manager's
responsibility. Option D identifies manager (attending meetings) and leadership (goals
of the facility) duties.
21. The LPN on the clinical unit is discussing client medication administration. The
medication nurse states, “I crushed the medication because the nurse on the prior shift
told me to do it.” This statement indicates a lack of which?
A) Responsibility
B) Management
C) Accountability
D) Leadership
Ans: C
Feedback:
Accountability means being answerable for one's actions. Following another's actions
and using that as a rationale is not being accountable for the action taken. Responsibility
is the duty or assignment to a specific task. Management entails assigning functions to
meet particular objectives. Leadership provides guidance to achieve common goals.
22. The nurse is planning care for the day for a client with multiple diagnoses. Which of the
following criteria should the nurse consider first when setting priorities for the care of
the client?
A) Consider the priority of maintaining vital signs.
B) Consider the priority of symptom management.
C) Consider the priority of management of pain.
D) Consider the priority of preventing spread of disease.
Ans: A
Feedback:
All options are a priority when providing care to a client. When prioritizing, vital signs
provide data on maintaining life and are considered first. All other options come after.
Page 9
23. Which nursing management duties would the LPN identify as the primary goal of
directing nursing care in the role of the team leader on a nursing unit?
A) To maintain the efficient flow of client care on the nursing unit
B) To ensure the personal care for all residents is completed
C) To assess vital signs on a client with changing hemodynamic status
D) To coordinate physician orders between the physician and nursing staff
Ans: A
Feedback:
The key words are “primary goal,” which is broad in nature. The best choice is to
maintain the efficient flow of the nursing unit. Individual staff also has the responsibility
to complete the nursing task of personal care and vital sign assessment. Coordinating
physician orders is a combined duty between the physician and nursing staff and falls
under the goal of maintaining efficient flow of client care.
24. A nurse is caring for clients on a surgical unit. Which nursing actions positively impact
the goal of healthcare cost containment? Select all that apply.
A) Completing a nursing assessment and setting up a breakfast tray in an isolation
client's room
B) Teaching and encouraging the use of an incentive spirometer
C) Delegating the ambulation of a client three times daily in the hall
D) Completing client wound dressing change prior to physician rounds
E) Checking the completion of foley catheter care with the nursing assistant
F)
Initiating a turning protocol for a bedbound client
Ans: A, B, C, E, F
Feedback:
Cost-consciousness measures include prudent use of expensive supplies, careful
monitoring of clients to reduce potential complications and lengths of stay, and
reduction of waste of limited resources. Options A, B, C, E, and F are examples of
these.
Page 10
25. A nurse is caring for a client with stage IV colon cancer and multiple-stage two wounds
on the coccyx area. The client confides feeling very weak and wanting to discontinue
further aggressive treatment. Which nursing action best demonstrates the nurse in the
role of the patient advocate?
A) The nurse relays the message to the physician and requests an antidepressant.
B) The nurse asks the client how might his or her family feel with this decision.
C) The nurse sits with the client and suggests that the client reconsider.
D) The nurse offers to be present to support the client at a family meeting.
Ans: D
Feedback:
Advocacy meaning promoting the cause of another person. The nurse functions as a
patient advocate by supporting the client and the client's decisions. Offering to support
the client as the client expresses healthcare decisions is the best example of a client
advocate. Relaying the message to the physician and asking for an antidepressant does
not demonstrate supporting the client. Opening conversation related to family response
is appropriate for discussion but is not the best choice to support the client. The nurse
would not ask the client to reconsider because this is a block to communication.
26. The nurse manager is discussing financial penalties for readmissions to the hospital.
Which nursing action, when caring for a client, is most helpful in decreasing hospital
readmission?
A) Emphasize client teaching
B) Fully explain discharge instructions
C) Sanitize hands upon entering a client room
D) Disinfect the client environment at discharge
Ans: C
Feedback:
All options help to reduce the potential for readmission but the key words are “most
helpful”. Handwashing is the best way to reduce hospital acquired infections, which
could lead to readmissions. Handwashing also maintains standards of care. Client
education during hospitalization and with discharge instructions empowers the client in
care of themselves. Disinfecting the client's room reduces cross contamination.
Page 11
27. The LPN is supervising the nursing unit staff when a nonlethal breach in client
standards of care occurs. Which situation demonstrates the limitations of supervising
client care in the role of the LPN?
A) The LPN supervisor is unable to write the incident report outlining the breach in
care standard.
B) The LPN supervisor reports the breach in care standard to the RN only.
C) The LPN supervisor oversees the staff but has no disciplinary responsibility.
D) The LPN supervisor is responsible for personal care and not all nursing functions.
Ans: C
Feedback:
The role of the LPN supervisor does not include hiring/firing or disciplinary actions of
employees. When a breach in the standards of care occurs, the LPN is responsible for
documenting the event and reporting the event to the proper individuals, such as RN
supervisor, administrator in charge, physician, family representative, etc. The supervisor
oversees client care.
28. The LPN supervisor is assigning LPNs to clients on a skilled nursing unit at a long term
care facility. In which situation would the LPN reduce the assignment due to client
acuity?
A) A client who desaturates with minimal exertion
B) A client with dementia who is combative during medication administration
C) A client who needs to be ambulated in the hall with the assistance of two for
restorative therapy
D) A client requires several intravenous antibiotics to treat a septic infection
Ans: A
Feedback:
Acuity refers to the severity of the illness and the potential rapid change in the client. A
client that desaturates with minimal exertion is at risk for respiratory compromise and
respiratory arrest. Careful and repeated nursing assessment is needed limiting the time
for other client interactions. Dementia is a chronic condition making daily activities
such as medication administration challenging. A restorative care client focuses on
improving activities of daily living. A client with multiple intravenous antibiotics should
improve as treatment progresses.
Page 12
29. A nurse in the physician's office must multitask assignments according to client needs.
Arrange the clients in order of which should be assessed/assisted from first to last?
A) A client in an examining room on an ill office call who reports flulike symptoms
B) A client in the office reception area who appears unannounced due to chest
heaviness
C) A client calling on the phone who is inquiring about doubling the morning dose of
medication because of forgetting the last day's dose
D) A client who needs to be called by the nurse to advice of a medication dosage
change
E) A client who stopped into the office to pick up sample medications
Ans: A, B, C, D, E
Feedback:
All nurses must manage multiple client needs in a timely manner. Nurses must prioritize
to determine the proper order of response. Maslow's Hierarchy of Needs can be helpful
to make that determination in certain circumstances. A client with chest heaviness
potentially could be having a life-threatening condition needing attention immediately.
Next, the client in the exam room needs vital signs and a history of present illness
before the physician enters. To maintain the flow of the office, this client is a priority.
Next, the nurse would answer the question of the client on the phone who may
otherwise incorrectly ingest a double dose of medication. Next, a client needs to be
called with medication dosage change. Lastly, the client in the office who has come to
obtain sample medication needs medication instruction on dosage and side effects.
30. A new client charting system is in the education phase at a healthcare facility. Much
discussion has been prompted regarding the new system. With which statement does the
nurse best exhibit the integrated leader/manager traits?
A) “Let's look at the daily benefits of using the new technology on the clinical unit.”
B) “I am not used to the new technology, but if it better serves the client and enables
easy sharing of client authorized records, I see a benefit.”
C) “New technology may be costly up front but will serve us well in the future.”
D) “I do not believe that this technology will be helpful in caring for a client because
it often is down during peak use times and is difficult to train for.”
Ans: B
Feedback:
The traits of an integrated leader/manager combine understanding the daily operations
on a clinical unit while seeing the big picture and thinking in the long term. Better
serving the client and sharing records as needed demonstrates the willingness to think
positively and take risks on improvement for the future. Option A and C only look at
one aspect of leadership/management. Option D is a negative statement.
Page 13
1. Chapter 7
Which of the following is one of the four categories of client needs identified by the
National Council of State Boards of Nursing?
A) Maintenance of function
B) Restoration of wellness
C) Psychosocial integrity
D) Reduction of fear and worry
Ans: C
Feedback:
The National Council of State Boards of Nursing identifies four categories of client
needs as the structure for its test plan: safe and effective care environment, health
promotion and maintenance, psychosocial integrity, and physiologic integrity. Nursing
care provides skills that help restore wellness, especially during an acute illness, or
maintain as much function as possible. The supportive relationship that develops reduces
fear and worry.
2. Which of the following is a component of nonverbal communication?
A) Paralanguage
B) Hearing acuity
C) Interpersonal attitudes
D) Listening
Ans: A
Feedback:
Nonverbal communication consists of components such as kinesics, paralanguage (vocal
sounds that communicate a message), proxemics (use of space when communicating),
touch, and silence. Hearing acuity, interpersonal attitudes, and listening are variables that
affect verbal communication.
3. Which of the following is a purpose of affective touch in the context of nursing?
A) Demonstrating concern
B) Providing contact for performing procedures
C) Encouraging verbal communication
D) Providing brief periods for response
Ans: A
Feedback:
Affective touch is touch used to demonstrate concern or affection. Task-oriented touch
involves the personal contact that is needed for performing nursing procedures. Silence
is the art of remaining quiet. Encouraging verbal communication and providing a brief
period during which clients can respond to a question are therapeutic uses of silence.
Page 1
4. Which of the following means of comprehending new information best describes a
cognitive learner?
A) The learner learns through information that appeals to feelings.
B) The learner likes to learn by doing.
C) The learner learns by combining three styles of learning.
D) The learner processes information by listening to facts.
Ans: D
Feedback:
The cognitive learner processes information best by listening to or reading facts and
descriptions. The affective learner is more attuned to learning when presented with
information that appeals to his or her feelings. The psychomotor learner typically likes
to learn by doing. A combination of the three styles tends to optimize learning, although
most people favor one style of learning.
5. Which of the following is a reason why silence is considered therapeutic?
A) It demonstrates concern or affection.
B) It communicates caring and support.
C) It encourages a client's verbal communication.
D) It is therapeutic when a client is uncomfortable.
Ans: C
Feedback:
Silence is the art of remaining quiet. One of its therapeutic uses is to encourage a client's
verbal communication. Affective touch is typically used to demonstrate concern or
affection. Its intention is to communicate caring and support. The nurse use affective
touch therapeutically in many situations, including when a client is uncomfortable.
6. Advocacy and support are activities associated with which learning style?
A) Cognitive
B) Cultural
C) Psychomotor
D) Affective
Ans: D
Feedback:
The affective learner learns best when presented with information that appeals to his or
her feelings, beliefs, and values. Cognitive learners process information best by listening
to or reading facts and descriptions. The psychomotor learner prefers to learn by doing.
There is no learning style classified as cultural.
Page 2
7. Which of the following is a person's intellectual ability to remember and apply new
information?
A) Learning style
B) Learning needs
C) Motivation
D) Learning capacity
Ans: D
Feedback:
Learning capacity is a person's intellectual ability to understand, remember, and apply
new information. Learning style is the manner in which a person best comprehends new
information. Learning needs are the skills and concepts that the client and family must
acquire to restore, maintain, or promote health. Motivation is the desire to acquire new
information.
8. Which of the following is a positive interpretation of body language?
A) Clenched jaw
B) Tilt of head
C) Arms crossed
D) Rubbing nose
Ans: B
Feedback:
An example of a positive interpretation of body language is the tilt of the head. Negative
examples of body language include a clenched jaw, crossed arms, and rubbing the nose.
9. Which type of learner processes information more adequately by listening or reading
facts?
A) Social
B) Psychomotor
C) Affective
D) Cognitive
Ans: D
Feedback:
Cognitive learners process information best by listening to or reading facts and
descriptions. There is no category of social learner. The psychomotor learner prefers to
learn by doing. The affective learner learns best when presented with information that
appeals to his or her feelings, beliefs, and values.
Page 3
10. Which of the following is a client responsibility in the nurse–client relationship?
A) Remain nonjudgmental.
B) Comply with the therapeutic regimen.
C) Function as an advocate.
D) Perform prescribed skill safely.
Ans: B
Feedback:
Complying with the therapeutic regimen is a client responsibility. Remaining
nonjudgmental, functioning as an advocate, and performing a prescribed skill safely are
nurse responsibilities.
11. The nurse is caring for a client who is hard of hearing. The nurse is in the room during
client and physician discussion and will relate the information to the client's power of
attorney. Which term best describes the role the nurse is assuming?
A) Friend
B) Caregiver
C) Leader
D) Coach
Ans: B
Feedback:
When the nurse assists the client is relaying information to the family, the nurse is in the
role of the caregiver. The caregiving role includes a close relationship and becomes a
client's guide, companion, and interpreter. The nurse loses perspective when in the role
of the friend. The nurse can be a leader and a coach; however, in the situation stated, the
best answer is caregiver.
12. The nurse enters the client's room and assesses that the client's affect appears sad. The
client is sitting near the window, staring into the distance with a tear in the eye. The
nurse approaches and places a hand on the client's shoulder asking for client thoughts.
What type of emotion is the nurse projecting?
A) Sympathy
B) Empathy
C) Ambivalence
D) Pity
Ans: B
Feedback:
The nurse is projecting empathy. Empathy is an intuitive awareness of what the client is
experiencing. Nurses perceive the client's emotional state and provide support.
Sympathy is the projection of understanding the way one may feel, many times by
having gone through the experience as well. Ambivalence projects conflicting feelings
and uncertainty. Pity is projects a feeling of sorrow.
Page 4
13. Which of the following is least effective in encouraging a client to follow a medication
regimen?
A) Provide information on the medications prescribed
B) Instruct the family members on treatment regimen
C) Discuss perspective from the nurse's personal experience
D) State potential consequences if medication regimen in not followed
Ans: C
Feedback:
When encouraging a client to follow a medically prescribed medication regiment, the
nurse is least effective when including personal experiences and the nurse's own
choices. The most effective strategy is providing information on the medication
regimen, including family member in the treatment regimen to support the client and to
provide information on the consequence if the medication regimen is not followed.
Ensuring that clients have all of the information to make an informed decision is a
nursing role.
14. The charge nurse delegates the administration of a pain medication to a practical nurse.
Which statement, made by the charge nurse, indicates that the final step in the
delegation process has been completed?
A) “Did you document the administration of the pain medication on the medication
record?”
B) “Is the physician aware of the client's need for pain medication?”
C) “What is the client's pain level since administering the pain medication 30 minutes
ago?”
D) “Have you ever administered this type of pain medication previously?”
Ans: C
Feedback:
The final step in the delegation process is to ensure that the task has been completed and
determine the resulting outcome of the action. In this case, it is ensuring the medication
is giving and assessing for pain relief. The other steps may be completed in the
delegation process, but they are not completed last.
Page 5
15. The nurse has been caring for a client and family for 6 months in the long-term care
facility. Which of the following nursing actions is appropriate during the terminating
phase of the nurse–client relationship? Select all that apply.
A) Teaching the client and family about care needs at home
B) Providing personal contact information if further guidance is needed
C) Accepting personal gifts of gratitude from the client
D) Relaying well wishes from the staff
E) Arranging health related services to support home care
F)
Coordinating medication regimen for home care
Ans: A, D, E, F
Feedback:
The terminating phase occurs when the client's health problems have improved and
nursing services in the long-term care facility are no longer necessary. The nurse's role
becomes transitioning the client and family to home care. Teaching about needs,
arranging health related services, and coordinating medication regimen for home care
are all appropriate. Also, relaying well wishes from the staff shows the caring nature of
the staff and highlights the nurse–client relationship while in the facility. It is typically
not appropriate to accept personal gifts or exchange personal contact information with
the client.
16. Which of the following nurse statements is completed in the working phase of the
nurse–client relationship?
A) “Tell me about your religious beliefs during this season of the year.”
B) “I will put a chair in the bathroom so you can begin personal care. I will return to
assist you as needed.”
C) “I understand that you are feeling anxious about going home. Let me assess you
before we talk.”
D) “Let's talk about a way to assist you to a standing position so you can walk in the
hall.”
Ans: B
Feedback:
During the working phase of the nurse–client relationship, the nurse and the client puts
the mutually developed plan into action. Each person shares in performing the task that
leads to the desired outcome, which supports the client's independence. In the
introductory phase, the nurse should be gathering information regarding religious
beliefs. In the terminating phase, the client may feel apprehensive about assuming
independent activity or self-care. Developing the plan with activities such as assisting to
a standing position to walk in the hall is completed in the introductory phase.
Page 6
17. The nurse is caring for a client and family who are awaiting the results of a diagnostic
test. Which of the following acts, made by the nurse, best demonstrate therapeutic
nonverbal communication?
A) The nurse listens to the client's frustration of waiting for test results.
B) The nurse smiles and rubs the shoulder of the client.
C) The nurse is silent while caring out her nursing duties.
D) The nurse shrugs the shoulders when asked when testing results will return.
Ans: B
Feedback:
A smile and rub of the client's shoulder is a nonverbal gesture that the nurse understands
the client's situation. Listening to client frustration is an activity that affects verbal
communication because, therapeutically, there is a response. Silence can be therapeutic
when the attention is with the client, not the nursing duties. Shrugging the shoulders can
be perceived as indifferent and not caring.
18. The nurse is instructing a client in a crowded semiprivate room. The nurse approaches
and moves equipment to allow for a comfortable conversation. At which distance should
the nurse stand?
A) Within 1 feet
B) 2 to 3 feet
C) At least 5 feet
D) Over 6 feet
Ans: B
Feedback:
Proxemics refers to the use of space when communicating. Most Americans feel
comfortable when individuals are 2 to 3 feet away.
19. Which nursing action is most therapeutic when a client says, “My daughter wants me to
go to a nursing home to get rid of me; I am just a burden.”
A) Pull up a chair and sit down to talk.
B) Offer self and discuss family behaviors the nurse sees.
C) Explore past relationship issues using reminiscence therapy.
D) Offer to call the daughter in to discuss the issues.
Ans: A
Feedback:
The nurse must respond delicately to an emotional client. The most therapeutic action
for the nurse is to pull up a chair and sit down to talk. When assuming a seated position,
it allows the nurse to be at eye level instead of overhead, which places the client in the
position of vulnerability. Offering of self is therapeutic but not to discuss the family
through the nurse's eye. Exploring past relationships does not focus on the issues today.
Offering to call the daughter would not be done until further information is obtained.
Page 7
20. The nurse cares for multiple ethnic populations. Which of the following examples best
demonstrates a facility adhering to The Joint Commission requirements that healthcare
workers facilitate communication with all clients?
A) The facility requires a family member of a non–English-speaking client be present
to discuss healthcare issues with a physician and member of social service.
B) Language dictionaries are placed in the facility library with open access for staff.
C) The facility requests bilingual staff and community members to voluntarily
provide contact information for interpreter services.
D) The facility subscribes to an online interpreting service.
Ans: C
Feedback:
It is a requirement of The Joint Commission that agencies develop a system to provide
aids and services to any client with literacy needs and also to provide language
interpreting and translation services. The best way to demonstrate this requirement is by
reaching out to staff and community members to provide personal interpreting services.
It is not appropriate to require a family member, if available, to be present. The other
options may be helpful in communicating with clients, but personal services are optimal.
21. The nurse is caring for a client who has been diagnosed with a cerebral vascular
accident and subsequent expressive aphasia. In which manner does the nurse best
promote communication?
A) Ask open-ended questions and allow time for the client to respond.
B) Use head nods and shakes to convey answers to questions.
C) Use hand gestures to facilitate nursing care.
D) Use a picture board with common responses.
Ans: D
Feedback:
For clients with aphasia, it is most helpful to have a picture board with responses to
convey meaning. This decreases some frustration and allows the client to have some
control over care. Asking closed-ended questions with limited responses and allowing
for additional response time is appropriate. Head nods and hand gestures are limited
ways of communication.
Page 8
22. The nurse is caring for a client who is newly diagnosed with atrial fibrillation. The client
states he has many questions. At what point in the client contact experience does
assessment for learning begin?
A) During a morning assessment
B) When presenting the client with a brochure
C) Once the physician confirms the diagnosis
D) At the time of arrival to the hospital for care
Ans: D
Feedback:
The time of the initial assessment for learning begins when the client arrives at the
hospital. Even when the client is in the emergency department, doctors and staff are
explaining testing and procedures. As a new medical diagnosis is confirmed, teaching
continues with information about the disease process, new medication, and treatment
regimen.
23. The nurse is discharging a client with an indwelling Foley catheter. Which instructional
method is best when teaching a psychomotor learner about the care necessary?
A) Provide a booklet that outlines directions.
B) Provide the phone number of a nursing agency to assist with care.
C) Provide testimonials of others who have had a Foley catheter at home.
D) Provide the Foley catheter and equipment to handle and practice care.
Ans: D
Feedback:
A psychomotor learner prefers to learn by doing. Providing equipment enables the
learner to use the equipment and reinforces the necessary care. The booklet would be
appropriate for the cognitive learner. A nursing agency is most often ordered by a
physician for nursing care but is not a daily service. Testimonials are effective for
affective learners.
Page 9
24. A nurse is caring for a client who is newly diagnosed with cancer and receiving a
peripherally inserted central catheter (PICC). Upon analysis, the nurse determines that
the client is an affective learner. Which type of learning situation would the client learn
from best?
A) Having the client make a poster with the equipment from the PICC line
B) Having the client prepare notes related to the PICC line to be discussed with the
physician
C) Having the client attend a group support meeting of people with PICC lines
D) Having the client look online for information related to the PICC line
Ans: C
Feedback:
An affective learner learns best when the information is presented with consideration of
the client's thoughts/feelings, values, or beliefs. Having a client attend a group support
meeting with individuals having similar life struggles provides the opportunity for the
client to learn how best to live with the new diagnosis and care for themselves. Making
a poster with equipment is helpful for a psychomotor learner. Preparing notes and
learning online is helpful for a cognitive learner.
25. A wound care nurse approaches a client to instruct in home care needs. In which clinical
scenario would the nurse delay teaching due to learning readiness?
A) The client says that a grandchild will be in soon.
B) The client is eating breakfast.
C) The client is anxious about physical therapy.
D) The client is meeting with the priest.
Ans: C
Feedback:
Learning readiness pertains to the optimal time for learning. This occurs when a client is
in a state of physical and psychological well-being. Being anxious about an upcoming
activity distracts the client from learning. Waiting until after the activity allows the
client to be more focused on the teaching. Nurses may decide to delay teaching due to
visiting family, eating breakfast, and meeting with a priest, but it is not from learning
readiness.
Page 10
26. The nurse is evaluating the comprehension of a client's knowledge of the administration
of Lovenox, an anticoagulant. Which method provides the best feedback?
A) Having the client explain the medication and injection site
B) Having the client demonstrate the injection technique on an orange
C) Having the client watch the nurse prepare the medication and administer it
D) Having the client prepare the syringe and independently administer the injection
Ans: D
Feedback:
Having the client prepare the syringe and independently administer the injection is the
“show back” portion of learning comprehension because it includes demonstrating the
skill. By independently demonstrating, the nurse is able to evaluate the knowledge base
and skill. Having the client watch the nurse administer the medication is in the teaching
process. Having the client explain the medication and injection site or administer the
injection into an orange demonstrates parts of the skill but does not allow the nurse to
evaluate the entire skill.
27. The nurse is employed at a diabetic clinic and is assisting a client with maintenance of
blood glucose status. When assessing nurse–client responsibilities, which responsibility
does the nurse most expect of the client?
A) Be courteous to others.
B) Comply with the set regimen.
C) Be nonjudgmental.
D) Possess knowledge.
Ans: B
Feedback:
The nurse most expects the client to comply with the set regimen. The other options are
nursing responsibilities.
28. The nurse is preparing a community education program about a new treatment for
prostate cancer. At what level would the nurse prepare the distributed educational
materials?
A) Upper grade school, 4th to 6th grade level
B) High school, 10th to 12th grade level
C) Middle school, 7th to 9th grade level
D) College, over the 12th grade level
Ans: C
Feedback:
When preparing educational materials for the general population, the language or words
used should be at the middle school, 7th to 9th grade level.
Page 11
29. The nurse is caring for a geriatric client who has decided to move to a skilled nursing
facility. The nurse assisted with the arrangements and, when leaving the room, touched
the client on the shoulder. Which therapeutic technique was the nurse demonstrating?
A) Therapeutic communication
B) Affective touch
C) Silence
D) Task-oriented contact
Ans: B
Feedback:
Affective touch is used to demonstrate concern or affection. Its intention is to
communicate caring and support. Therapeutic communication and silence can be helpful
in this situation but does not it into the scenario. Task-oriented “touch” involves the
personal contact that is required when performing nursing procedures.
30. Which of the following teaching scenarios best illustrates the nurse providing informal
teaching on a low-sodium diet?
A) The nurse discusses dietary guidelines while the client watches a cooking show on
television.
B) The nurse, client, and spouse review dietary orders on the discharge instructions.
C) The nurse and client discuss the sodium contained in prepared canned soup.
D) The nurse and client meet with a dietician to discuss ways of limiting sodium.
Ans: A
Feedback:
Informal teaching is unplanned and occurs spontaneously such as when the client is
watching television and a teaching moment occurs. The remaining options were formal
teaching to meet the goal of dietary teaching on a low-sodium diet.
Page 12
31. An experienced nurse is evaluating a new nurse to the unit who is providing discharge
instructions to an adult client. The experienced nurse views the following: The nurse
approaches and decreases the volume on the television and then sits beside the client,
presenting the information to the client and spouse. The nurse states, “You are to take
Cipro 250 mg, two tablets b.i.d. A regular diet is ordered, and you are to follow up with
your physician in 2 weeks. Here is printed information on the medication ordered.” The
nurse obtains appropriate signatures and leaves. Which point would the experienced
nurse address?
A) The nurse should use shorter sentences when teaching.
B) The nurse should improve professionalism and stand.
C) The nurse should minimize medical terms when teaching.
D) The nurse should continue with the same method without changes.
Ans: C
Feedback:
When teaching adult clients, it is best to minimize technical terms and medical jargon
(“bid” for example) whenever able. The nurse used appropriate sentence length. Sitting
beside the client is appropriate, and it is best to reduce noise and distraction by
decreasing the volume of the television. With minimal change, the new nurse can
improve her teaching skill.
32. The charge nurse in a long-term facility is addressing a breach in care with a client's
family. Which body language would the family interpret as being sincere in the
statement?
A) Open hands
B) Downcast eyes
C) Shifting from foot to foot
D) Steepled fingers
Ans: A
Feedback:
Open hands is a form of body language representing sincerity. This body language
shows that the staff and facility care for the quality of care of the client and are open
about the details of care. Downcast eyes denotes remorse. Shifting from foot to foot
denotes a desire to get away or avoid the discussion. Steepled fingers is interpreted as an
authoritative approach.
Page 13
33. The nurse is providing therapeutic communication while changing a client's linen. The
client states, “Every time I urinate, I still feel the need to urinate again. This is so
disappointing.” The nurse states, “You don't feel that you are emptying your bladder.”
Which communication technique has the nurse used?
A) Open-ended questioning
B) Paraphrasing
C) Reflecting
D) Broad opening
Ans: B
Feedback:
Paraphrasing restates what the client is saying to demonstrate listening. This
communication technique also allows the client to offer further information on the
subject. Open-ended questioning provides an open-ended question for the client to
provide further information. Reflecting states the content back to the client and confirms
that the nurse is following the conversation. A broad opening starts the interaction and
relieves tension before addressing other issues.
34. The nurse is caring for a client who received a poor prognosis when the physician made
rounds. The client is quiet, tearful at times, and prefers to be in a darkened room. The
nurse observes a nursing assistant entering the room, turning on the lights, and stating
“Are we ready to get out of bed yet, the day is half over?” When addressing the
statement of the nursing assistant, which communication technique would the nurse be
most correct to discuss?
A) Giving disapproval
B) Belittling
C) Using clichés
D) Patronizing
Ans: D
Feedback:
Patronizing treats the client condescendingly as if incapable of making a decision.
Giving disapproval holds the client to a rigid standard and is sarcastic in response.
Belittling disregards how the client is responding as an individual and groups him or her
with others in the similar position. Using clichés provides worthless advice and curtails
exploring alternatives.
Page 14
35. The student nurse is providing skilled care for a palliative care client. The client is
bedbound, requiring skin care during bathing, oral care, and every 2 hours positioning.
Which NCLEX-PN test category would the student anticipate finding questions related
to this clinical care situation?
A) Health promotion and maintenance
B) Psychosocial integrity
C) Physiologic integrity
D) Safe and effective care environment
Ans: C
Feedback:
The role of the NCLEX-PN is to ensure that the student has sufficient knowledge to
progress to a competent entry-level practitioner. Linking clinical experiences to
classroom knowledge base is essential. This content falls under the physiologic integrity
subcategory of basic care and comfort. This category tests the skill of the nurse in a
clinical situation completing basic care needs. The health promotion and maintenance
category has content areas including caring for individuals through life transitions.
Psychosocial integrity includes caring for mental health needs and using therapeutic
communication. Safe and effective care environment ensures appropriate nursing care
and infection control.
36. Which of the following nursing statements, made to the client, best provides an example
of a broad opening?
A) “Wow, the weather is looking nice outside.”
B) “Would you like your pills whole or cut in half?”
C) “So you live in a ranch-style home with a bathroom off your bedroom.”
D) “Oh, your daughter lives within walking distance of your home.”
Ans: A
Feedback:
A broad opening is intended to open communication on a common topic and relieve
tension. Focusing on the weather provides that common topic to initiate communication.
Further communication and specific topics flow from this point. Inquiring about
medication administration is on a specific topic and in need of a specific response. The
other options deal with specific topic points presented during a discussion.
Page 15
1. Chapter 8
Which of the following concepts characterizes transcultural nursing?
A) Performing health-related activities and restoring wellness
B) Acknowledging that clients with the same skin have similar social situations
C) Planning care compatible with the client's health belief system
D) Influencing culture by specific conditions related to an environment
Ans: C
Feedback:
Planning care compatible with the client's health belief system is a characteristic of
transcultural nursing. Acknowledging that clients with the same skin color have similar
social situations leads to stereotyping. Stereotyping can be dangerous because it is
dehumanizing and also interferes in accepting others as unique individuals. Culture is
influenced by specific conditions related to environment. Performing health-related
activities and restoring wellness is an important aspect of nursing and does not only
pertain to transcultural nursing.
2. While providing personal care for a client, the nurse observes that the client is not
comfortable with the close physical proximity. How will the nurse alleviate the
discomfort of the client during personal care?
A) Speak words or phrases in the client's language.
B) Maintain sufficient distance.
C) Ensure that the client's family member is present.
D) Provide simple explanations of the need for physical proximity.
Ans: D
Feedback:
Simple explanations of the need for physical proximity during clinical procedures and
personal care alleviate the discomfort that the client may experience. Maintaining
sufficient distance and ensuring that the client's family member is present may not help
alleviate the discomfort some clients may experience. Speaking words or phrases in the
client's language will help in communicating with clients who do not speak English.
3. Native Americans who are wearing their tribal dress are demonstrating their native
dance to a community group. This is an example of which of the following?
A) Acculturation
B) Ethnicity
C) Race
D) Ethnocentrism
Ans: B
Feedback:
Ethnicity is the bond or kinship people feel with their country of birth or place of
ancestral origin. Race refers to biologic differences in physical features, such as skin
color and eye shape. Ethnocentrism is the belief that one's ethnic heritage is the
“correct” one and superior to others. Acculturation involves the process of adapting to
or taking on the behaviors of another group.
Page 1
4. Which of the following is the belief that one's values and beliefs are superior to others?
A) Acculturation
B) Ethnocentrism
C) Cultural imposition
D) Cultural taboo
Ans: B
Feedback:
Ethnocentrism is the belief that one's ethnic heritage is the “correct” one and superior to
others. Acculturation involves the process of adapting to or taking on the behaviors of
another group. Cultural imposition is the inclination to impose one's cultural beliefs,
values, and patterns of behavior on people of a different culture. Cultural taboos are
activities governed by rules of behavior that a particular cultural group avoids, forbids,
or prohibits.
5. The nurse patted the head of the child after examining her but noticed her parents did
not look pleased. In which of the following cultures is touching the head impolite?
A) Asian American
B) Native American
C) Orthodox Jewish
D) Anglo-American
Ans: A
Feedback:
In Asian American culture, touching of the head is impolite because the spirit rests
there. Native Americans may interpret the Anglo-American custom of a strong
handshake as offensive. Orthodox Jewish women highly value their modesty and must
keep their head and limbs covered.
6. The nursing instructor discussed the theory of energy forces existing between organisms
and objects in the universe and called this yin-yang. Yin-yang is an example of which
societal view of illness?
A) Biomedical perspective
B) Magico-religious perspective
C) Naturalistic perspective
D) Scientific perspective
Ans: C
Feedback:
The naturalistic view espouses that human beings are only one part of nature. The
yin-yang theory promotes the idea that energy forces exist between organisms and
objects in the universe. The balance between these forces is health. The biomedical or
scientific view embraces a cause-and-effect philosophy of human body functions. The
magico-religious view believes that supernatural forces dominate.
Page 2
7. Which of the following is a process by which the nurse consistently works in the
cultural context of the client, family, and community?
A) Stereotyping
B) Ethnicity
C) Cultural competence
D) Subculture
Ans: C
Feedback:
Providing culturally competent care is a process by which the nurse consistently
endeavors to work in the cultural context of the client and his or her family and
community. Stereotyping means assuming that all people in a particular cultural, racial,
or ethnic group share the same values and beliefs, behave similarly, and are basically
alike. Ethnicity is the bond or kinship that people feel with their country of birth or
place of ancestral origin. Subculture refers to a particular group that shares
characteristics identifying the group as a distinct entity.
8. People in Middle Eastern cultures do not drink milk after childhood. The nurse has
provided yogurt for the client at mealtimes. This is an example of which approach?
A) Culturally competent care
B) Ethnocentrism
C) Acculturation
D) Cultural blindness
Ans: A
Feedback:
Providing culturally competent care is a process by which the nurse consistently
endeavors to work in the cultural context of the client and his or her family and
community. Ethnocentrism is the belief that one's own ethnic heritage is the “correct”
one and superior to others. Acculturation involves adapting to or taking on the behaviors
of another group. Cultural blindness is an inability to recognize the values, beliefs, and
practices of others because of strong ethnocentric preferences.
Page 3
9. Which of the following refers to a group that shares characteristics identifying the group
as a distinct entity?
A) Minority
B) Culture
C) Subculture
D) Race
Ans: C
Feedback:
Subculture refers to a particular group that shares characteristics identifying the group as
a distinct entity. The term minority describes a group of people who differ from the
majority in a society in terms of cultural characteristics. Culture provides a means for
understanding people's values and beliefs. Race refers to biologic differences in physical
features, such as skin color and eye shape.
10. The nursing assistant was reluctant to allow the Muslim patient room for a prayer rug in
her room. The inability to recognize the values, beliefs, and practices of others because
of strong ethnocentric preferences is which of the following?
A) Acculturation
B) Cultural imposition
C) Cultural blindness
D) Cultural taboos
Ans: C
Feedback:
Cultural blindness is an inability to recognize the values, beliefs, and practices of others
because of strong ethnocentric preferences. Cultural taboos are activities governed by
rules of behavior that a particular cultural group avoids, forbids, or prohibits.
Acculturation involves adapting to or taking on the behaviors of another group. Cultural
imposition is an inclination to impose one's cultural beliefs, values, and patterns of
behavior on people from a different culture.
11. It is predicted that by 2080, Caucasians will be a minority in the United States. Which
statement best illustrates the correct assumption of the nurse in regard to minority
groups in the United States today?
A) Minority groups are decreasing in number due to the melting pot society.
B) Caucasian/White is in the majority so not considered a minority group.
C) Minority groups are classified according to the number of members in the group.
D) Society views minority groups as having less influence and power.
Ans: D
Feedback:
The defining characteristics for a minority group are not based on numbers but rather on
lack of control and powerlessness. White/Caucasian is one of the five population groups
delineated as a minority in the United States. Minority groups continue to be on the
increase in the United States.
Page 4
12. An elderly Japanese client refuses the care provided by a Korean-born nurse. The
outcome of this nurse–client assignment could be attributed to which cultural concept?
A) Ethnicity
B) Race
C) Generalization
D) Gender
Ans: A
Feedback:
Although both nurse and client are from the Asian race, they do not share a kinship or
originate from the same country. Trending of culture through generalization does not
apply, and the gender of the client is not explicit.
13. Among the Amish, decisions for healthcare treatment are made by the bishop who
governs the community. The nurse who provides extra time for the Amish client to
select a treatment option and access to discussion with the community bishop would be
best supported by which cultural concept?
A) Ageism
B) Stereotyping
C) Generalization
D) Ethnocentrism
Ans: C
Feedback:
Among the Amish, decisions for healthcare treatment are a community decision,
governed by the bishop. Generalization is using the knowledge of the trends within the
Amish community to guide the care of this client without stereotyping. Age and
superiority are not an issue with the care of this client.
Page 5
14. The nurse is completing discharge instructions for an Asian American client. The nurse
can best evaluate the likeliness of the client to adhere to the instructions by use of which
method?
A) Make the client promise to follow the instructions and be compliant with the plan.
B) Ask the client if he or she agrees with the instructions that are outlined.
C) Ask the client if there is anything in the discharge plan that will interfere with
compliance.
D) Observe the client's face to see if he or she is smiling, which can be interpreted as
compliance.
Ans: C
Feedback:
Asian Americans will not openly disagree with people in authority or who possess
advanced education. Often, smiling is a sign of harmony not acceptance or proof of
compliance in the Asian culture. Agreeing with the plan of care is not the same as
“doing” or complaining but finding out if there is anything in the plan of care that the
client does not agree to adhere to is a step to establishing a plan of care that is client
oriented.
15. The nurse is interviewing a Native American client for admission. The client is avoiding
answering the health history questions presented. Which is the best action for the nurse
to take?
A) Repeat the questions until they are understood and answered.
B) Direct the questions to the family members present.
C) Keep a written record of the conversation and refusal to answer questions.
D) Be patient and provide the opportunity for the client to tell his or her story.
Ans: D
Feedback:
Many Native Americans are private people and take time to place trust in others.
Questioning others and impatience are viewed as disrespectful in this culture. Listening
and patience is valued, whereas written records are a tradition of value.
Page 6
16. A Chinese client who believes in yin-yang theory is requesting permission for an
acupuncturist to restore the flow of energy (chi). Which is the best response by the
nurse?
A) “I welcome alternative therapies and hope you have good results.”
B) “I will check with your physician to see if this can be arranged.”
C) “If you take the pain medication that is ordered, you will not need an
acupuncturist.”
D) “Wow, I can't wait to see how this is done. I will make the arrangements for you.”
Ans: B
Feedback:
The nurse must inform the physician of requests for alternative treatment modalities
prior to arrangements for treatment. The nurse should not be judgmental in the choice of
treatment practiced by the client.
17. A Swedish client with the diagnosis of ovarian cancer confides in the nurse that they
practice holistic medicine. The client believes a cure exists through a macrobiotic diet,
rather than what surgery or medical treatment can achieve. Which statement by the
nurse is most appropriate?
A) “I wouldn't bet my life on a diet treatment plan.”
B) “We can talk to your doctor about adding this diet as a complementary therapy.”
C) “You should listen to your doctor, who is the expert on this condition.”
D) “Alternative treatments do not have good outcomes for this type of cancer.”
Ans: B
Feedback:
Nurses should support clients in their beliefs about health and illness. Complementary
treatments are treatments used in conjunction with mainstream medicine. Clients should
be provided the opportunity to incorporate health belief in practices into their plan of
care.
18. The nurse is caring for a Jewish client who follows a strict kosher diet. The nurse
discovers that the client has not taken the antihypertensive medication since discovering
the capsule was made of a pork gel. What should the nurse do first?
A) Contact the pharmacist to see if the medication comes in another form.
B) Notify the physician to report the lack of treatment as prescribed.
C) Assess the client's vital signs and document refusal of medication.
D) Remove the powder from the capsule and give to the client.
Ans: C
Feedback:
Assessing the data, including blood pressure is the first step of the nursing process.
Removing the powder does not solve the problem for continuing treatment. Contacting
the pharmacist to determine another form of the medication should be done after
assessing the client, and then the physician should be contacted and information/data
shared.
Page 7
19. A client of Japanese descent describes a family trait of having less relief from analgesics
than friends of White/Caucasian descent. The nurse recognizes that, because of this trait,
which statement applies?
A) The client may need higher doses of this drug.
B) The client may need lower doses of this drug.
C) This medication should not be prescribed to this client.
D) Biocultural ecology is the study of biologic cultural differences.
Ans: A
Feedback:
Even though biocultural ecology is the study of biologic cultural differences, it does not
answer the question. According to biocultural assessment, people of Japanese descent
metabolize certain drugs more quickly, which predisposes them to subtherapeutic drug
concentration, requiring higher drug doses.
20. The nurse is completing a cultural heritage assessment. Which items will be included in
this portion of the health assessment? Select all that apply.
A) Religion
B) Participation in religious traditions
C) Health history
D) Celebration of holidays
E) Use of tobacco
F)
Use of alternative therapies
Ans: A, B, D, F
Feedback:
Health-related beliefs and practices (such as religious traditions and celebration of
holidays, and use of alternative health practices) can reflect the cultural heritage of the
client. Asking questions can assist in determining cultural heritage. Religion, tobacco
use, and/or health history assists in the health history but does not reflect upon heritage
or culture.
Page 8
21. Because the nurse knows that many Arab groups embrace the hot/cold therapy
following childbirth, when the mother refused her lunch of Cobb salad and Jell-O,
which action should the nurse take?
A) Allow the mother time to rest.
B) Provide a menu for the next meal.
C) Offer a tuna salad sandwich and chips.
D) Ask the patient what she prefers to eat.
Ans: D
Feedback:
Many Arab groups embrace the hot/cold theory, and following childbirth, hot foods are
offered. Allowing a time for rest is appropriate, and providing an opportunity to select
the food for the next meal is also appropriate, but only after the mother is provided
nourishment. Tuna salad is cold.
22. Which is the best thing the nurse can do to provide culturally sensitive care?
A) Become familiar with physical differences among ethnic groups.
B) Provide the proper food for nourishment.
C) Accept each client as a unique individual.
D) Facilitate rituals that bring comfort to the client.
Ans: C
Feedback:
Becoming familiar with physical differences, providing food that is customary to the
culture, and facilitating rituals are all recommendations for enhancing sensitive cultural
care, but according to Leininger, accepting each client as an individual is a characteristic
that is found in the specialty of transcultural nursing.
23. The nurse is assigned to care for an elderly woman from India. As the nurse attempts to
obtain vital signs, the client pulls away, gathers covers to the chin, and speaks in a
language unintelligible to the nurse. What is the best action for the nurse to take?
A) Talk slowly and explain what he is doing.
B) Use gesturing and pictures to explain his actions.
C) Smile and take the vital signs anyway.
D) Attempt to retrieve an interpreter.
Ans: D
Feedback:
Ideally, obtaining an interpreter will increase the communication between client and
nurse. Talking slower or gesturing may not provide a clear understanding for client or
nurse. Proceeding without the approval of client could violate the client's cultural
beliefs.
Page 9
24. The nurse walks into the client's room and finds a shaman “fluffing the aura” of the
client. What is the best action of the nurse?
A) Leave the room and provide privacy to the client.
B) Call the physician to report the findings.
C) Ask the shaman to stop the process and leave the facility.
D) Notify security of the activity in progress.
Ans: A
Feedback:
By leaving the room and providing privacy the nurse supports the client in the quest to
practice health practices within his or her culture and beliefs. Documentation of the
activity is appropriate. Notifying the physician will not stop or support the belief.
Notifying security and/or asking the shaman to leave may anger the client and violate
the practice of a religious/cultural ritual.
25. A postpartum mother requested her placenta be sent home with her spouse. The
maternity nurse is upset and disgusted by the request and shares this view with the
charge nurse. What is the best action taken by the charge nurse?
A) Ignore the conversation and nurse's reaction.
B) Report the nurse for violation of HIPAA.
C) Report the conversation to the client and apologize for the lack of sensitivity of
the nurse.
D) Use this as a teachable moment on cultural sensitivity and health practices.
Ans: D
Feedback:
Increasing one's awareness of cultural sensitivity and health practices is the first step
toward transcultural nursing. Use this as a teachable moment. This is not a violation of
HIPAA. Reporting the conversation to the client would inflame the incident and not
serve a purpose.
26. The nurse would recognize which of the following statements as the best example of
stereotyping?
A) Many African Americans celebrate Kwanzaa.
B) Most Mexicans are living in the United States illegally.
C) Older adults tend to be more financially sound.
D) Hispanic men are at greater risk for stroke.
Ans: B
Feedback:
Stereotyping is a preconceived idea that is not supported by fact. There is no data to
support that most Mexicans are living in the United States illegally. There is data to
support the generalization of African Americans celebrating the cultural custom and
holiday of Kwanzaa. Older adults in the United States are the richest age group in the
United States, and Hispanic men do have a greater risk for hypertension and stroke.
Page 10
27. Which treatment option would the nurse identify as a viable option for the treatment of a
Jehovah's Witness client recovering from open heart surgery?
A) Erythropoietin (EPO)
B) Packed red blood cells
C) Fresh frozen plasma
D) Autotransfusion
Ans: A
Feedback:
The Jehovah's Witness takes a religious stand that those who respect life as a gift of God
will not sustain life by taking blood. The four primary components that are considered
blood are RBC, WBC, platelets, and plasma. Erythropoietin is a hematopoietic agent
and acceptable in use for promotion of blood stimulation.
Page 11
1. Chapter 9
Which type of therapy is speculated to affect the ion exchange of electrolytes, such as
calcium, sodium, and potassium?
A) Electromagnetic therapy
B) Shiatsu
C) Hypnosis
D) Yoga
Ans: A
Feedback:
Electromagnetic therapy is speculated to influence ion exchange of electrolytes, such as
calcium, sodium, and potassium. Shiatsu uses acupoints, and yoga uses exercises for
therapy. Hypnosis is not known to affect ions in the body.
2. Chiropractors treat disorders by which of the following methods?
A) Applying force to a specific location
B) Massaging the area to encourage circulation
C) Manipulating the spine to align vertebrae
D) Channeling the universal energy
Ans: C
Feedback:
According to chiropractic theory, misalignment of the spinal vertebrae changes activities
of nerves that control body functions in distant organs. This may lead to diseases. Spine
manipulation treats the disorders by correcting the alignment of the vertebrae. Applying
force to a specific location is the method of acupressure and not chiropractic. Massage
improves circulation, but this is not the main job of the chiropractor. Channeling
universal energy happens only in Reiki.
3. Which of the following complementary and alternative therapies uses 7,000 nerve
endings to improve the body's ability to facilitate natural healing?
A) Reflexology
B) Magnetism
C) Acupuncture
D) Chiropractic
Ans: A
Feedback:
Practitioners of reflexology claim that reflex centers in the extremities have more than
7,000 nerve endings connected to the body organs and tissues. When pressure is applied
to one reflex center, the impulse travels to the spinal cord and brain. This reconditioning
of the neural reflex facilitates natural healing. Magnetism seeks to cure by influencing
the natural magnetic field of body cells. Acupuncture is a procedure used in or adapted
from Chinese medical practice in which specific body areas are pierced with fine needles
for therapeutic purposes. Chiropractors manipulate the spine to correct its misalignment.
Page 1
4. A patient is entering the clinic today requesting a method that has few physical risks,
can be taught easily, and has provided evidence of positive effects. The patient is
requesting a conventional method. What type of treatment would you advise them of?
A) Reflexology
B) Magnetism
C) Acupuncture
D) Biofeedback
Ans: D
Feedback:
Biofeedback is a mind–body medical technique. Mind–body interventions, such as
imagery, humor, and hypnosis, have few physical risks, are easy to teach, and have
proved to be effective. Although reflexology, magnetism, and acupuncture have also
found acceptance, they lack these attributes, and questions remain about their
effectiveness.
5. Although 25% of prescription drugs are derived from plants, interest in self-treatment
using herbs has been on the rise. Which of the following is the reason for this?
A) Prescribed drugs are subjected to federal regulations.
B) Herbs are easily available.
C) There are differences in molecular structure between the source plant and the
synthesized drug.
D) Using only parts of a plant may not have the same effects as using the whole
plant.
Ans: D
Feedback:
Herbalists argue that consuming the whole plant has different effects. Prescribed drugs
contain only one or two extracts or synthetic substances that match the molecular
structure of the source plant. Therefore, in many cases, the molecular structure may be
the same. Regulations are relevant to producers of drugs or herbal products, not the
users.
6. In which of the following therapies is it believed that the practitioner gathers knowledge
about the disease and its cure from a higher power?
A) Herbal therapy
B) Ayurveda
C) Native American system
D) Chinese medicine
Ans: C
Feedback:
In the Native American system of medicine, the shaman or medicine man or woman
goes into a trance and communicates with a higher power to gather knowledge about the
disease and its remedy. Herbal therapy uses herbs with medicinal value, and Ayurveda
and Chinese medicine do not involve shamans and such spiritual practices.
Page 2
7. A client is taking gingko to improve her memory. In the teaching plan regarding this
herb, the nurse should include which of the following?
A) It may raise blood pressure.
B) Avoid this herb if allergic to plants.
C) There is a possible sensitivity to light.
D) Use caution if taking aspirin.
Ans: D
Feedback:
Clients should be advised to use caution if taking aspirin in conjunction with gingko.
Ginseng may raise blood pressure. Avoid echinacea if allergic to plants in the daisy
family. Taking St. John's wort may cause sensitivity to light.
8. Which of the following is an important benefit of incorporating laughter
therapeutically?
A) Increases cortisol levels
B) Increases the number of white blood cells
C) Blocks the release of endorphins
D) Stimulates the immune system
Ans: B
Feedback:
Laughter stimulates the immune system by increasing the number of white blood cells
and lowering cortisol, which suppresses immune function.
9. A patient is suffering from stress and tension of the neck and muscles. What
manipulative therapy would you use to apply pressure and movement to soft tissues?
A) Chiropractic
B) Shiatsu
C) Massage therapy
D) Yoga
Ans: C
Feedback:
Massage therapy involves applying pressure and movement to stretch and knead soft
body tissues. Chiropractic theory proposes that subluxation (misalignment) of the spinal
vertebrae alters nerve activities that regulate body functions in distant organs. Shiatsu is
similar to acupressure and acupuncture. Yoga does not involve applying pressure to soft
tissues.
Page 3
10. Proponents of which type of complementary health practice believe that reprogramming
the neural reflex improves the body's ability to facilitate natural healing?
A) Shiatsu
B) Reflexology
C) Yoga
D) Chiropractic
Ans: B
Feedback:
Reflexologists believe that reconditioning or reprogramming the neural reflex improves
the body's ability to facilitate natural healing. Yoga, shiatsu, and chiropractic do not use
this type of healing.
11. A client with hyperlipidemia is taking niacinamide (niacin). The nurse understands this
to be which type of treatment?
A) Herbal therapy
B) Complementary therapy
C) Alternative therapy
D) Conventional therapy
Ans: C
Feedback:
Niacin is a biologically based therapy (vitamin) that can assist in lowering cholesterol
levels. Biologically based practices used alone are considered alternative therapy.
Niacin would not be considered conventional in the treatment of hyperlipidemia and
unless used in conjunction with a prescription drug would not be considered
complementary. Niacin is not an herbal preparation.
12. A client asks the nurse if watching funny videos can help in the treatment of cancer.
Which is the best response from the nurse?
A) “Visualizing your body fighting the cancer can be helpful.”
B) “Laughter can stimulate your immune system.”
C) “Laughing is better than crying.”
D) “Use of humor is an approved form of cancer treatment.”
Ans: B
Feedback:
Laughter stimulates the immune system by increasing the number of WBCs and
suppressing the cortisol levels. Visualizing the fighting of cancer is imagery, not humor
therapy. Use of humor is an optional mind–body therapy not an approved
evidence-based form of cancer treatment.
Page 4
13. Which statement by the nurse best supports an understanding of complementary and/or
alternative therapies in the treatment of clients?
A) “Alternative therapies are mainstay to conventional medical care.”
B) “Complementary therapies should be avoided in advanced disease.”
C) “Complementary therapies are evidence-based in theory.”
D) “Alternative and complementary therapies are sensitive to culture and tradition.”
Ans: D
Feedback:
Complementary and alternative therapies are sensitive to culture and tradition and can
be used in conjunction with, or independent of, conventional therapies. In advanced
disease processes, complementary therapies can assist with comfort measures for the
client.
14. The nurse understands that offering chaplain services in the acute care facility supports
which healing concept?
A) Cure for disease
B) Relief for the hopeless
C) Spiritual healing
D) Body cleansing
Ans: C
Feedback:
Chaplains provided spiritual support and prayer as forms of spiritual healing. No
evidence supports prayer as a cure for disease but can bring comfort during hopeless
situations. Body cleansing is a physical not spiritual event.
15. What is the best response by the nurse when explaining biofeedback to a client?
A) “It is a spiritual practice that combines exercise with mental focus.”
B) “It is beneficial in expressing feelings.”
C) “It allows a reduction of symptoms through voluntary control measures.”
D) “It requires the use of machines in a controlled environment.”
Ans: C
Feedback:
Biofeedback is a technique in which an individual voluntarily controls physiologic
function. Yoga is the spiritual practice that combines exercise with mental focus. Music
and art are ways to express feelings. Initially, biofeedback uses a machine but
eventually the client can alter physiologic response at will.
Page 5
16. A client with multiple sclerosis (MS) reports an improvement of symptoms after
apitherapy. The nurse knows that apitherapy falls under which category of treatment?
A) Mind–body medicine
B) Biologically based practices
C) Manipulative and body-based therapies
D) Energy medicine
Ans: B
Feedback:
Apitherapy is the medicinal use of bee venom and falls under the category of
biologically based practices. Mind–body, manipulative, and energy medicine are
categories of complementary and alternative therapies but do not include apitherapy.
17. What is the primary reason the nurse needs to ascertain client use of vitamins and
minerals and the dosage of each?
A) Intake of vitamins and minerals through diet is more beneficial.
B) Vitamin and minerals should be used as a complementary therapy.
C) Recommended daily allowance (RDA) for each vitamin and mineral may vary
with special populations.
D) Vitamins and minerals are purchased over-the-counter (OTC) and no purchase
record is maintained.
Ans: C
Feedback:
Special populations (such as pregnant women, elderly, and people with certain medical
problems) may have different RDA requirements and levels for toxicity. Answers A, B,
and Dare all true statements but are not the primary reason for accurate information
collection.
18. A client, who is taking a variety of herbal preparations, makes the following comment to
the nurse: “Herbs are natural products and therefore safe.” Which is the best response by
the nurse?
A) “Just because a product is natural does not mean safe.”
B) “If the manufacturer is reputable, the product is considered safe.”
C) “Many herbs are safe, but serious effects can occur if mixed with prescribed
drugs.”
D) “The chemicals used when growing herbs can prove to be poisonous or toxic to
people.”
Ans: C
Feedback:
Herbal therapy is one of the greatest risk factors for adverse effects when combined with
other conventional treatment such as drugs. The U.S. Food and Drug Administration
(FDA) do not regulate herbals making natural not necessarily safe. The use of reputable
manufacturers should be considered but again not a guarantee for safety. The process of
growing and harvesting herbs is not regulated.
Page 6
19. A client with stage II cancer has opted to use reflexology and herbal therapy for
treatment. The nurse understands this treatment falls under which modality?
A) Culture care
B) Complementary therapy
C) Integrative therapy
D) Alternative therapy
Ans: D
Feedback:
The use of reflexology and herbs is considered alternative therapy when not used in
conjunction with conventional medicine. Integrative therapy would combine alternative,
complementary, and conventional medicine. Culture care is the delivery of care as
sensitive to the culture and ethnic traditions of a client.
20. A client with arthritis finds relief of pain in the practice of tai chi, acupuncture, and
massage. The nurse understands this medical system approach to originate from which
culture?
A) Ayurvedic medicine
B) Western medicine
C) Chinese medicine
D) Native American medicine
Ans: C
Feedback:
Balancing life's energy source through the use of tai chi, acupuncture, and massage are a
part of Chinese Medicine. Ayurvedic medicine is practiced in India using fasting, yoga,
cleansing, etc. Native American medicine uses shaman, symbols, and herbs in
treatments. Western medicine is a form of conventional medicine.
21. Which nursing comment would best describe the conventional medical system to a
client?
A) “Focus is on treating illness or injury.”
B) “Sensitive to cultural traditions.”
C) “Health results from harmony between person and universe.”
D) “Approach is based on traditional use.”
Ans: A
Feedback:
Conventional medical systems are based on scientific approach for treating illness or
injury. Alternative medical systems are sensitive to culture and harmony between person
and universe, which uses a more traditional approach.
Page 7
22. Body-based therapy that uses manipulation can be delivered to the client via which
forms of treatment? Select all that apply.
A) Acupuncture
B) Aromatherapy
C) Tai chi
D) Therapeutic touch
E) Apitherapy
F)
Reflexology
Ans: C, F
Feedback:
Tai chi and reflexology are manipulative body-based therapies. Acupuncture and
therapeutic touch (Reiki) are energy therapies. Aromatherapy and apitherapy are
biologically based practices.
23. In preparing the client for a reflexology consult, the nurse knows to allow full access to
which body parts?
A) Spine
B) Face
C) Lower extremities
D) Abdomen
Ans: C
Feedback:
Reflexology is the application of pressure to the foot. Manipulation of the spine is used
in chiropractic care. Iridology looks into the eyes, and Reiki uses therapeutic touch to all
seven chakras, which involve both head and trunk.
24. A client with fibromyalgia is using magnets as a form of complementary treatment.
Which rationale given by the nurse best explains the physiologic principle of this
technique?
A) Free flow of energy
B) Stimulates the release of endorphins
C) A means of therapeutic touch
D) No therapeutic effects with this technique
Ans: B
Feedback:
Static magnet therapy can be used to affect the cell membrane and stimulate the release
of endorphins. No scientific basis is available to support this effect, but people continue
to claim benefits if nothing other than placebo effect. Free flow of energy refers to
acupuncture, whereas therapeutic touch is associated with Reiki therapy.
Page 8
25. Which key information can the nurse provide to the client, in regard to the health-related
benefits of herbals and botanicals? Select all that apply.
A) Certain herbs can interact with prescription drugs.
B) No one should take herbs while acutely ill.
C) Herbs can mimic disease symptoms.
D) Not all herbs are safe.
E) Herbs are regulated by the U.S. Food and Drug Administration.
F)
Only natural herbs are safe.
Ans: A, D
Feedback:
Herbal therapy is one of the greatest risk factors for adverse effects when combined with
other conventional drugs. Some herbs have been placed on the “unsafe” list due to
known impurities and adverse effects, even though all herbs are considered natural.
Herbs can be used to treat some acute illnesses. Herbal therapy is not regulated by the
FDA.
26. A child recovering from a traumatic injury is encouraged to express feelings through
pictures. The nurse recognizes this as which type of therapy?
A) Music therapy
B) Relaxation therapy
C) Imagery
D) Mind–body therapy
Ans: D
Feedback:
Art, music, imagery, and relaxation therapy are all mind–body interventions.
27. When the nurse is assisting the client in the selection of complementary therapies, which
of the following factors is most important to consider?
A) Supporting the client's choice at all costs
B) Evidence-based support
C) Certification of the therapist
D) Cultural beliefs of the client
Ans: D
Feedback:
What constitutes health and illness is dependent on the social, education, and spiritual
differences between cultures. Nurses should be supportive of client's choices as long as
they are not potentially harmful. Not all therapies have extensive research or evidence to
support use so benefits, and risks need to be reviewed on an individual basis. The use of
therapists who are certified or well established should be a consideration.
Page 9
28. When the views of the nurse and client differ in regard to complementary therapies,
what is the best action taken by the charge nurse?
A) Have the nurse attend cultural care classes.
B) Counsel the nurse to understand her differences in opinion.
C) Encourage the nurse to support the client.
D) Maintain the assignment as posted.
Ans: B
Feedback:
It is important for the nurse to respect and advocate for the client even when cultures or
choice of therapies differ. When the nurse is unable to support the client in this process,
due to culture or religious concerns, the assignment should be altered. Opportunities to
share or attend culture care classes should be offered to all staff.
29. The client asks the nurse to assist in the selection of complementary therapy. Which of
the following should guide the nurse in this process?
A) Comfort zone of the nurse
B) First do no harm
C) Reason for the treatment
D) Knowledge of all nontraditional options
Ans: B
Feedback:
The nurse should support the client in choice of therapy as long as there is no potential
for harm. The nurse's comfort zone is not the focus of importance. The reason for the
treatment is not as important as the desired outcome or goal. Gaining knowledge about
complementary and alternative therapies is an important role of the nurse, but knowing
about all options may not be realistic.
30. Which statement by the nurse provides the best description of homeopathic medicine?
A) “Like cures, like in treatment of disease.”
B) “Prevention is the key to good health.”
C) “Opposites attract in keeping balance.”
D) “A fight between body and spirit.”
Ans: A
Feedback:
Homeopathy proposes that the remedy for an illness be one that produced the
symptoms. Preventive care is naturopathic in nature. Chinese medicine deals with the
yin and yang in keeping balance. Folk medicine deals with the struggle between body
and spirit.
Page 10
31. A cancer client considers traveling to Mexico to begin coffee enema therapy and asks
the nurse for advice. Which is the best response by the nurse?
A) “There are many unproven treatments for cancer. Let's discuss this with your
doctor.”
B) “That would be an expensive trip. Can you afford it?”
C) “Maybe your doctor can order the coffee enemas to be given here.”
D) “Sounds like a good option. How can I help you make the arrangements?”
Ans: A
Feedback:
Nurses can play a pivotal role in assisting clients in therapy selection, but they need to
be cognizant of realistic options choices that are legal, without false hope, and within
the scope of practice for nurses. Although the trip could be expensive, this response is
not therapeutic. For those techniques that are still investigational, the nurse should
caution the client.
32. Following antibiotic treatment, the client has developed diarrhea. Which is an
appropriate complementary treatment for the nurse to offer this client?
A) Apples
B) Peppermint
C) Cultured yogurt
D) Whole milk
Ans: C
Feedback:
Cultured yogurt is a probiotic that can lower the frequency or duration of diarrhea.
Apples do not assist in relieving diarrhea. Peppermint is helpful in decreasing nausea.
Whole milk is not a probiotic unless it is acidophilus milk.
33. A client, who uses compresses to relieve hemorrhoid discomfort, asks the nurse for
some witch hazel. Which is the best action of the nurse?
A) Explain that witch hazel is not an available drug.
B) Contact the physician for an order for Tucks hemorrhoid wipes.
C) Have the family bring witch hazel from home.
D) Set up a sitz bath for the client.
Ans: B
Feedback:
Tucks hemorrhoid wipes contain witch hazel, an herbal supplement that helps to soothe
the discomfort associated with this condition. It is not appropriate to ask family to bring
OTC drugs into the facility. A sitz bath may be helpful in treating the symptoms but
requires a physician's order and is not the complementary therapy requested by the
client.
Page 11
34. The client is presently taking a multivitamin and is considering adding mineral-rich
(liquid vitamins) and eye health vitamins to the daily routine. Which is the best response
by the nurse?
A) “It is best to consume vitamins through a food source.”
B) “Can you show me the vitamin containers so we can review them together?”
C) “Some vitamins can have toxic effects.”
D) “Are you having symptoms of night blindness?”
Ans: B
Feedback:
Reviewing the vitamin containers will provide the nurse and client with information on
the dose of vitamins and whether they fall within the RDA. This can also provide an
opportunity for further teaching. Vitamins consumed in food sources are better than
supplements, but this is not the best response. Fat-soluble vitamins can have toxic
effects, but determining doses is a preventable measure. Vitamin A found in eye vitamin
supplements is used to prevent night blindness but is not the best response for this client.
35. The nurse is concerned when the prothrombin time (PT) for a client receiving warfarin
(Coumadin) is fluctuating beyond normal range. The nurse suspects which supplement
to be the cause of this elevation?
A) Garlic
B) Saw palmetto
C) Vitamin C
D) Ginseng
Ans: A
Feedback:
Combining garlic with other anticoagulants can prolong bleeding. Saw palmetto is used
to treat enlarged prostate and has no effects on bleeding. Vitamin C is a water-soluble
vitamin and can cause calculi formation. Ginseng is used to increase energy and can
result in elevation of blood pressure.
Page 12
1. Chapter 10
Which of the following nursing interventions will a nurse perform to transfer heat and
improve circulation in a dying client?
A) Change the position frequently.
B) Gently massage the arms and legs.
C) Administer warm intravenous fluids.
D) Administer intramuscular injections.
Ans: B
Feedback:
A nurse should gently massage the client's arms and legs to transfer heat and improve
circulation in a dying client. Changing the position frequently helps protect the client's
skin from breakdown. Administering warm intravenous fluids and intramuscular
injections will not help transfer heat and improve circulation in a dying client.
2. Which of the following should the nurse report so that the team can consider alternative
nutritional and fluid administration routes for a dying client?
A) Altered gastrointestinal function
B) Drop in blood pressure and rapid heart rate
C) Weight loss and inadequate food intake
D) Irregular eating habits
Ans: C
Feedback:
The nurse should report weight loss and inadequate food intake so that the team can
consider alternative nutritional and fluid administration routes for a dying client. The
nurse need not report altered gastrointestinal function because it is a normal part of the
dying process. A nurse should also not report a drop in blood pressure and rapid heart
rate or irregular eating habits.
3. Which of the following nursing interventions should a nurse perform to promote the
dignity and self-esteem of a dying client?
A) Communicate hopefulness.
B) Keep the client clean and well groomed.
C) Share emotional pain.
D) Help the client live according to his or her wishes.
Ans: B
Feedback:
A nurse should keep the client clean, well groomed, and free of unpleasant odors to
promote his or her dignity and self-esteem. Although sharing emotional pain is an
essential component of care for dying clients, it will not promote their dignity and selfesteem. Communicating hopefulness helps sustain hope in dying clients. Helping the
client live according to his or her wishes is a feature of hospice care.
Page 1
4. Which of the following interventions should the nurse perform to prevent drying of the
oral mucous membranes and lips in a dying client?
A) Place the client in a cool temperature.
B) Provide water to the client at regular intervals.
C) Provide the client with absorbent pads.
D) Provide oral care, ice chips, and petroleum jelly.
Ans: D
Feedback:
The nurse provides oral care, ice chips, and petroleum jelly because mouth breathing
makes the oral mucous membranes and lips dry. Placing the client in a cool temperature
and providing water to the client at regular intervals will not help prevent drying of the
oral mucous membranes. Providing the client with absorbent pads is useful only when
the client has lost bladder control and does not prevent drying of the mucous
membranes.
5. Which of the following nursing interventions should be implemented for the dying
client who is incontinent of urine, with associated skin breakdown, and exhibits a
decreased level of consciousness?
A) Insertion of an indwelling catheter
B) Use of absorbent pads
C) Offering a bedpan every 4 hours
D) Assisting the client to the commode every 2 hours
Ans: A
Feedback:
The client may need an indwelling or external catheter, particularly if skin breakdown is
a problem. The other options would not be appropriate for the dying client.
6. Which of the following is an appropriate intervention for the client with pulmonary
edema?
A) Administer the prescribed sedative to decrease anxiety.
B) Suction as needed to clear the lungs.
C) Position the client supine.
D) Use chest percussion.
Ans: A
Feedback:
Suctioning will not clear the lungs or ease breathing if the client has pulmonary edema.
In this situation, the physician may prescribe a sedative to relieve the anxiety created by
the feeling of suffocation.
Page 2
7. What major complication is associated with oral intake in the client with a decreased
level of consciousness?
A) Distended abdomen
B) Nausea
C) Aspiration
D) Pocketing of food
Ans: C
Feedback:
Difficulty in swallowing, gastric and intestinal distention, and vomiting create a
potential for aspiration of fluids and a decrease in food intake.
8. Which of the following is a nursing intervention for promoting self-care in the dying
client?
A) Apply glycerin to the lips.
B) Promote active range-of-motion exercises every hour.
C) Avoid oral hygiene to minimize risk of aspiration.
D) Assist with personal hygiene.
Ans: D
Feedback:
The nurse may need to assist with personal hygiene. Petroleum jelly helps keep the lips
lubricated. Active range-of-motion exercises do not need to be done every hour. The
nurse gives oral care and ice chips because mouth breathing makes the oral mucous
membranes and lips dry.
9. Which of the following is an example of near-death awareness?
A) Feeling warm and peaceful
B) Floating above one's body
C) Premonition regarding date and time of death
D) Moving rapidly toward a bright light
Ans: C
Feedback:
Near-death awareness is a phenomenon characterized by a dying client's premonition of
the approximate time and date of death. Near-death experiences include feeling warm
and peaceful, floating above one's body, and moving rapidly toward a bright light.
Page 3
10. Which of the following is an appropriate intervention to promote sleep in the dying
client?
A) Cluster necessary activities.
B) Awaken client every three hours.
C) Allow a steady stream of visitors.
D) Provide maximal environmental stimulation to the client.
Ans: A
Feedback:
Nurses must cluster activities to avoid awakening the client and to protect the client
from a steady stream of healthcare workers or visitors.
11. The nurse is caring for a pediatric client who is dying. The best way to provide care and
comfort to dying clients and their families is to first do which of the following?
A) A workshop on caring for the dying client
B) Use evidence-based practice in daily care regimen.
C) Explore own feelings on mortality and death and dying.
D) Participate in a support group to learn clients' feeling on care.
Ans: C
Feedback:
To care for others in the dying process, the nurse must explore his or her own feelings
about mortality and death and dying. Understanding self provides a perspective to cope
with and then support clients and families experiencing pain and grief. The other options
are helpful in determining appropriate nursing care but not the first step.
12. A client has learned of a terminal illness and impending death. The client asks the nurse
to explain the concepts and care that are provided under the definition of palliative care.
Which of the following would the nurse include in the explanation for this client? Select
all that apply.
A) Provides pain relief
B) Includes chemotherapy
C) Integrates spirituality
D) Hastens death
E) Offers a team approach to care
F)
Enhances quality of life
Ans: A, C, E, F
Feedback:
The principles of palliative care include providing relief from pain and distressing
symptoms. In the early course of disease, chemotherapy and radiation may be used to
define care needed, but in the later stages, chemotherapy is typically not used.
Psychological support including spirituality and bereavement counseling for family
members is available. The care does not hasten nor postpone death but is aimed at
enhancing a quality of the life that is remaining. A team approach meets the needs of the
client and family.
Page 4
13. When considering care for the dying, which awareness, by the nurse, provides the best
rationale for general nursing care?
A) Comfort measures are essential during this period.
B) Death is the final stage of growth and development.
C) Care for grieving family members is important.
D) Technology extends death and dying.
Ans: B
Feedback:
When providing nursing care for the dying, it is important to recognize that death is
natural, universal, and the final stage of growth and development. Comfort measures
and care for grieving family members are specifics that guide nursing interventions.
Technology does not always extend death and dying.
14. The nurse is caring for a client who just learned of his terminal diagnosis. After the
physician leaves, the nurse remains to answer further questions so that the client can
make an informed decision about further treatment. By providing all available
information, the nurse is promoting which ethical principle?
A) The principle of justice
B) The principle of nonmaleficence
C) The principle of fidelity
D) The principle of autonomy
Ans: D
Feedback:
By promoting open discussion and informed decision making, the nurse is empowering
the client to make his own decisions leading to autonomy. The principle of justice
requires fairness and justice to all clients. The principle of nonmaleficence requires that
nurse does not intentionally or unintentionally inflict harm on others. The principle of
fidelity maintains that nurses are faithful to the care of the clients.
Page 5
15. A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation
for an aggressive lung cancer. The treatment success is limited in shrinking the tumor,
and the treatments are making the client very ill. The client states, “I feel that I would
like to stop treatments. I would like to enjoy the time that I have remaining with my
family.” Which emotional reaction does the nurse recognize that the client is
experiencing?
A) Denial
B) Bargaining
C) Anger
D) Acceptance
Ans: D
Feedback:
In the final stage, dying clients accept their fate and makes peace spiritually and with
those to whom they are close. Clients begin to detach themselves socially and wish to be
with only a small group of close friends and family. The other options are stages that
occur earlier in the process.
16. The nurse is caring for a client who has diminished lung function due to emphysema.
The terminally ill client is short of breath on exertion and states he has difficulty
sleeping in bed. The client states, “I am so afraid of getting any worse.” Which
statement, by the nurse, assists the client in sustaining hope?
A) “Do not worry, I will be here for you to help you with your needs.”
B) “I will talk with the physician to determine the next step in your care.”
C) “Your grandchild is almost here, and you will enjoy seeing it.”
D) “I hear you say that you are not sleeping well.”
Ans: B
Feedback:
The client is assisted in hopefulness by believing that the healthcare team will make his
remaining days meaningful. By conveying a sense that the nurse will discuss the client's
condition with the physician, the client recognizes that the healthcare team will use
whatever treatment and comfort measures are available. Telling a client not to worry is
not therapeutic and is condescending. Waiting for a grandchild does not address the
client's thought. Reflecting what the client said for clarification opens communication
but does not instill hopefulness.
Page 6
17. The nurse is caring for a 90-year-old male who has never completed an advanced
directive. The man has a son but has not seen him in several years. A neighbor has
assisted him with meals and housecleaning for many years. The neighbor states that the
client expressed only wanting to have comfort measures. The estranged son wants his
father to be treated aggressively. Which would be the nurse's initial step?
A) Follow the son's directive.
B) Follow the neighbor's directive.
C) Assess the client's ability to state wishes.
D) Notify the physician of the discrepancy.
Ans: C
Feedback:
It cannot be assumed that the client is unable to make his own decisions just because of
his advanced age. Before any other person is asked about the client's wishes, the client
needs to be asked first. The physician, who has a healthcare relationship with the client,
may also have documented information about wishes.
18. A terminally ill client is admitted to a hospice facility. The client has an advanced
directive indicating that no heroic measures be used to prolong life. What is the most
appropriate nursing action when death appears imminent?
A) Sit quietly and stroke the client's hand.
B) Notify the client's clergy of the potential for death.
C) Call the funeral home to notify of imminent death.
D) Move the client to a private room.
Ans: A
Feedback:
The nurse's greatest gift to give the client at the end of life is to spend time with the
client. That time can be spent quietly. This helps the client to not feel abandoned and to
die with dignity. It is premature to notify the clergy or funeral home. The nurse would
not move the client to another room at this time.
19. The family of a terminally ill client is deciding between home care and a hospice
facility. When comparing options, which factor of home care needs regular assessment?
A) Pain control
B) Caregiver strain
C) A comfortable environment
D) Transportation to appointments
Ans: B
Feedback:
A negative factor of home care is the burden it places on the primary caretaker. If
prolonged, the role can be isolating and tiring. Regular assessment, by the nurse, is
needed to ensure care for both client and family. Pain control is the same in home care
or at a hospice facility. Although a comfortable environment is important and
transportation to appointments may be needed, it is not as important.
Page 7
20. The nurse is caring for a client at the end of life. The client is ordered a regular dosage
of narcotics and short-acting narcotics for breakthrough pain. When administering the
narcotics, the nurse is correct to realize which of the following?
A) Death is imminent.
B) Side effects must be treated.
C) Dosages are restricted.
D) Patient may become sedated.
Ans: B
Feedback:
The nurse who is administering narcotics at the end of life still must realize that there
are side effects from the narcotics which must be addressed. Depending on the status of
the client, death may be days or weeks away, not imminent. Pain medications are
liberally given at the end of life to ensure that the client is comfortable. Typically, pain
medications relax the client as the pain level is eased. The client is not sedated.
21. A nurse is caring for a terminally ill client inquiring about physician-assisted suicide.
Which statement, made by the nurse, would correctly advocate for the practice?
A) The physician administers a lethal dose of medication via IV.
B) The physician provides the means for the clients to take their life.
C) The physician provides the means and waits to pronounce them dead.
D) The physician provides counseling and has a third party physician assist in the
suicide.
Ans: B
Feedback:
Physician-assisted suicide is the practice of providing a means by which a client can end
his or her life. Much controversy exists concerning the practice. Oregon, Washington,
and Montana are the only states that permit physician-assisted suicide. The physician
does not personally administer the dose, wait until the client is dead, or have a third
party physician involved.
Page 8
22. Which cardiovascular findings indicate to the nurse that the condition of the dying client
is worsening?
A) Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with
mottled feet and ankles
B) Pulse 72 beats/minute, irregular; patient confused and agitated
C) Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor
D) Pulse 60 beats/minute, blood pressure 90/42 mm Hg, difficult to arouse
Ans: A
Feedback:
Earlier, a client with failing cardiac function exhibits a higher pulse as the body attempts
to circulate oxygen. Next, cardiac output is decreased due to ineffective filling of the
chambers, impairing circulation, and diminishing the heart's own oxygen supply. The
heart rate and blood pressure then decrease. Peripheral circulation is impaired with the
feet and ankles becoming pale and mottled.
23. The nurse is caring for a dying client in a hospice setting. The family is unsure whether
to go home for rest or spend the night with the client. Which body system would the
nurse assess to provide the first data on decline?
A) Central nervous system
B) Cardiovascular system
C) Respiratory system
D) Gastrointestinal system
Ans: B
Feedback:
The key word is “first.” Failing of cardiac functioning is one of the first signs that a
condition is worsening. Symptoms within the other systems can also denote
deterioration over time.
Page 9
24. A nurse is caring for a dying patient. The family asks the nurse why there is a rattling in
their loved one's chest. Which response is most appropriate?
A) The client picked up a virus and has respiratory symptoms.
B) The client has been lying in bed and secretions pool in the lung bases.
C) There is an accumulation of fluid in the pulmonary circulation and secretions
throughout the respiratory tract.
D) Thick sputum accumulates as the client dehydrates from having little oral intake.
Ans: C
Feedback:
Failure of the heart's pumping function causes fluid to collect in the pulmonary
circulation. Also, there is an accumulation of secretions in the respiratory tract. Both
account for noisy respirations or what is called the death rattle. The client is typically
not exposed to crowds where virus can be passed. Also, the symptoms the dying process
would be different from that of a viral infection. It is true that secretions may pool in the
lung bases; however, further symptoms cause the audible rattling in the upper bronchial
tree. Although oral fluids may be limited, thick sputum is not common during the dying
process.
25. As the moment of death approaches, which of the following does the nurse encourage
the family to do?
A) Have the family sit in front of the client so they can be seen.
B) Rub the client's hand and arm to comfort the client.
C) Speak to the client in a calm and soothing voice.
D) Lie next to the client and hold the client.
Ans: C
Feedback:
Sight and touch diminish as the client approaches death; however, hearing tends to
remain intact. Speaking to the client calmly is most appropriate.
26. Which of the following is the nurse's primary concern when providing end-of-life care
for a client and the family? Select all that apply.
A) Maintaining client comfort
B) Arranging plans for after death
C) Supporting family members
D) Providing personal care
E) Completing a head-to-toe assessment
F)
Encouraging fluids
Ans: A, C, D
Feedback:
Nursing care of dying clients focuses on providing palliative care to the client and
supporting family members. Arranging the plans after death is not a priority at this time.
Completing a head-to-toe assessment may be completed for information but is not a
priority at the end of life. There is no need to encourage fluids.
Page 10
27. The family of a dying client being cared for at home is requesting information on how
best to prepare food. Which suggestion by the nurse may stimulate appetite?
A) Eating alone so the client can eat at his own pace and not be hurried
B) Providing several choices on the plate so that the client has what may appeal to
him
C) Offering high caloric foods to build fat and muscle
D) Preparing cool or cold foods that may be better tolerated
Ans: D
Feedback:
Preparing cool or cold foods may be tolerated better by the client and thus stimulate
appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a
mealtime companion making the eating experience more pleasurable. Offering small
portions is appropriate because large, multiple portions/choices may shut down the
appetite. Although weight loss may be significant, clients should have the ability to pick
and choose foods that interest them.
28. The nurse is caring for a client who is in the dying process. The nurse is reviewing
orders to confirm that all is being done to meet client needs. Which additional nursing
intervention may be helpful?
A) Lay client in the supine position.
B) Apply glycerin products for moisture.
C) Reposition client every 2 hours.
D) Remove extra blankets and covers.
Ans: C
Feedback:
A drop in blood pressure and heart failure lead to poor tissue and organ perfusion.
Repositioning the client every 2 hours protects the skin from breakdown. Typically, the
client is at a semi-Fowler's position to assist with respiratory function. Glycerin products
pull moisture from the tissue and accentuate the drying process. Extra covers are
typically needed to ensure comfort.
29. The nurse is caring for a client who is interested in learning about hospice care. Which
of the eligibility criteria would the nurse stress?
A) Serious, progressive illness
B) Choice of palliative care over cure focused
C) Limited life expectancy
D) Physician-certified illness
Ans: B
Feedback:
An important focus of hospice care is that care is palliative in nature. No further
aggressive treatment to find a cure for the illness is administered. The client must accept
this philosophy of care. The other options are factual and agreed on.
Page 11
30. The family of a dying client is noticing that their loved one is short of breath, restless in
bed, and appears to be trying to tell them something. Which nursing intervention is
appropriate at this time?
A) Offer the bedpan to urinate.
B) Call the physician to obtain an anxiolytic.
C) Get the client out of bed to the chair.
D) Offer the client sips to drink.
Ans: B
Feedback:
Clients may become restless and agitated when experiencing difficulty breathing.
Obtaining an anxiolytic can reduce the client's anxiety and agitation. It is difficult for
families to see the client agitated and trying to express something. It leaves the family
feeling frustrated and with a lingering memory after death. Before death, the client loses
muscle control of the bowel and bladder, needing a disposable undergarment. Sitting in
the chair and offering sips to drink is not something necessary at the end of life.
31. The hospice nurse is visiting the client in the home. The client is comfortable with
talking to the nurse. Which of the following statements, made by the client,
demonstrates that the spiritual needs are being met?
A) “I believe that there is a better place.”
B) “I am comfortable and feel no pain.”
C) “Family is the most important thing to me.”
D) “There have been many positives in my life, and I am grateful.”
Ans: A
Feedback:
When the client states hopefulness in an afterlife, it is a positive statement that the
spiritual needs are being met. Religious beliefs and customs influence attitudes about
death. The other options are positive statements of living in the here and now. This does
not address the spiritual needs.
32. All nurses care for clients who are grieving. It is important for the nurse to understand
the grieving process for which reason?
A) Allows for the nurse to facilitate the grieving process
B) Allows for the nurse to take the client through in the appropriate order
C) Allows for the nurse to understand when the grieving process should be concluded
D) Allows the nurse to express his or her feelings
Ans: A
Feedback:
Grieving is a painful yet normal reaction that helps clients cope with loss and leads to
emotional healing. The nurse is responsible for facilitating the grieving process and
helping the client and family deal with their emotions.
Page 12
33. Which action, following the death of a loved one, would the nurse witness the Chinese
American family members doing?
A) Praying beside the body
B) Washing the body
C) Calling the spirits
D) Perfuming the body
Ans: B
Feedback:
Following the death of the Chinese American client, some family members prefer to
wash their loved one themselves. By cleansing the body, it is a sign of respect. Many
cultures offer prayers beside the body. Calling spirits and perfuming the body is not
commonly completed.
34. Which statement, made by the nurse, can be most helpful when caring for a client in the
third stage of Kübler-Ross's emotional reactions to dying?
A) “Let's review the laboratory results and compare them with the diagnostic tests.”
B) “I understand that it would be wonderful to see your daughter's graduation.”
C) “What makes you most angry about getting the disease?”
D) “I like your idea of living for today and enjoying those around you.”
Ans: B
Feedback:
The third stage of Elisabeth Kübler-Ross's series of reactions is bargaining. Confirming
the intention to live to a certain time is common in this stage. Reviewing laboratory and
diagnostic tests occurs in the first stage, denial. Talking about anger occurs in the
second stage, anger. Living for the day is an idea which occurs in the final stage,
acceptance.
35. In which scenario would the nurse, caring for the palliative care client, encourage the
treatment of chemotherapy?
A) When the chemotherapy can assist in managing distressing clinical symptoms
B) When the client and family requests to have more chemotherapy
C) When the client feels chemotherapy will cure the disease
D) When the chemotherapy helps the psychological state of the client
Ans: A
Feedback:
The use of chemotherapy for a palliative care client is encouraged when used to manage
distressing symptoms. Palliative care clients have accepted that the focus of care is
comfort not cure. The nurse would open communication to understand why the client
and family are requesting chemotherapy. The nurse continuously assesses the
psychological state of the client; however, chemotherapy at this stage, typically is not
helpful.
Page 13
1. Chapter 11
A client is being taught to self-administer a narcotic analgesic by means of an
intravenous pump system. Which of the following functions is designed to help prevent
the patient from unintentionally overdosing?
A) Reducing the dosage of the narcotic analgesic
B) Reducing the frequency of administration of the narcotic analgesic
C) Programming the dosage and time interval into the device
D) Drawing up a schedule chart for the client
Ans: C
Feedback:
When the client is being taught to self-administer a narcotic analgesic, the dosage and
time interval between doses are programmed into the intravenous pump system to
prevent accidental overdose. The frequency or dosage of the narcotic analgesic need not
be reduced. Although a schedule chart is useful to the client, it does not effectively
prevent accidental overdose.
2. Which of the following nursing interventions contributes to achieving a client's pain
relief?
A) Minimize the client's description of pain or need for pain relief.
B) Collaborate with the client about his or her goal for a level of pain relief.
C) Use all forms of available pain management techniques.
D) Prevent the client from self-administering analgesics.
Ans: B
Feedback:
The nurse should collaborate with each client about his or her goal for a level of pain
relief; this helps implement interventions for achieving the goal. The client's description
of pain or need for pain relief should never doubted or minimized. The client need not
refrain from self-administering analgesics; providing a client with equipment to
self-administer analgesics promotes a more consistent level of pain relief. The nurse
should also inform the client of available pain management techniques and incorporate
any preferences or objections to interventions for pain management that the client may
have when establishing a plan of care; using all forms of available pain management
techniques is not necessary.
Page 1
3. How should the administration of analgesics be scheduled to provide a uniform level of
pain relief to a client?
A) Administering the analgesics on a regular basis, as per physician's order
B) Administering the analgesics intravenously
C) Administering the analgesics on an as-needed basis
D) Administering analgesics with increased dosage
Ans: A
Feedback:
Scheduling the administration of analgesics every 3 hours, rather than on an as-needed
basis, often affords a uniform level of pain relief. Administering the analgesics
intravenously or with increased dosage is not advisable unless prescribed by the
physician.
4. A client is prescribed pain medications. Which of the following interventions will
enable the client to consume an adequate meal during treatment?
A) Administer the medication with plenty of fruit juice.
B) Administer the medication intravenously.
C) Administer the medication 30 to 45 minutes before meals.
D) Administer the medication 30 to 45 minutes after meals.
Ans: C
Feedback:
Some pain medications may cause nausea or sedation. However, pain medications
administered 30 to 45 minutes before meals may enable the client to consume enough
food. Administering the medication with plenty of fruit juice, intravenously, or 30 to 45
minutes after meals does not minimize the risk for imbalanced nutrition in a client with
pain.
5. A client has been using NSAIDs daily over an extended period. Which of the following
effects should the nurse carefully monitor for in this client?
A) Cardiac disorders
B) Urinary tract infection
C) Hypothyroidism
D) Gastrointestinal bleeding
Ans: D
Feedback:
NSAIDs when used daily over an extended period may cause undesirable side effects
such as gastrointestinal bleeding and hemorrhagic disorders. Use of analgesics does not
increase the risk for developing cardiac disorders, urinary tract infections, or
hypothyroidism.
Page 2
6. An older adult is being treated with opioids for pain relief. Which of the following
should the nurse strongly recommend to this client?
A) Exercise regularly.
B) Avoid harsh sunlight.
C) Follow a bowel regimen.
D) Reduce fiber intake.
Ans: C
Feedback:
The nurse should ensure that a bowel regimen to prevent constipation is started when
any older adult is treated with opioids. A high-fiber diet along with increased fluids
should be encouraged. The client should not reduce fiber intake because this increases
the risk for constipation. The client need not exercise regularly or avoid harsh sunlight
because these have no effects on the drug therapy.
7. Which phase of pain transmission occurs when the one is made aware of pain?
A) Transmission
B) Modulation
C) Transduction
D) Perception
Ans: D
Feedback:
Perception is the phase of impulse transmission during which the brain experiences pain
at a conscious level, but many concomitant neural activities occur almost
simultaneously. Transmission is the phase during which peripheral nerve fibers from
synapses with neurons in the spinal cord. Modulation is the last phase of pain impulse
transmission during which the brain interacts with the spinal nerves in a downward
fashion to alter the pain experience. Transduction is the conversion of chemical
information in the cellular environment to electrical impulses that move toward the
spinal cord.
8. Which of the following is the most important potential nursing diagnosis for the client
receiving opiate therapy?
A) Risk for Injury
B) Risk for Impaired Gas Exchange
C) Diarrhea
D) Altered Mobility
Ans: B
Feedback:
Problems that may develop with opioid and opiate therapy include Risk for Impaired
Gas Exchange related to respiratory depression, Constipation related to slowed
peristalsis, and Risk for Injury related to drowsiness and unsteady gait.
Page 3
9. Which of the following is the only reliable source for quantifying pain?
A) The nurse
B) The pain assessment tool
C) The physician
D) The client
Ans: D
Feedback:
The client is the only responsible source for quantifying pain. The nurse, the pain
assessment tool, and the physician are not reliable sources to quantify pain.
10. The nurse is aware that when corticosteroids are administered, it is important that which
of the following occurs?
A) Doses are tapered when discontinuing.
B) Monitor for excessive sedation.
C) Avoid alcohol.
D) Monitor blood levels.
Ans: A
Feedback:
When administering corticosteroids, it is important to taper the doses when
discontinuing. Excessive sedation is not a side effect of corticosteroids. Avoidance of
alcohol and monitoring of blood levels are not indicated with use of corticosteroids.
11. The nurse asks the client about a reddened area on the left arm. The client states that he
was bitten by an insect, and it burned briefly. What type of pain does the nurse
document this as?
A) Superficial somatic pain
B) Visceral pain
C) Deeper somatic pain
D) Neuropathic pain
Ans: A
Feedback:
Superficial somatic pain, also known as cutaneous pain (such as that from an insect bite
or a paper cut), is perceived as sharp or burning discomfort. Visceral pain arises from
internal organs such as the heart, kidneys, and intestine that are diseased or injured.
Causes for visceral pain are varied and include ischemia, compression of an organ,
intestinal distention with gas, or contraction as occurs with gallbladder or kidney stones.
Deeper somatic pain is caused by trauma and produces localized sensations that are
sharp, throbbing, and intense. Neuropathic pain is processed abnormally by the nervous
system and results from damage to either the pain pathways in peripheral nerves or
pain-processing centers in the brain.
Page 4
12. The nurse is caring for a client with kidney stones who is complaining of severe pain.
What type of pain does the nurse understand this client is experiencing?
A) Somatic Pain
B) Visceral Pain
C) Neuropathic Pain
D) Chronic Pain
Ans: B
Feedback:
Visceral pain arises from internal organs such as the heart, kidneys, and intestine that
are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or
electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures
composed of connective tissue. Neuropathic pain is pain that is processed abnormally by
the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is
almost totally opposite from those of acute pain.
13. A client arrives in the emergency department with complaints of nausea and pain in the
left shoulder and arm. The physician determines that the client is having a myocardial
infarction (heart attack). What type of pain does the nurse understand the client is
experiencing since the location of the pain is not the chest?
A) Breakthrough pain
B) Chronic pain
C) Neuropathic pain
D) Referred pain
Ans: D
Feedback:
Referred pain is a term used to describe discomfort that is perceived in a general area of
the body but not in the exact site where an organ is anatomically located. Breakthrough
pain is when chronic pain sufferers have periods of acute pain. Neuropathic pain is pain
that is processed abnormally by the nervous system, resulting from damage to either the
pain pathways in peripheral nerves or pain processing centers in the brain.
Page 5
14. A client, who had an above the knee amputation of the left leg related to peripheral
vascular disease from uncontrolled diabetes, complains of pain in the left lower
extremity. What type of pain is the client experiencing?
A) Breakthrough pain
B) Neuropathic pain
C) Visceral pain
D) Referred pain
Ans: B
Feedback:
An example of neuropathic pain is phantom limb pain or phantom limb sensation, in
which individuals with an amputated arm or leg perceive that the limb still exists and
that sensation such as burning, itching, and deep pain are located in tissues that have
been surgically removed. Chronic pain sufferers may have periods of acute pain, which
is referred to as breakthrough pain. Visceral pain arises from internal organs such as the
heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to
describe discomfort that is perceived in a general area of the body but not in the exact
site where an organ is anatomically located.
15. A client with appendicitis has an appendectomy. After surgery, what type of pain does
the nurse anticipate the patient will have?
A) Acute pain
B) Chronic pain
C) Neuropathic pain
D) Referred pain
Ans: A
Feedback:
Acute pain is a discomfort that has a short duration (from a few seconds to less than 6
months). It is associated with tissue trauma, including surgery, or some other recent
identifiable etiology. The characteristics of chronic pain, discomfort that lasts longer
than 6 months, are almost totally opposite from those of acute pain. An example of
neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals
with an amputated arm or leg perceive that the limb still exists and that sensation such
as burning, itching, and deep pain are located in tissues that have been surgically
removed. Referred pain is a term used to describe discomfort that is perceived in a
general area of the body, but not in the exact site where an organ is anatomically
located.
Page 6
16. A client comes to the outpatient clinic to receive cortisone injections in the neck for pain
that has been occurring consistently for 8 months. What type of pain is this client
experiencing?
A) Referred pain
B) Neuropathic pain
C) Acute pain
D) Chronic pain
Ans: D
Feedback:
The characteristics of chronic pain, discomfort that lasts longer than 6 months, are
almost totally opposite from those of acute pain. Referred pain is a term used to describe
discomfort that is perceived in a general area of the body but not in the exact site where
an organ is anatomically located. An example of neuropathic pain is phantom limb pain
or phantom limb sensation, in which individuals with an amputated arm or leg perceive
that the limb still exists and that sensation such as burning, itching, and deep pain are
located in tissues that have been surgically removed. Acute pain is a discomfort that has
a short duration (from a few seconds to less than 6 months). It is associated with tissue
trauma, including surgery, or some other recent identifiable etiology.
17. A client with chronic back pain reports to the nurse that since diagnosis, family and
friends have been making negative comments because the pain has been going on for so
long. What negative reactions to the client's chronic nature of illness would the nurse
expect to hear? Select all that apply.
A) Ignoring the client's concerns and complaints
B) Getting angry with the client
C) Telling the client he is faking illness
D) Suggesting that the pain has a psychological basis
E) Telling the client that he needs to see another physician
Ans: A, B, C, D, E
Feedback:
The longer pain exists, the more far-reaching its effects on the sufferer. Others begin to
show negative responses such as saying they are tired of hearing about the pain,
ignoring the sufferer's concerns and complaints, getting angry with the sufferer,
suggesting that the pain has a psychological basis, telling the sufferer that he or she is
using the pain to manipulate others for selfish purposes, criticizing the sufferer for using
drugs as a crutch, suggesting that the person with chronic pain is addicted to analgesic
medication, and suggesting they should see another doctor.
Page 7
18. A male client has been in pain for 12 hours related to the presence of kidney stones and
states, “I can't take this pain any longer. It is getting worse by the minute.” What does
the nurse understand about the client's ability to tolerate pain?
A) Fatigue diminishes the ability to cope with pain and heightens the perception of
pain.
B) Men tend to report higher pain intensity and demonstrate lower pain tolerance.
C) Men tend to rate their pain at higher levels and report pain in more body regions
than women.
D) Fatigue allows the client to feel less pain.
Ans: A
Feedback:
Pain tolerance is the amount of pain a person endures once the threshold has been
reached. The ability to endure a great deal of pain indicates a high pain tolerance; a low
pain tolerance refers to very little ability to endure pain. Various factors can affect pain
tolerance. For example, fatigue diminishes the ability to cope with pain and heightens
the perception of pain. There are gender differences in pain tolerance. Men tend to
report lower pain intensity and demonstrate higher pain tolerance; women tend to rate
their pain at higher levels and report pain in more body regions than men.
19. The LPN has been assigned to obtain vital signs on several patients. While obtaining
vital signs such as temperature, blood pressure, heart rate, and respiratory rate, what
other vital sign should the nurse be sure to include in her documentation?
A) Peripheral pulses
B) Lung sounds
C) Pain
D) Bowel sounds
Ans: C
Feedback:
The American Pain Society has proposed that pain assessment should be considered the
fifth vital sign. The nurse should check and document the client's pain every time he or
she assesses the client's temperature, pulse, respirations, and blood pressure. Peripheral
pulses, lung sounds, and bowel sounds are important parts of a head-to-toe assessment
but are not included in the collection of vital signs.
Page 8
20. A severely cognitively impaired adult has had a surgical procedure, and the nurse is
having a difficult time assessing the level of pain the client is having postoperatively.
What method can the nurse use to obtain data about the client's pain?
A) Have the client point to a smiley face or a frown.
B) Ask the client to point to a pain level between 0 and 10 on a chart.
C) Use behavioral comparison of the client's current and previous behavior patterns.
D) Ask the client loudly if he is having any pain and what level it is.
Ans: C
Feedback:
Cognitively impaired older adults may be unable to report pain; comparison of current
behavior with previous behavior patterns and reports from caregivers can help in
assessing pain in these clients. Pain may manifest as agitation; aggression; withdrawal;
or changes in behavior, positioning, or sleep patterns. The other methods would not be
appropriate for a cognitively impaired client. Asking the client loudly will not increase
his understanding.
21. A preschool-age child is admitted for complaints of abdominal pain and vomiting. What
is the best method for the nurse to collect data about the pain level of the child?
A) Ask the child to rate the pain on a scale of 0 to 10.
B) The Wong-Baker FACES scale
C) Ask the child to describe the pain.
D) A word scale
Ans: B
Feedback:
The Wong-Baker FACES scale is best for pediatric, culturally diverse, and mentally
challenged clients. It uses pictures and short descriptive phrases. The preschool-age
child would have difficulty understanding the meaning of numbers in relation to pain.
Asking the child to describe the pain does not give information about the level of pain
the child is experiencing. Because the preschool child has a limited vocabulary, a word
scale would not be appropriate for the rating of pain.
22. The nurse is administering a narcotic analgesic for the control of a newly postoperative
patient's pain. What medication will the nurse administer to this patient?
A) Midazolam (Versed)
B) Ibuprofen (Motrin)
C) Acetaminophen (Tylenol)
D) Fentanyl (Duragesic)
Ans: D
Feedback:
Opioid and opiate analgesics such as morphine and fentanyl (Duragesic) are controlled
substances referred to as narcotics. The other medications are not opioid analgesics and
should not be given for a newly postoperative patient.
Page 9
23. A client informs the nurse that he has been taking ibuprofen every 6 hours for 3 weeks
to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is
taking a proton pump inhibitor for the treatment of this disorder. What should the nurse
instruct the client about the use of the ibuprofen?
A) “You should never take ibuprofen; it can cause considerable problems.”
B) “Ibuprofen is contraindicated when taking a proton pump inhibitor.”
C) “It would be best to contact the physician prior to take any over-the-counter
medications.”
D) “Don't you know that you can cause bleeding when you take that medication so
often?”
Ans: C
Feedback:
Clients should not use an over-the-counter analgesic agent, such as aspirin, ibuprofen, or
acetaminophen, consistently to treat chronic pain without first consulting a physician.
Ibuprofen is not contraindicated when taking a proton pump inhibitor. Option D is
accusatory and not a therapeutic response.
24. A client is receiving morphine sulfate intravenously (IV) every 4 hours as needed for the
relief of pain related to a surgical procedure the client had 3 days previously. The
physician is discontinuing the IV and will be starting the patient on oral pain
medication. What would provide the client with optimal pain relief when discontinuing
the IV dose?
A) Administer a lower dose so the client does not get addicted to the medication.
B) Administer an equianalgesic dose.
C) The client should be ordered the medication to be administered intramuscularly
(IM) instead of by mouth.
D) Administer a higher dose of the medication by mouth.
Ans: B
Feedback:
When changing from a parenteral to an oral route, it is best to administer an
equianalgesic dose, an oral dose that provides the same level of pain relief as when the
drug is given by a parenteral route. Administering a lower dose of the medication will
not provide the client with an adequate pain relief. Administering an IM dose may
decrease the absorption and not provide the client with adequate relief. Administering a
higher dose may cause side effects that would be detrimental to the client.
Page 10
25. A client sustained severe burns over both lower extremities 1 week ago. The client
informs the nurse that he had to wait for 30 minutes last night to receive pain
medication, which caused the pain not to be relieved after administration. What
suggestions could the nurse make to the physician to provide adequate relief of pain?
A) Provide the patient with a patient-controlled analgesia (PCA) pump.
B) If the nurse is going to be late with administration, have an extra dose of
medication available.
C) Increase the frequency of the medication so that the client will have less time to
wait.
D) Increase the dosage of the medication so the client will stay medicated longer.
Ans: A
Feedback:
Patient-controlled analgesia (PCA) allows clients to self-administer their own narcotic
analgesic by means of an intravenous pump system. The client infuses the drug by
pressing a hand-held button. The dose and time intervals between doses are
programmed into the device to prevent accidental overdose. The nurse should not be late
when administering a pain medication; giving an extra dose, increasing the frequency,
or increasing the dose also increases the risk of overdosing the client.
26. A client is experiencing intractable pain related to terminal pancreatic cancer. What
does the nurse understand is the goal of palliative sedation for this patient?
A) To administer sedative medication at the minimum dosage necessary to decrease
consciousness and relieve pain
B) To administer analgesics at the highest dose possible to relieve the pain related to
the pancreatic cancer
C) To only require the use of analgesics and decrease the amount of sedation
required to keep the client comfortable
D) To decrease the amount of sedative and analgesics to avoid prolonging the client's
life
Ans: A
Feedback:
Palliative sedation is a method of relieving intractable pain and suffering experienced by
a dying client. The aim of this pain-relieving approach is to administer sedative
medication at the minimum dosage necessary to decrease consciousness and relieve
pain. It is used only when there is no other means available to alleviate suffering with
speeding up or slowing down the dying process. The other options will either create
respiratory depression or not give enough pain relief.
Page 11
27. A client sustained second- and third-degree burns to the chest and neck 4 days ago and
is now refusing analgesics stating, “I don't want to become addicted to pain
medication.” What is the best response by the nurse?
A) “I don't blame you for feeling that way; we have people who do become
addicted.”
B) “Don't worry about this now; take the pain medications, and we will worry about
addiction later.”
C) “Although misusing the medication may cause addiction, there is little evidence
that those who require narcotics for legitimate pain become addicted.”
D) “The physician has ordered the medication every 4 hours, and you must take it so
that you will heal quicker.”
Ans: C
Feedback:
Addiction refers to a repetitive pattern of drug seeking and drug use to satisfy a craving
for a drug's mind-altering or mood-altering effects. Although opioid drugs can result in
addiction, there is very little evidence that those who require narcotics for legitimate
pain actually become addicted. The other options are nontherapeutic responses to the
patient's concern about addiction.
28. A client comes to the clinic and informs the nurse that he needs more analgesics for
chronic pain. The client states that the medication is not as strong, and he requires more
than the prescribed dose. What does the nurse suspect is occurring with the client?
A) Addiction
B) Tolerance
C) Physical dependence
D) Withdrawal symptoms
Ans: B
Feedback:
Tolerance is a condition in which a client needs increasingly larger doses of a drug to
achieve the same effect as when the drug was first administered. Addiction refers to a
repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's
mind-altering or mood-altering effects. Physical dependence means that a person
experiences physical discomfort, known as withdrawal symptoms.
Page 12
29. The nurse is caring for a client in the hospital who has been taking an analgesic for pain
related to a chronic illness and has developed a tolerance to the medication. What is the
most appropriate action by the nurse?
A) Inform the client that he will not be able to receive more medication than the
physician has ordered.
B) Suggest a consultation with a psychiatrist to treat the client's addiction.
C) Inform the client that you will ask the physician to order a non-narcotic analgesic.
D) Consult with the physician regarding the need for an increased dose of the drug
and not to reduce its dosage or frequency of administration.
Ans: D
Feedback:
The most appropriate action by the nurse would be to consult with the physician
regarding the need for an increased dose of the drug and not to reduce its dosage or
frequency of administration. As a rule of thumb, an ineffective dose should be increased
by 25% to 50%. Informing the client that he will not be able to receive more medication
is not acting as a patient advocate nor acting in the best interest of the client. Suggesting
a psychiatrist consultation would not be an appropriate action because the client has a
chronic illness that requires medication. Taking a non-narcotic analgesic would not
provide the client with the pain relief that he has.
30. The nurse is obtaining data regarding the medication that the client is taking on a regular
basis. The client states he is taking duloxetine (Cymbalta), an antidepressant for the
treatment of neuropathic pain. What type of therapy does the nurse understand the client
is receiving?
A) Adjuvant drug therapy
B) Replacement drug therapy
C) Alternate drug therapy
D) Withdrawal therapy
Ans: A
Feedback:
Adjuvant drugs are medications that are ordinarily administered for reasons other than
treating pain. Cymbalta is used to treat depression but is being used for neuropathic pain
for this client. The other answers are distractors with no relation to the question.
Page 13
31. A client arrives in the orthopedic clinic with complaints of twisting the right ankle while
playing softball. The nurse collects data including complaints of pain and swelling in the
right ankle. What intervention will the nurse provide that will decrease vasodilation and
reduce localized swelling?
A) Warm compresses
B) Ice bag
C) Elevation of the extremity
D) Injection of a steroid into the joint space
Ans: B
Feedback:
Pain associated with injury is best treated initially with cold applications such as an ice
bag or chemical pack. The cold decreases vasodilation which reduces localized
swelling, which may be useful for minor or moderate pain. Heat will increase
vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the
scope of practice for the nurse to inject steroids into the joint space.
32. The nurse is monitoring a client who is in the hospital and has a fentanyl (Duragesic)
patch in place for the control of breakthrough pain for breast cancer. What would be a
concern for the nurse when she obtains vital signs for this client?
A) Temperature of 99° F
B) Blood pressure 100/60 mm Hg
C) Respiratory rate of 10 breaths/minute
D) Heart rate of 96 beats/minute
Ans: C
Feedback:
The nurse should not administer this medication if the respiratory rate is less than 12
breaths/minute. The temperature, blood pressure, and heart rate are within normal range.
33. A client is brought to the emergency department by a family member that states that he
found the client crying on the bed with an empty bottle of Tylenol with approximately
30 pills missing. What should the nurse anticipate administering to this client?
A) N-acetylcysteine (Mucomyst)
B) Amitriptyline (Elavil)
C) Duloxetine (Cymbalta)
D) Lamotrigine (Lamictal)
Ans: A
Feedback:
Be prepared to administer N-acetylcysteine (Mucomyst) to protect the liver in the case
of toxic overdose. The other medications referred to in the distractors will not require
the administration of Mucomyst.
Page 14
34. The client will be using transcutaneous electrical nerve stimulation (TENS) for the
treatment of lower back pain. What does the nurse explain to the client that this will do
for his back pain?
A) Deliver a burst of electricity to the skin and underlying nerves, decreasing pain
B) Causes decrease in vasodilation to decrease swelling
C) Applies heat to the skin and subcutaneous tissues
D) Interrupts the pain pathways in the spinal cord
Ans: A
Feedback:
TENS is a pain management technique that delivers bursts of electricity to the skin and
underlying nerves. It is safe for managing acute and chronic pain and does not produce
systemic side effects or addiction. The electricity is delivered from a battery-operated
TENS unit through electrode patches that are placed at appropriate sites, such as directly
over the affected are, at areas along a nerve pathway, or at points distal to the painful
area. Cold compresses cause decrease in vasodilation. Warm compresses cause heat to
the skin and subcutaneous tissues. A cordotomy interrupts the pain pathways in the
spinal cord.
35. The nurse is providing a gentle massage on a painful area of a client's hip. What is the
goal of the nurse in providing this intervention?
A) Floods the brain with alternative stimuli closes the spinal gate
B) Interrupts pain perception
C) Release of endorphins and enkephalins
D) Keep the pain at a manageable level
Ans: C
Feedback:
Gently massaging a painful area or the same area on the opposite side of the body will
promote the release of endorphins and enkephalins that moderate the sensation. Warm
or cool compresses to a painful sensory site will flood the brain with alternative stimuli
closes the spinal gates that transmit pain. Visualizing a pleasant experience will
interrupt the pain perception. Administration of an analgesic will keep the pain at a
manageable level.
Page 15
1. Chapter 12
You are caring for a client with a stage IV leg ulcer. You are closely monitoring the
client for sepsis. What would indicate that sepsis has occurred and that you should
notify the physician of immediately?
A) The client feels restless and hungry.
B) The client exhibits an increased urinary output.
C) The client's heart rate is greater than 90 beats/minute.
D) The client's respiratory rate is less than 20 breaths/minute.
Ans: C
Feedback:
A heart rate greater than 90 beats/minute or a respiratory rate greater than 20 breaths/
minute will indicate that sepsis has occurred. Sepsis does not increase the client's
appetite or affect the client's urinary output.
2. The nurse is giving an educational talk to a local parent–teacher association. A parent
asks how he can help his family avoid community-acquired infections. What would be
the nurse's best response to help prevent and control community-acquired infections?
A) “Encourage your family to adopt a healthy diet and exercise regimen.”
B) “Encourage your family to stop smoking.”
C) “Make sure your family has all their childhood immunizations.”
D) “Make sure your family has regular checkups.”
Ans: C
Feedback:
To help prevent and control community-acquired infections, nurses should encourage
childhood immunizations. Vaccines stimulate the body to produce antibodies against a
specific disease organism. The immunization protects children as well as adults who
may not have developed sufficient immunity. Following a proper diet and exercise
regimen and going for regular checkups are important, but these measures do not help
prevent or control community-acquired infections. Smoking cessation does not reduce
the risk of such infections either.
Page 1
3. You are teaching a health class in the local public health center. What instructions
should you provide as the single most important measure to prevent the spread of
infection?
A) Minimal social contact
B) Regular immunizations
C) Thorough handwashing
D) Sufficient food intake
Ans: C
Feedback:
Hand hygiene remains the single most important measure to prevent the spread of
infection. It reduces the number of transient and resident microorganisms. Sufficient
food intake helps restore biologic defense mechanisms but does not prevent spread of
infections. Although minimal social contact and regular immunizations may help
prevent the spread of infection, especially community-acquired infections, these are not
practical measures.
4. A nurse on your unit sustains a needlestick injury while caring for a client whose
infectious status is unknown. What would be the best course of action for the nurse to
follow?
A) Avoid notifying the supervisor of the injury until the client's infectious status is
confirmed.
B) Avoid revealing the identity of the client or source of blood.
C) Be tested for disease antibodies at appropriate intervals.
D) Document the injury in writing after the client's infectious status is confirmed.
Ans: C
Feedback:
If a needlestick injury has occurred, the nurse should be tested for disease antibodies
immediately and at appropriate intervals thereafter. The nurse should document the
injury in writing immediately and should not wait until the client's infectious status is
confirmed. The nurse should also notify the supervisor of the injury immediately and
identify the person or source of blood, if possible.
Page 2
5. The nursing instructor is teaching beginning nursing students about infection. Toward
the end of class, the instructor gives the students a scenario of a client with an infection
who has developed fever and diarrhea. What should the student nurse instruct the client
to avoid?
A) Tea and coffee
B) Ice water and broth
C) Fruit juices
D) Milk and gelatin
Ans: A
Feedback:
A client with fever and diarrhea should avoid tea, coffee, and carbonated beverages
containing caffeine because these promote diuresis. The intake of ice water, broth, fruit
juices, gelatin, and milk should be encouraged to add proteins and calories.
6. You are working on a gerontology unit. A family member calls and tells you he wants to
bring the family in to see one of the clients on the unit. The family member is concerned
because several of the family members have colds. What instructions should you
provide to someone with a respiratory infection?
A) Avoid intake of frozen foods.
B) Avoid visiting older adults.
C) Avoid direct sunlight.
D) Avoid meats and other protein-rich foods.
Ans: B
Feedback:
The nurse should instruct anyone with respiratory infections to avoid visiting older
adults until symptoms subside; older adults are more susceptible to infections because
their defense mechanisms are less efficient. It is not essential for the client to avoid
frozen or protein-rich foods or direct sunlight.
Page 3
7. You are an intensive care unit nurse caring for a client with a transmissible spongiform
encephalopathy. You know that this type of encephalopathy is caused by what type of
infectious agent?
A) Prion
B) Protozoa
C) Helminth
D) Rickettsia
Ans: A
Feedback:
A prion is a protein that does not contain nucleic acid. Research suggests that normal
prions present in brain cells protect against dementia. When a prion mutates, however, it
is capable of becoming an infectious agent and altering other normal prion proteins into
similar mutant copies. The mutant prions, which can be formed by genetic
predisposition or acquired by transmission between the same or similar infected animal
species, cause transmissible spongiform encephalopathies. Transmissible spongiform
encephalopathies are not caused by protozoa, helminths, or rickettsias.
8. Which of the following would be considered a mechanical defense mechanism?
A) Cast
B) Coughing
C) Clothing
D) Sunscreen
Ans: B
Feedback:
Mechanical defense mechanisms are physical barriers that prevent microorganisms from
gaining entry or expel microorganisms before they multiply. Examples are the skin and
mucous membranes, physiologic reflexes (e.g., sneezing, coughing, vomiting), and
macrophages. Casts, clothing, and sunscreen do not keep microorganisms from gaining
entry to the body.
9. You have admitted a new client to your unit. This client has an open draining sore on his
leg. What diagnostic test would you anticipate being ordered?
A) Platelet count
B) Culture and sensitivity
C) Sputum culture
D) Urinalysis
Ans: B
Feedback:
A culture identifies bacteria in a specimen taken from a person with symptoms of an
infection. The source of the specimen may be body fluids or wastes, such as blood,
sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound.
A platelet count would not tell you about the infection. A sputum culture would not be
indicated for a leg wound, nor would a urinalysis.
Page 4
10. You are caring for a client with breast cancer who has been receiving chemotherapy.
The client was admitted with an infected lesion on her left leg. The physician has
ordered Neupogen. What will Neupogen do for this client?
A) Increase platelet count
B) Boost the immune system
C) Increase white blood cell production
D) Boost red blood cell production
Ans: B, C
Feedback:
Bone marrow transplantation or administration of drugs that boost white blood cell
production, such as filgrastim (Neupogen), may help immunosuppressed clients.
Neupogen does not increase the platelet count or boost red blood cell production.
11. A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has
received treatment with three courses of antibiotics without eliminating the infection.
What does the nurse understand has occurred with the client?
A) The client has a multidrug-resistant strain of bacteria.
B) The client has been misdiagnosed and has another type of microorganism present.
C) Staphylococcus aureus cannot be treated by antibiotics.
D) Staphylococcus aureus is a fungus and must be treated with an antifungal agent,
not an antibiotic.
Ans: A
Feedback:
Some bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, and
Escherichia coli, are developing multidrug resistance, the ability to remain unaffected
by antimicrobial drugs such as antibiotics. There are no facts to indicate the client has
been misdiagnosed. Staphylococcus aureus is treated with antibiotics and is a bacterium,
not a fungus.
Page 5
12. A client is diagnosed with a viral illness and requests an antibiotic to “cure” his illness.
When the request is refused by the physician, the client states to the nurse, “I will never
get better.” What is the best response by the nurse?
A) “I will speak with the physician again. You will only get better while taking an
antibiotic.”
B) “Prescribing antibiotics for a viral infection may result in drug-resistant bacteria.”
C) “You need to think positively, and you will get better soon.”
D) “Taking antibiotics when you don't need them will make you sick.”
Ans: B
Feedback:
Causes of antibiotic resistance, a consequence of bacterial mutations that interfere with
the mechanism of antibiotic action, are related to inappropriate prescription of
antibiotics for viral (rather than bacterial) infection. Because viral infections are often
self-limiting, with symptoms control, the client will get better. Indicating that the client
is not thinking positively is a nontherapeutic comment. Option D is not an informative
response.
13. The infection control nurse collects data that indicates an increase in the number of
clients in the hospital with multidrug-resistant infections. What priority education
should healthcare providers receive?
A) Using contact precautions on all clients in the hospital
B) Administering antibiotics to all clients prophylactically
C) Hand hygiene
D) Emptying trash cans immediately in client's rooms
Ans: C
Feedback:
Infections with multidrug-resistant microorganisms are very difficult to destroy with
current pharmacologic agents, increasing the need to be vigilant about performing hand
hygiene measures. It is unnecessary to use contact precautions, administer antibiotics
prophylactically, or empty trash cans immediately for the preventions of
multidrug-resistant infections.
Page 6
14. A client visits the clinic with the complaint of a circular rash on the upper right arm. The
rash is diagnosed as tinea corporis. What type of infection does the nurse anticipate the
client will be treated for?
A) Rickettsiae
B) Protozoans
C) Mycoplasma
D) Fungus
Ans: D
Feedback:
One type of fungal infection is superficial (dermatophytoses), which affect the skin,
hair, and nails; examples include tinea corporis, or ringworm, and tinea pedis, also
known as athlete's foot. Rickettsiae, protozoans, and mycoplasma have different
characteristics and transmission than fungus.
15. A client has received a diagnosis of Lyme disease. What does the nurse understand
about the transmission of infection resulting in this disease?
A) The disease is spread by a prion.
B) The disease is spread by single-celled fungi-like microorganisms
C) The disease is spread by helminths
D) The disease is spread by arthropods.
Ans: D
Feedback:
Example of arthropods includes fleas, ticks, lice, mosquitoes, and mites. Some
rickettsial diseases that are spread by arthropods include Lyme disease. Prions may
mutate and can be formed by genetic predisposition or acquired by transmission
between the same or similar infected animal species and are not the same as arthropods.
The disease is not spread by single-celled fungi-like microorganisms or helminths.
Page 7
16. A family member wants to donate blood for a client who needs a blood transfusion.
What information from the family member would make them ineligible for donation?
A) The family member was serving in the military in England in 1993 for 2 years.
B) The family member had a surgical procedure 4 years previously for an inguinal
hernia.
C) The family member received a blood transfusion 10 years previously at a hospital
in Canada.
D) The family member takes an antihypertensive medication for control of blood
pressure.
Ans: A
Feedback:
The American Red Cross bans blood collection from anyone who has lived in the
United Kingdom for a total of 6 months or longer between 1980 and 1996, lived in
various countries in Europe including while serving in the military since 1980, received
a blood transfusion in the United Kingdom, or lived 5 or more years in various
European countries from 1980 to the present. There is a higher risk among these
potential donors for BSE or “mad cow disease.” The other answers are not exclusion
criteria for donating blood.
17. A family member of a client in a long-term care facility asks the nurse why he cannot
insert a catheter so the client will not develop skin breakdown from being wet. What
should the explanation include when the nurse responds to the family member?
A) Catheters are no longer used for treatment of incontinence.
B) Older adult residents are able to have catheters inserted if the family requests
them.
C) The invasive nature of the catheter provides a portal for infection.
D) If a catheter is inserted, it must be flushed with normal saline daily.
Ans: C
Feedback:
Catheters provide a portal for infection because they are invasive. Although catheters
are not used as frequently in older adults for the control of urinary incontinence, there
are some bed-confined clients who use them. Family requests for catheters may be
considered, but physicians make the decision if it will benefit the patient. Catheters are
not flushed daily with anything.
Page 8
18. The nurse is caring for an older adult client who develops a fever, rash over the trunk,
and back and complains of feeling achy and very tired. What should the nurse suspect is
occurring with this client?
A) A roundworm infection
B) Bacterial meningitis
C) A urinary tract infection
D) An autoimmune response
Ans: D
Feedback:
Healthcare providers must carefully assess for symptoms in older adults that may
indicate autoimmune responses (i.e., rash, malaise, fever, aching, etc.).
19. A client informs the nurse that she has been using a douche to cleanse the vagina on a
daily basis and is now experiencing itching and burning in the vaginal area. What
should the nurse explain to the client that occurs when the vaginal pH is changed?
A) It causes destruction of the normal flora of the vagina and allows the development
of vaginal infections.
B) The bottle must be contaminated with bacteria, and when the pH is changed, it
allows the bacteria to enter the vaginal area.
C) It will cause an allergic reaction in the vaginal area.
D) When the vaginal pH is changed, it allows cancer cells to spread from the vagina
to the cervix.
Ans: A
Feedback:
The acid environment is unfavorable for the multiplication of pathogenic bacteria and
fungi. A change in vaginal pH or destruction of the normal flora, however, can promote
the development of a vaginal infection. Bacteria do not cause the vaginal pH to change;
the pH change allows bacteria to grow. Change in vaginal pH does not cause an allergic
reaction and does not allow the development of cancer cells.
20. A client is admitted to an acute care facility with a diagnosis of appendicitis. Which
laboratory results demonstrate the client's leukocytosis?
A) Hemoglobin of 12 mg/dL
B) Lymphocytes 1,500
C) Neutrophils of 3,150/mm3
D) White blood cell (WBC) count of 22,000 cells/mm3
Ans: D
Feedback:
The body manufactures more WBCs as needed, a process referred to as leukocytosis.
The WBC of 22,000 cells/mm3 indicates an abundance of white blood cells.
Hemoglobin does not represent the presence of infection. The lymphocytes and
neutrophils are within normal range and do not demonstrate leukocytosis.
Page 9
21. A client comes to the clinic and informs the nurse that he has a “painful area under his
armpit.” The nurse observes a 2-cm raised area that is erythremic and has a white
substance inside of it. What does the nurse suspect the patient may be experiencing?
A) A lesion
B) An abscess
C) A fluid-filled vesicle
D) A cancerous tumor
Ans: B
Feedback:
To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the
injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection
of pus is called an abscess, which may break through the skin and drain or continue to
enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor.
A fluid-filled vesicle is associated with a viral type illness.
22. A client is suspected of sepsis from a postsurgical incision infection. What characteristic
of sepsis would the nurse recognize? Select all that apply.
A) Temperature of 102° F
B) Heart rate of 120 beats/minute
C) Respiratory rate of 24 breaths/minute
D) PaCO2 of 42 mm Hg
E) Blood pressure of 120/80 mm Hg
Ans: A, B, C
Feedback:
Two or more of the following characterize sepsis: temperature greater than 100.4° F
(38° C), heart rate greater than 90 beats/minute, respiratory rate greater than 20
breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000
cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis,
and a PaCO2 of 42 mm Hg is not an indicator.
Page 10
23. A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous
(IV) catheter is inserted for the delivery of IV fluids. A family member is with the client
and observes the nurse enter the room and begin touching the IV site without washing
his hands or wearing gloves. Why should the client and family member be concerned
with the nurse's actions?
A) The client will have an allergic reaction to the IV.
B) The nurse could develop the same symptoms.
C) The client will develop a nosocomial infection.
D) Dislodging of the IV catheter.
Ans: C
Feedback:
Nosocomial infections are infections acquired while receiving care in a healthcare
agency that were not active, incubatory, or chronic at admission. They occur for many
reasons. Hospitalized clients are more susceptible to infections than well people because
they are exposed to pathogens in the healthcare environment; may have incisions or
invasive equipment (e.g., IV lines) that compromise skin integrity; or may be
immunosuppressed from poor nutrition, their disease process, or its treatment. Also,
because healthcare personnel are in frequent and direct contact with many clients who
harbor various microorganisms, the risk for transmitting pathogenic microorganisms
between and among clients is high. Allergic reaction to the IV, the nurse developing the
same symptoms, and dislodging of the IV catheter are not the priority concerns.
24. A client arrives at the clinic with the complaint that she is having a vaginal discharge
after having sexual intercourse with her boyfriend 1 week ago. The patient is diagnosed
with gonorrhea and given a prescription for treatment. What type of infection
transmission does the nurse understand occurred?
A) Direct contact
B) Droplet
C) Airborne
D) Vehicle
Ans: A
Feedback:
The route of transmission for a sexually transmitted disease is by direct contact. An
infected person transmits the infection to a susceptible person. A droplet transmission is
a spray of moist particles within a 3-foot radius of an infected person. An airborne
transmission is suspension and transport on air currents beyond 3 feet. An infection
transmitted by vehicle is on or in contaminated food, water, objects, or equipment.
Page 11
25. A client arrives at the emergency department complaining of severe diarrhea and
vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the
nurse understand that the contaminated food was transmitted to the client?
A) Droplet
B) Airborne
C) Vehicle
D) Vector
Ans: C
Feedback:
Vehicle is the route of transmission for this client's illness. It is found on or in
contaminated food, water, objects, or equipment and can occur from eating or drinking
tainted products. The route of transmission, droplet is by a spray of moist particles
within a 3-foot radius of infected persons. Airborne is a route of transmission that is a
suspension and transport on air currents beyond 3 feet. An infection by vector is found
on infected animals or insect to susceptible persons.
26. A client comes to the clinic with complaints of fever, chills, and coughing and is found
to be positive for influenza. The nurse is aware that the flu is transmitted from one
infected person to another. What type of infection is this considered?
A) Localized
B) Generalized
C) Community acquired
D) Nosocomial
Ans: C
Feedback:
Community-acquired infections are transmitted from one infected species to another.
Common signs and symptoms are the same as generalized plus organ-specific or
disease-specific manifestations. Examples of the infections transmitted are influenza,
chickenpox, and tuberculosis. Localized infection is confined to a small area such as a
furuncle (boil). Generalized infection is a systemic or widespread infection in one or
two organs such as urosepsis. A nosocomial infection is acquired in a healthcare agency.
Page 12
27. The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and
has developed oral thrush. What type of infection is the nurse aware that has developed
due to the immunocompromised state of the client?
A) Acute
B) Chronic
C) Secondary
D) Opportunistic
Ans: D
Feedback:
An opportunistic or superinfection occurs among immunocompromised hosts. Examples
would be yeast infections in the mouth, bladder infections, gastroenteritis, and
Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes
life-threatening manifestations. A chronic infection is an extended infection that resists
treatment. A secondary infection is a complication of some other disease process that
occurred first.
28. A client informs the nurse that he “thinks he is getting sick.” Chief complaint of the
client is low-grade fever, headache, and “has no energy.” What stage of the infection
does the nurse recognize the client is experiencing?
A) Incubation period
B) Prodromal stage
C) Acute stage
D) Convalescent stage
Ans: B
Feedback:
In the prodromal stage, the initial symptoms appear; they may be vague and nonspecific.
Possible symptoms include mild fever, headache, and loss of usual energy. The
incubation period does not exhibit any recognizable symptoms. The acute stage is when
the symptoms become severe and specific to the affect tissue or organ. The convalescent
stage is when symptoms subside as the host overcomes the infectious agent.
Page 13
29. The nurse is caring for a group of five clients at the hospital. In order to control
infections when caring for the group of clients, what intervention can the nurse perform?
A) Use standard precautions with all clients.
B) Only use standard precautions with clients who have an infection.
C) Wear a mask while taking care of all clients and changing the mask between
clients.
D) Place the clients on isolation precautions.
Ans: A
Feedback:
Nurses and other healthcare personnel must take precautions to control infections when
caring for all clients, regardless of diagnosis or infection status. These precautions are
called standard precautions, measures for reducing the risk of transmitting pathogens
from both recognized and unrecognized sources of infections. It is unnecessary to use a
mask when caring for clients who do not have a droplet or airborne infection. Clients
should not be placed in isolation unless they have an infection that could be transmitted
to others.
30. The nurse gave a client an injection and, when attempting to recap the needle, sustained
a needlestick injury to the finger. What is the priority action by the nurse?
A) Report the injury or exposure to the supervisor.
B) Document the injury in writing.
C) Receive instructions on monitoring potential symptoms and medical follow-up.
D) Receive the most appropriate postexposure prophylaxis.
Ans: A
Feedback:
Should needlestick injury or other exposure to a potential blood-borne pathogen occur,
healthcare workers are advised to follow postexposure recommendations; report the
injury or exposure to one's supervisor immediately; document the injury in writing;
identify the person or source of blood; obtain the HIV and HBV statuses of the source of
blood, if it is legal to do so. Unless the client gives permission, testing and revealing
HIV status are prohibited. Obtain counseling on the potential for infection. Receive the
most appropriate postexposure prophylaxis; be tested for disease antibodies at
appropriate intervals. Receive instructions on monitoring potential symptoms and
medical follow-up.
Page 14
31. The nurse is caring for a client with an abscess on his back. The nurse observes purulent
drainage coming from the abscess. What type of specimen does the nurse anticipate the
physician will order to determine the type of bacteria present in the exudate?
A) A sensitivity test
B) Test for ova and parasites
C) White blood cell (WBC) count
D) A culture
Ans: D
Feedback:
A culture identifies bacteria in a specimen taken from a person with symptoms of an
infection. The source of the specimen may be body fluids or wastes, such as blood,
sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound.
A test for ova and parasites is a stool specimen that is examined for evidence of any
forms in the infecting microorganism's life cycle. A WBC count may determine that
infection is present in the body but does not isolate the bacteria. A sensitivity test is
done to determine which antibiotic inhibits the growth of a nonviral microorganism and
will be most effective in treating the infection.
32. A nurse is having a yearly employee tuberculin skin test. Which skin test results would
indicate a positive result?
A) An induration of 12 mm
B) An uneven erythemic area
C) An induration of less than 1 mm
D) An induration of 4 mm
Ans: A
Feedback:
The size of the induration, not including the surrounding area of erythema, is measured
in millimeters. The measurement determines whether the reaction is significant. For
example, a tuberculin skin test is test is considered positive if the induration is 10 mm or
greater in persons with no known risk factors for TB; smaller measurements are
significant in certain risk groups, such as immunocompromised clients. The other
answers are not indicative of positive results.
Page 15
33. A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician
is planning to remove the dead and damaged tissue. What type of procedure will the
nurse prepare the client for?
A) Application of a dry dressing
B) Debridement
C) Administration of filgrastim (Neupogen)
D) Inject antibiotics into the wound
Ans: B
Feedback:
Debridement is the removal of dead and damaged tissue surgically. Application of a dry
dressing will not debride the wound, nor will the administration of Neupogen or
injecting antibiotics into the wound.
34. A client is in the acute care facility for the administration of intravenous (IV) antibiotics
to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the
IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client
has developed due to the antibiotic use?
A) Food poisoning
B) An allergic reaction to the antibiotic
C) A helminth infection
D) Pseudomembranous colitis
Ans: D
Feedback:
When a client is taking an antibiotic, a superinfection can result from overgrowth of
microorganisms not affected by the drug. This can lead to a serious inflammation of the
colon called pseudomembranous colitis accompanied by potentially life-threatening
diarrhea. Report fever, abdominal cramps, and severe diarrhea immediately. The other
distractors are incorrect and not related to the use of the antibiotics.
Page 16
1. Chapter 13
You are training nurses at your hospital to insert midline catheters. What would you
teach the nurses about how many inches of the catheter should be inserted into the
required site and for how long can it be used?
A) 1 to 3 inches, used for up to 3 weeks
B) 3 to 6 inches, used for up to 4 weeks
C) 7 to 8 inches, used for up to 5 weeks
D) 8 to 9 inches, used for up to 6 weeks
Ans: B
Feedback:
A midline catheter is 7 to 8 inches long, but only 3 to 6 inches of the catheter are
inserted. This type of catheter can be used for up to 4 weeks before it requires
replacement. Therefore, the other options are incorrect.
2. Your client is going out on pass for the afternoon with his family. The physician has
ordered that his venipuncture device needs to be temporarily capped. How will you
ensure that the vein remains patent?
A) Flush the lock with potassium chloride.
B) Flush the lock with saline or heparinized saline.
C) Flush the lock with cyclical total parenteral nutrition (TPN).
D) Flush the lock with colloid solutions.
Ans: B
Feedback:
When a venipuncture device is temporarily capped, the vein is kept patent by flushing
the lock with saline or heparinized saline. Deaths have occurred when potassium
chloride has been used incorrectly to flush a lock. TPN solutions are used to provide
nutrition, and colloid solutions are used to replace circulating blood volume; these
solutions are not used to flush locks.
3. You are the emergency department nurse caring for a client who has just been admitted
by ambulance for a suspected myocardial infarction. The physician orders IV fluids of
normal saline to be hung at 100 mL/hr. You know that this is what type of IV solution?
A) Crystalloid
B) Colloid
C) Hypertonic
D) Hypotonic
Ans: A
Feedback:
The two types of IV solutions are crystalloid and colloid solutions. Crystalloid solutions
consist of water and uniformly dissolved crystals such as salt (sodium chloride) or sugar
(glucose, dextrose). Normal saline is an isotonic crystalloid solution. Colloid solutions
are used to replace blood. Hypertonic solutions are rarely used. Hypotonic solutions
contain fewer dissolved substances compared with plasma.
Page 1
4. The nursing instructor is discussing the different types of IV fluids with the nursing
students. What type of fluid would the instructor tell the students is used to replace
circulating blood?
A) Hypertonic solutions
B) Crystalloid solutions
C) Hypotonic solutions
D) Colloid solutions
Ans: D
Feedback:
Colloid solutions are used to replace circulating blood volume because the suspended
molecules in the solutions pull fluid from other fluid compartments in the body.
Colloids contain blood cells such as RBCs. Crystalloid solutions are made from water
and sodium chloride or sugar. Hypotonic solutions contain more dissolved substances
compared with plasma. Hypertonic solutions pull fluids into plasma but do not assist
with replacement of cells.
5. You are caring for a client who has an order to receive Hespan IV. The client asks you
what this solution is for. What would be your response?
A) “This solution pulls fluid into the vascular space.”
B) “This is a colloid solution used to replace blood.”
C) “Hespan is a solution used instead of a transfusion.”
D) “Hespan is an artificial blood replacement product.”
Ans: A, B, C
Feedback:
Plasma expanders are nonblood solutions, such as dextran 40 (Rheomacrodex) and
hetastarch (Hespan), that pull fluid into the vascular space. Options B and C are also
correct. Hespan is not artificial blood.
6. The nurse caring for a client with an intravenous infusion is looking up her institution's
policy on changing IV equipment used in a venipuncture. When is most IV tubing
changed?
A) Every 12 hours
B) Every 24 hours
C) Every 48 hours
D) Every 72 hours
Ans: D
Feedback:
Most IV tubing is changed every 72 hours, but the exact parameters depend on agency
policy. Some exceptions include tubing used to administer TPN and intermittent
secondary infusions. Therefore, options A, B, and C are incorrect.
Page 2
7. You are caring for an older adult client with an IV infusing at 100 mL/hr. What should
you monitor this client for?
A) Urinary retention
B) Circulatory overload
C) Pulmonary embolism
D) Incontinence
Ans: B
Feedback:
Circulatory overload can develop if the volume of infusing solution exceeds the heart's
ability to circulate it effectively. The scenario does not indicate that the client is at risk
for urinary retention or incontinence. IV fluids infusing at 100 mL/hr do not put the
client at risk for a pulmonary embolism.
8. You are caring for a client who has just had total parenteral nutrition (TPN) ordered.
The LPN is correct when informing the client that TPN is used for what?
A) To meet the client's need for protein
B) To provide calories and prevent weight loss
C) To provide glucose to the client and prevent weight loss
D) To meet the client's caloric and nutritional needs
Ans: D
Feedback:
TPN uses a solution of nutrients to meet the client's caloric and nutritional needs. TPN
does provide calories and glucose to the client, but it does not prevent weight loss. TPN
does include protein, but it usually does not meet the total protein requirement of the
adult client.
9. Your client has just had a transfusion ordered for severe anemia. You are gathering the
supplies that you need in order to transfuse the client. What kind of tubing do you know
that you need to infuse blood or blood products?
A) Y-administration tubing
B) Macrodrip tubing
C) Minidrip tubing
D) Primary tubing
Ans: A
Feedback:
Blood is administered through Y-administration tubing. Blood is never infused through
any tubing except Y-administration tubing, which makes options B, C, and D incorrect.
Page 3
10. The nursing instructor is teaching student nurses about venipuncture techniques and
possible complications from the procedure. What can happen if the venipuncture device
is left in the clients' vein too long?
A) Phlebitis can develop.
B) Gangrene can set in.
C) Necrosis of the skin will develop.
D) Cold packs will need to be used to reduce the pain.
Ans: A
Feedback:
Because the venous access device traumatizes the vein wall and disturbs the flow of
blood cells in the vein, there is a potential for phlebitis, inflammation of the vein, and
thrombus formation (development of a clot). Gangrene is not an issue; necrosis of the
skin depends on the fluid being infused and if it has infiltrated; and warm compresses
are used, not cold packs.
11. Which of the following provides the best practice for the graduate nurse in the
administration and regulation of intravenous fluids to clients?
A) Nursing supervisor
B) The physician
C) Nursing instructor
D) State licensing board
Ans: D
Feedback:
The state nurse practice act specifies the qualifications and regulations for scope of
practice of nurses. In addition, the nurse must follow the policies/procedures of the
institution in which presently employed. The nursing supervisor should be able to
provide guidance to a new employee but is not the ultimate authority. The nursing
instructor prepares the educational track for learning but does not provide guidance in
employment situations. The physician initiates the orders for IV therapy but does not
provide nursing guidance.
Page 4
12. The nurse would expect to hang which of the following intravenous (IV) solution to a
client with ascites?
A) Isotonic solution
B) Low osmolarity solution
C) Hypotonic solution
D) Hypertonic solution
Ans: D
Feedback:
With ascites, minimizing the fluid in the cells can be accomplished with the use of
hypertonic solutions. Hypertonic solutions act by pulling the fluid from the cells to the
blood vessels. Isotonic solutions stay within the blood vessels and do not minimize
ascites. Hypotonic solutions are lower in osmolarity and shift fluids from the blood
vessels to the cells.
13. A client is brought to the emergency department with full-thickness burns to 27% of the
body. The nurse knows to prepare intravenous (IV) fluid administration from which
solution group?
A) Isotonic
B) Hypertonic
C) Lower osmolarity solution
D) Higher osmolarity solution
Ans: C
Feedback:
Lower osmolarity solutions are hypotonic solutions and will shift fluid from the blood
vessels to the cells (where damage has occurred). Isotonic solutions will assist in
preventing hypovolemia but will not rescue the damaged cells and prevent further
dehydration. Higher osmolarity solutions are hypertonic and will pull fluid from the
cells to the blood vessels.
14. A client is scheduled for a test that requires an NPO status and has been ordered 5%
dextrose in water (D5W). The nurse understands which of the following to be the best
rationale for this action?
A) Isotonic solutions maintain body fluid balance.
B) Hypotonic solutions replenish the cells.
C) Hypotonic solutions reduce need for circulatory fluids.
D) Hypertonic solutions replace lost fluids.
Ans: A
Feedback:
Isotonic solutions, such as D5W, are administered for maintenance of fluid balance.
Hypotonic solutions do provide fluid to the cells, but this is not the purpose for D5W.
Hypertonic solutions are used to pull fluid into the blood vessels and are not used to
replace lost fluids.
Page 5
15. The nurse receives an order for a client to be given a colloid solution. Which is the
likely reason for the use of this type of solution?
A) Dependent edema
B) Increased blood loss
C) Skin turgor is decreased.
D) The blood pressure has increased.
Ans: B
Feedback:
Colloid solutions create oncotic pressure that pulls fluid into the blood vessels and
expands the space. Common colloid products are blood products. Dependent edema
would be remedied by careful use of hypertonic (crystalloid solution). Increased blood
pressure can be caused by hypertonic solutions or use of colloid solutions. Decreased
skin turgor is caused by dehydration not blood loss.
16. A client with severe malnutrition is ordered intravenous (IV) albumin. Which is the
primary assessment in providing nursing care for this client?
A) Monitor hematocrit and hemoglobin (H&H).
B) Monitor for fluid overload.
C) Assess for thrombocytopenia.
D) Assess for elevation of white blood cells (WBCs).
Ans: B
Feedback:
Albumin attracts fluid so care is taken to monitor clients for signs of fluid overload
during and after albumin administration. Albumin is a plasma protein and should not
affect H&H. Albumin does not lower thrombocytes or elevate WBCs.
17. A client is brought to the emergency department with a diagnosis of possible cerebral
vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma
(FFP). Which is the best nursing understanding for this action?
A) Best treatment for embolus causing stroke
B) The stroke is still evolving.
C) Client is experiencing a hemorrhagic stroke.
D) The client is experiencing hypervolemia.
Ans: C
Feedback:
FFP contains fibrinogen and components for coagulation and is used to treat clotting
disorders and/or hemorrhage. An embolus is not treated with FFP. An evolving stroke is
a stroke in which the symptoms are still changing and does not define the cause of the
stroke. Hypervolemia means intravascular overload, which is not usually associated
with a stroke.
Page 6
18. Which is the best option for raising the white blood cell count in a cancer client who is
at risk for congestive failure?
A) Granulocyte transfusion
B) Packed red blood cells (PRBCs)
C) Whole blood
D) Injection of filgrastim (Neupogen)
Ans: D
Feedback:
Neupogen stimulates bone marrow production of granulocytes and is used in clients
with cancer. Neupogen is given as a 0.6-mL injection. Granulocyte transfusions are
usually 400 mL units and will add to fluid in the intravascular fluid space. One unit of
whole blood will add 500 mL, whereas PRBCs add 250 mL of added fluid.
19. A client is ordered an intravenous (IV) solution of Ringer's lactate 1000 mL to infuse at
40 mL/hr. What is the maximum amount of time the nurse should allow this IV to hang?
A) 22 hours
B) 23 hours
C) 24 hours
D) 25 hours
Ans: C
Feedback:
Although the 1000-mL bag can deliver 25 hours of infusion (at the rate of 40 mL/hr) the
nurse knows that once the IV solution bag is spiked, the bag cannot hang for more than
24 hours.
20. Thirty minutes after hanging a glass intravenous bottle of total parenteral nutrition
(TPN), the nurse notices the solution has stopped dripping. Which is the best
troubleshooting action of the nurse?
A) Restart the IV.
B) Hang vented tubing.
C) Turn off infusion pump.
D) Hang in-line filtered tubing.
Ans: B
Feedback:
Vented tubing draws air into the container and must be used with glass bottles.
Restarting the IV is unnecessary and places the client at risk for further complications.
Turning off the pump will not correct the problem. In-line filtered tubing should always
be used with TPN but will not correct the problem.
Page 7
21. There are limited infusion pumps available on the nursing unit. Which client has the
greatest need for accurate fluid monitoring? Select all that apply.
A) Young adult with pneumonia
B) Adolescent with knee infection
C) Older adult receiving potassium chloride in the solution
D) Middle-aged adult receiving medication for congestive failure
Ans: C, D
Feedback:
A client with congestive failure should be monitored closely for signs of worsening
fluid overload and is at great risk. Young adult and adolescent would need monitoring
but not at greatest risk. Potassium chloride can cause extravasation if not monitored
closely and is also at great risk.
22. A central venous catheter has been inserted in the right subclavian vein of the client.
Which of the following would be the priority nursing action before total parenteral
nutrition (TPN) can be started?
A) Assess for swelling, redness, and drainage of the site.
B) Allow the TPN solution warm to room temperature.
C) Call for portable chest x-ray.
D) Assess blood sugar via glucometer.
Ans: C
Feedback:
Insertion of a central venous access device in the subclavian can result in an accidental
puncture of the pleural membrane, resulting in a pneumothorax. Verification of the
insertion site is completed before TPN is started. Swelling, redness, and drainage are
symptoms of infection which would not be present immediately following insertion.
Hyperglycemia is a common occurrence with the use of hypertonic solutions such as
found in TPN, but because the TPN has not been started, this is not a priority
assessment. Cold solutions can result in venous spasms but not the priority.
23. The client complains that the intravenous (IV) site is stinging. No signs of infiltration or
inflammation are assessed, but the nurse notices the rate is running faster than ordered.
Which action should the nurse take first?
A) Stop the infusion.
B) Reset the drip rate.
C) Document the findings.
D) Assess the vital signs.
Ans: B
Feedback:
Decreasing the rate of flow and reassessing the symptoms is the priority. If no adverse
symptoms are noted, stopping the infusion would not be indicated. Assessing the vital
signs during IV infusion is a routine part of nursing care of clients with IV therapy but
not a priority for this complaint. Documentation is not the first action to be taken.
Page 8
24. The nurse is preparing an intravenous partial bottle (IVPB) of anti-infective as ordered.
Which is the best method of delivery for a client with a history of congestive failure?
A) IV push
B) Continuous IV infusion
C) Intermittent infusion via medication lock
D) Infusion via midline catheter
Ans: C
Feedback:
A medication lock provides a route for intermittent infusion of medications/solutions
that limits the amount of solution given. IV push is not the preferred route for
administration of anti-infective and is not an approved route for the LPN/VPN. Midline
catheter is used for long-term peripheral IV therapy is not indicated. Continuous IV
infusion would place the client at greater risk for fluid over load.
25. Which isotonic solution is often used in providing a source of energy to clients receiving
total parenteral nutrition (TPN)?
A) Lipid emulsions
B) Normal saline solution (NSS)
C) Dextrose 5% in water (D5W)
D) Ringer's lactate (RL)
Ans: A
Feedback:
A lipid emulsions prevent and treat essential fatty acid deficiencies and provide a major
source of energy. NSS, D5W, and RL are all isotonic solutions but are not used in
addition to TPN and do not a good source of energy.
26. When flushing an intravenous (IV) lock with saline, the nurse avoids forcing the
injection into the client. Which is the best rationale for this action?
A) Prevents IV infiltration
B) Minimizes discomfort/burning
C) Minimizes potential for clot release
D) Prevents dislodging the venous access device
Ans: C
Feedback:
Forcing the solution through a resistant lock may dislodge a clot into the client's
circulation. The risk of IV infiltration and dislodgement is not a priority. Discomfort and
burning associated with lock flushing is related to the rate of infusion not force.
Page 9
27. To avoid complications of blood transfusion reaction, which nursing action is most
important?
A) Matching numbers on blood bag to client bracelet
B) Making sure IV catheter size is 20 gauge or larger
C) Hanging normal saline before and after blood infusion
D) Only allowing the registered nurse to initiate, maintain, and discontinue the blood
Ans: A
Feedback:
When the laboratory draws a sample of blood for typing and crossmatching, an
identification bracelet is attached to the client and must match to confirm the correct
blood at time of administration. A 20-gauge needle or greater is preferred for
administration of blood but not a priority for avoiding transfusion reaction. Normal
saline is the isotonic solution used with transfusions but not indicated for prevention of
reactions. Registered nurses are required to initiate blood transfusions, but the scope of
practice is changing in some states for the LPN/VPN to maintain and/or discontinue the
transfusion after the initial assessment period.
28. Before instilling any additives to a client's medication lock, normal saline is used to
flush the device. Which of the following provides the best rationale for this action?
A) Prevents drug/solution incompatibilities
B) Dilutes the medication for easier administration
C) Decreases the drug's irritating effect
D) Maintains the serum sodium level and pH balance
Ans: A
Feedback:
To prevent incompatibility between medication doses, the line should be flushed with
normal saline. The medication is diluted and mixed in the partial bottle prior to
administration. Following the instructions for mixing and preparation of the drug should
allow for safe (less irritating) administration of the drug. Saline flush is used in small
amounts (approximately 2 to 3 mL) and will not affect the sodium level or pH of the
blood.
Page 10
29. The major advantage for giving a client medication via intravenous (IV) route is which
of the following?
A) Fewer adverse reactions noted
B) Less costly to the client
C) Rapid distribution of the drug to all target tissues
D) Ease of maintaining drug therapy in the home setting
Ans: C
Feedback:
The IV route produces a rapid drug effect throughout the body. IV administration of
drugs can be more costly than the oral route. Adverse reaction toward the medication is
not effected by the route. The easiest route for drug therapy in the home is usually oral
route.
30. In providing nursing care to a client, which actions should the nurse take to reduce the
risk of administering a precipitated intravenous (IV) solution? Select all that apply.
A) Use in-line filters on peripheral and central line IV solutions.
B) Avoid reconstituting powder drugs when preparing the solution.
C) Inspect IV solutions prior to administration.
D) Do not use any solution that is expired.
Ans: C, D
Feedback:
Inspecting the solution to make sure the solution is clear, transparent, and does not
contain a precipitant is the primary action to be taken prior to any IV administration.
In-line filters are not used routinely on peripheral IVs but are used for TPN and blood
transfusions. IV drugs are often packaged in the powder form. The nurse should inspect
the IV container for expiration date and should not use those solutions that are past the
expiration date.
31. The client asks the nurse why it is necessary to prime the intravenous tubing. Which is
the best response by the nurse?
A) “It eliminates air and potential of complications.”
B) “It helps to keep the catheter open and flowing.”
C) “It allows for air lock, which ensures the delivery of all the medication.”
D) “It adheres to infection control and prevention of infection.”
Ans: A
Feedback:
A bolus of air that is forced into the venous system can result in pulmonary emboli,
shock, or death. Priming the tubing does not keep the catheter open and flowing and is
not indicated for infection control purposes. An air lock used in intramuscular injections
is not indicated for IV administration.
Page 11
32. The client has been receiving intravenous (IV) fluids for the last 6 hours and now is
demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure
more than 15 mm Hg higher than baseline. Which is the most likely nursing diagnosis
for this client?
A) Ineffective Peripheral Tissue Perfusion
B) Ineffective Airway Clearance
C) Excess Fluid Volume
D) Impaired Tissue Integrity
Ans: C
Feedback:
The symptoms the client is experiencing indicated excess fluid volume. If the edema
continues in the lower extremities, peripheral tissue perfusion and integrity can become
impaired. Ineffective airway associated with the crackles is directly related to the fluid
volume overload.
33. The client is receiving total parenteral nutrition (TPN), and the solution bag is almost
empty. The nurse discovers there are no containers prepared for use. Which is the
immediate action of the nurse?
A) Hang dextrose 10% in water (D10W) until new container is ready.
B) Hang normal saline solution (NSS).
C) Slow the rate to keep vein open (KVO) until new container is ready.
D) Stop the infusion and then flush the catheter to maintain patency.
Ans: A
Feedback:
Abruptly stopping the administration of hypertonic, high-glucose solutions will result in
a rebound hypoglycemic effect and can be avoided if the approximate glucose
concentration can be assessed and added to D10W solution. NSS does not contain
glucose. Slowing or stopping the rate of infusion will not prevent rebound
hypoglycemia.
34. A postoperative total hip replacement client is to receive salvaged blood through the cell
saver system. The nurse is most concerned about which possible transfusion reaction?
A) Incompatibility reaction
B) Allergic reaction
C) Hepatitis B
D) Septic reaction
Ans: D
Feedback:
Infusion of blood products that contain microorganisms can result in septic reaction.
The cell saver system requires specific guidelines and timelines for safe administration
of the salvaged blood. Incompatibility reactions and allergic reactions are associated
with mismatched donor and recipient blood, but salvaged blood comes directly from the
client. Hepatitis B is not indicated with self-transfusions.
Page 12
Page 13
1. Chapter 14
You are caring for a client 6 hours postsurgery. You observe that the client voids urine
frequently and in small amounts. You know that this most probably indicates what?
A) Requirement of intermittent catheterization
B) Calculus formation
C) Urine retention
D) Urinary infection
Ans: C
Feedback:
Voiding frequent, small amounts of urine indicates retention of urine with elimination of
overflow. The nurse should assess the volume of first voided urine to determine
adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should
consult with the physician regarding instituting intermittent catheterization until
voluntary voiding returns and is not required in this case. Frequent and small amounts of
urine voiding does not indicate urinary infection nor does it indicate the formation of a
calculus.
2. You are caring for a client during the immediate postoperative period. What signs and
symptoms indicate that the client may be in shock?
A) Weak and rapid pulse rate
B) Warm, dry skin
C) Pooling of secretions in the lungs
D) Obstructed airway
Ans: A
Feedback:
Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse
rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an
obstructed airway predispose the client to hypoxia and not to shock.
3. You are caring for a client postoperatively. What nursing interventions help prevent
venous stasis and other circulatory complications in a client who has undergone surgery?
A) Place pillows under the client's knees or calves.
B) Encourage the client to move legs frequently and do leg exercises.
C) Apply pressure on the client's lower extremities.
D) Maintain the client in a side-lying position.
Ans: B
Feedback:
The nurse should encourage the client to move legs frequently and do leg exercises to
prevent venous stasis and other circulatory complications. The nurse should not place
pillows under the client's knees or calves unless ordered and should avoid placing
pressure on the client's lower extremities. Placing the client in a side-lying position will
not help prevent venous stasis and other circulatory complications in a client who has
undergone surgery.
Page 1
4. The nursing instructor is talking with her class about spinal anesthesia. What would be
the nursing care intervention required when caring for a client recovering from spinal
anesthesia?
A) Turn the client from side to side at least every 2 hours.
B) Assist the client to a sitting position at the side of the bed.
C) Instruct the client to stay in bed until sensation and movement returns.
D) Monitor respiratory rate and sensation every 2 hours or as per ordered.
Ans: C, D
Feedback:
The client who has received spinal anesthesia should remain in bed until sensation and
movement returns. Also, the respiratory rate and sensation must be monitored every 2
hours. If permitted, the nurse should turn the client from side to side at least every 2
hours. The client who has received spinal anesthesia should be permitted to sit.
5. Your client required reversal drugs after surgery. What nursing intervention is required
when caring for a client who is treated with reversal drugs?
A) Instruct the client to lie flat.
B) Observe the client for an extended period.
C) Help the client slowly move to an upright or standing position.
D) Emphasize the dietary restriction.
Ans: B
Feedback:
If reversal drugs are required, the nurse must observe the client for an extended period
because the reversal effects nearly always are shorter than the effects of the drugs being
reversed. This may result in sedation. The client need not lie flat and may not require
assistance for ambulation. There is no specific dietary restriction required when treated
with reversal drugs.
6. Several of the clients at the clinic are preparing to have surgery within the next 2 weeks.
They are completing preoperative paperwork today with their visit. What are some of
the reasons that people might need to have surgery? Select all that apply.
A) Cosmetic
B) Diagnostic
C) Palliative
D) Normative
E) Causative
Ans: A, B, C
Feedback:
Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative
surgeries, exploratory surgeries, and curative surgeries. Options D and E are distractors.
Page 2
7. You are a PACU nurse caring for an older adult client who is recovering from surgery.
The client tells you he is in pain. You know older adults react to medications differently
than younger clients. What does this client's age put them at increased risk for? Select
all that apply.
A) Acute agitation
B) Overdose of pain medication
C) Anxiety
D) Longer recovery time
E) Greater requirement for pain medication
Ans: A, B, C, D
Feedback:
The mechanisms of medication clearance in older adults may be prolonged, leading to
risk of overdose. Therefore, older adults usually receive smaller doses of preoperative,
intraoperative, and postoperative medications, especially those that affect the central
nervous, cardiovascular, and renal systems. The older adult client's reaction to
medication puts them at risk for agitation, anxiety, and a longer recovery time.
8. A physically fit 86-year-old is scheduled for right knee replacement. What factor in this
client makes him at increased risk for surgery?
A) Age
B) Type of surgery
C) Ability to metabolize medication
D) Nutritional status
Ans: A
Feedback:
On admission, the nurse reviews preoperative instructions, such as diet restrictions and
skin preparations, to ensure the client has followed them. If the client has not carried out
a specific portion of the instructions, such as withholding foods and fluids, the nurse
immediately notifies the surgeon. He or she identifies the client's needs to determine if
the client is at risk for complications during or after the surgery. General risk factors are
related to age; nutritional status; use of alcohol, tobacco, and other substances; and
physical condition. In this scenario, the risk to the client is age; the other options are
incorrect according to the scenario described.
Page 3
9. The nurse is completing an assessment of the patient prior to surgery. What areas of the
patient assessment should the nurse question further? Select all that apply.
A) Medication
B) Elimination
C) Activity
D) Support system
E) Religious preference
Ans: A, B, C, D
Feedback:
When preparing a client for surgery, these areas need to be addressed: skin preparation,
elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In
addition, medication, activity, and the client's support system must be assessed.
10. You are working in the preoperative area with a client going to surgery for a
cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively.
The client asks you why these medications are needed. What would be your best
answer?
A) “These medications slow motor activity.”
B) “These medications decrease the amount of anesthesia you will need.”
C) “These medications decrease anxiety before surgery.”
D) “These medications decrease gastric acidity and volume.”
Ans: D
Feedback:
The anesthesiologist frequently orders preoperative medications. Common preoperative
medications include the following: anticholinergics, which decrease respiratory tract
secretions, dry mucous membranes, and interrupt vagal stimulation; antianxiety drugs,
which reduce preoperative anxiety, slow motor activity, and promote induction of
anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume;
narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and
pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce
the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent
emesis, and enhance preoperative sedation.
Page 4
11. The nurse has provided preoperative instructions to a client scheduled for surgery at an
ambulatory care center. Which statement, made by the client, would indicate that further
instruction is needed?
A) “If I do not follow the instructions, my surgery could be cancelled.”
B) “The nurse will explain the details of the surgery before I sign a consent.”
C) “My medical records will be sent to the ambulatory care center prior to my
surgery.”
D) “The physician will update my family after the procedure and provide specific
discharge instructions.”
Ans: B
Feedback:
Further instruction would be needed to clarify that the physician, not the nurse, explains
the details of the surgery and obtains voluntary consent for the procedure. It is correct
that preoperative instructions must be followed prior to surgery for the safety of the
client, medical records are present for review prior to surgery, and the physician speaks
with the family following the procedure and provides instructions for discharge.
12. The nurse is reviewing a preoperative informed consent when preparing the client for
surgery. Which contents of the informed consent are required? Select all that apply.
A) Explanation of procedure
B) Estimated time of procedure
C) Potential risks
D) Benefits of surgery
E) Personnel present
F)
Description of alternatives
Ans: A, C, D, F
Feedback:
Informed consents should be in writing and contain an explanation of procedure and
risks, description of benefits and alternative, an offer to answer questions about
procedure, ability to withdraw consent, and statement informing the client if the
protocol differs from customary procedure. An estimated time of procedure and
personnel present are not required in the informed consent.
Page 5
13. When assessing a postoperative client, the nurse is correct to relate which surgical risk
factor that would decrease if the surgical client maintained a blood glucose level under
150 mg/dL?
A) Nutrient deficiencies
B) Respiratory complications
C) Wound healing
D) Liver dysfunction
Ans: C
Feedback:
In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with
an increased risk of surgical incision infections and delayed wound healing. There is no
direct correlation between blood glucose levels and nutrient deficiencies, respiratory
complications, and liver dysfunction.
14. The nurse has received shift report on a postoperative surgical client. Which medication
order would indicate that the medication was being administered prophylactically?
A) A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
B) Percocet two tablets every 4 hours as needed for pain
C) Humulin NPH 12 units at 0800.
D) Amoxicillin 500 mg two tablets every 8 hours for 48 hours
Ans: D
Feedback:
A prophylactic antibiotic is administered either before surgery, after surgery, or both
before and after surgery to prevent postoperative infections. Intravenous solutions are
typically administered for hydration and allow for medication administration. Pain
medications such as a Percocet decrease surgical pain. Humulin NPH insulin reduces
blood glucose levels.
15. When assessing the client postoperatively, which nursing consideration is essential
before offering oral fluids?
A) Assess ability to swallow.
B) Assess urinary output.
C) Assess pain level.
D) Assess positioning.
Ans: A
Feedback:
Before giving oral fluids, it is essential that the client has recovered sufficiently to be
able to swallow. Assessing urinary output, pain level, and positioning is completed
postoperatively but does not impact the ability to offer oral fluids.
Page 6
16. The nurse is caring for a client being transitioned from the postanesthesia care unit
(PACU) to the surgical nursing floor. Which nursing action is first when a client states,
“I am nauseated”?
A) Obtain an emesis basin and cool washcloth.
B) Check the medication record for antiemetic medication orders.
C) Obtain vital signs.
D) Encourage sips of clear liquids.
Ans: A
Feedback:
Nausea is a frequent symptom in the postoperative period. When a client states being
nauseated, the nurse's first action is to provide an emesis basin in case the client vomits.
Once the client is provided for, next the nurse would check the MAR to provide a
prescribed antiemetic. Vital signs would be obtained per postoperative protocol, and
liquids would be held until the nausea subsides.
17. The nurse is reviewing a postoperative client's chart prior to a physician's office visit.
Lab reports reveal a prior WBC of 40,000/mm3, a current WBC count of 8000/mm3, and
a current wound culture negative, following a Staphylococcus aureus infection. Tertiary
intention of wound healing is documented at the last visit. Which current assessment of
wound healing is anticipated?
A) Wound edges well approximated. No redness/swelling noted.
B) Edges of incision well approximated with the center of incision open. Green
purulent drainage noted.
C) Wound edges sutured. Scant amount of drainage noted. No foul odor.
D) Wound packed with 1 2 inch sterile packing material; interior pink.
Ans: C
Feedback:
The scenario stated a previous wound infection that has resolved. Sutured wound edges
are present once the wound has been cleaned of infection as noted in tertiary intention of
wound healing. Well-approximated edges are healing without infection. Wound packing
is noted in secondary intention. Green purulent drainage is noted with a wound
infection.
Page 7
18. The nurse is providing community instruction on the impact of aging and surgical
incisional considerations. Which instructional areas would be included in the
presentation? Select all that apply.
A) Increase protein in the diet.
B) Instruct on symptoms of wound/incision infection.
C) Cleanse wound/incision with products such as soap and water.
D) Avoid showering until healing has occurred.
E) Wash with half-strength peroxide to prevent infection.
F)
Remove any crusted areas from incisional line.
Ans: A, B, C
Feedback:
The nurse realizes that there is a thinning of the skin and loss of subcutaneous tissue,
which is normal in the aging process. Also, older adults may have a diminished
immunological response, making them more susceptible to infection. For this reason,
instructional areas would include areas which promote healing and diminish the risk of
infection. Increasing protein in the diet promotes wound healing. Instructing on signs
and symptoms of wound infection allows for early symptom recognition. Cleansing, as
per physician instruction, but with products, such as soap and water, decreases bacteria
on the skin. Showering may begin prior to healing with the stream of the water not
directly on the incision. Peroxide is not recommended for wound/incisional care.
Crusted areas should be allowed to heal and flake off. Removing the areas could open a
wound allowing for bacteria to enter.
19. The nurse is caring for the client in the preoperative period and documenting rationale
for a palliative surgical procedure. Which rationale is most appropriate?
A) The physician needs additional information to plan medical treatment.
B) The client wishes to improve body structures and elects a procedure.
C) The physician is repairing a deformity from birth or disease process.
D) The client and physician are focusing on symptom relief not a cure.
Ans: D
Feedback:
The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or
enhancement of function without a cure. Diagnostic surgical procedures provide
additional information for medical diagnosis and treatment. Cosmetic surgery
procedures are elective, with the purpose of improving body appearance. Reconstructive
surgery corrects a deformity.
Page 8
20. The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory
care setting. During which phase of perioperative care would the nurse document the
admission vital signs in the recovery room?
A) During the preoperative phase
B) During the intraoperative phase
C) During the transfer phase
D) During the postoperative phase
Ans: D
Feedback:
The nurse realizes that documentation of vital signs in the recovery room begins the
postoperative phase of perioperative care. The preoperative phase occurs until the client
reaches the operating area. The intraoperative phase includes the entire surgical
procedure until the transfer to the recovery area. There is no transfer phase of
perioperative care.
21. At which time does the nurse realize that it is best to begin teaching about care needed
during the postoperative period?
A) During the preoperative period
B) Upon arrival to the surgical unit
C) Following the surgical procedure
D) At the time of discharge instructions
Ans: A
Feedback:
The best time to begin teaching about care needed in the postoperative period is during
the preoperative time. At this time, the client is more alert and focused on the
information provided by the nurse. Clients and family members can better be prepared
and participate in the recovery period if they know what to expect. Anxiety is a factor
on arrival to the surgical unit that could interfere with learning. Pain could interfere with
the learning process, following a surgical procedure. At the time of discharge, both pain
and timeliness may be an issue in understanding and obtaining care needed during the
postoperative time.
Page 9
22. The nurse is caring for a client needing emergency surgery. Which preoperative
teaching should be omitted to prepare the client for surgery?
A) Effective coughing and deep breathing
B) Types of postoperative pain medication
C) Frequency of postoperative vital signs
D) Knowledge of surgical procedure
Ans: C
Feedback:
The least helpful postoperative teaching that could be omitted due to the need to obtain
emergency surgery is explaining the frequency of postoperative vital signs. This is not
essential information to improve client participation in their postoperative recovery.
Coughing and deep breathing is essential in the immediate postoperative period. Clients
are often concerned about postoperative pain so instruction on pain medication can
decrease anxiety. Knowledge of the surgical procedure must be explained by a
physician when signing a surgical consent.
23. Which nursing statement would best decrease a client's anxiety before an emergency
operative procedure?
A) “You will be just fine; the operating room nurses will take good care of you.”
B) “It is best to take deep breaths and relax before the procedure.”
C) “Let me explain to you what will happen next.”
D) “We will keep your family informed of your progress.”
Ans: C
Feedback:
Many clients feel fearful of knowing little about the operative procedure and what to
expect. This fear causes anxiety and can lead to a poorer response to surgery and
surgical complications. Explanations of what the client is to expect can help to decrease
anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and
relaxation techniques can be helpful to the client, but addressing the source of the
anxiety is more beneficial. Keeping the family informed helps the family and is not
client focused.
Page 10
24. The nurse is admitting and preparing the client for surgery. Following administration of
Ativan 2 mg orally, one time dose, which safety measure is most appropriate?
A) Place the client in a semi-Fowler's position.
B) Place the side rails in the up position.
C) Remove the water pitcher from the bedside.
D) Instruct the family to call for any client needs.
Ans: B
Feedback:
Ativan is a common hypnotic administered to reduce preoperative anxiety. The most
appropriate safety measure is to limit the client's ability to get out of bed following
administration of a preoperative sedative. Assistance is needed to maintain client safety.
Placing the client in a semi-Fowler's position aids in gas exchange, but this is not
indicated as a concern in this question and does not relate to a safety concern associated
with this medication. Water should not be at the bedside for a client in the preoperative
phase. Families can be helpful support for the client; however, it is the nurse's
responsibility to maintain safety.
25. The surgical unit nurse is developing a postoperative plan of care. In which client's plan
of care would the nurse document interventions of coughing and deep breathing,
gastrointestinal assessment, and effective regulation of temperature?
A) A client with gastrointestinal surgery and general anesthesia
B) A client having a knee replacement and regional anesthesia
C) A client having lower extremity muscle repair and spinal anesthesia
D) A client with spinal stenosis and a regional nerve blockade
Ans: A
Feedback:
General anesthesia acts on the central nervous system to produce a loss of sensation,
reflexes, and consciousness. The anesthesiologist monitors the vital functions of
breathing, circulation, and temperature. Following general anesthesia, nurses must
closely monitor for effective breathing and oxygenation, temperature regulation, and
adequate fluid balance. Nursing interventions for those clients with regional anesthesia,
spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions,
neurovascular assessments to specific body regions, and side effects of the medication.
Page 11
26. The nurse is caring for a client during an intraoperative procedure. When assessing vital
signs, which result indicates a need to alert the anesthesiologist immediately?
A) Pulse rate of 110 beats/min
B) Respiratory rate of 18 breaths/min
C) Blood pressure of 104/62 mm Hg
D) Temperature of 102.5° F
Ans: D
Feedback:
Intraoperative hyperthermia can indicate a life-threatening condition called malignant
hyperthermia. The circulating nurse closely monitors the client for signs of
hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a
significant concern.
27. An enterostomal therapy nurse is caring for a postoperative client with a gaping wound.
Which nursing measure is most helpful when a wound dressing adheres to the wound
bed?
A) Place a transparent dressing between the wound and dressing.
B) Place an emollient based ointment on the wound bed.
C) Use normal saline to soak the dressing for removal.
D) Allow the dressing to dry and release the wound bed.
Ans: C
Feedback:
When a dressing adheres to the wound bed, using normal saline to moisten the dressing
material can loosen the dressing for easier dressing removal without damaging the new
tissue or causing discomfort. The transparent dressing and ointment are not helpful in
assisting with dressing removal. Allowing the dressing to dry promotes wound
adherence.
28. A client is placed on the operating room table for the surgical procedure. Which surgical
team member is responsible for handing sterile instruments to the surgeon and
assistants?
A) Scrub nurse
B) Circulating nurse
C) First assistant
D) Certified registered nurse anesthetist
Ans: A
Feedback:
The scrub nurse is sterile and assists the surgical team by handing instruments to the
surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting
sponges and needles. The circulating nurse is not sterile and obtains and opens sterile
equipment, adjusts lights, and keeps records. The first assistant is involved with the
client's preoperative care. The certified registered nurse anesthetist assists in the client's
anesthesia.
Page 12
29. A postoperative client is moving from the bed to a chair when blood drips from the
dressing. The nurse assesses the incision and notes evisceration. What does the nurse do
first?
A) Place a dry, sterile dressing over the protruding organs.
B) Place a pressure dressing over the opening and secure.
C) Have the client lay quietly on back and call the physician.
D) Moisten sterile gauze with normal saline and place on any organ.
Ans: D
Feedback:
A wound evisceration occurs when the wound completely separates, and the internal
organs protrude. The first action by the nurse would be to cover the protruding organs
with sterile dressings moistened with normal saline. Once the client is safe, the nurse
can notify the physician. The client is positioned in a manner that places the least stress
on the organs. Dry or pressure dressings are placed over the protruding organ.
30. The nurse is planning care for a client following abdominal surgery. Which outcome
demonstrates a return of functioning to the gastrointestinal tract?
A) The client is tolerating sips of water.
B) The client reports a small bowel movement.
C) The client is passing flatus.
D) The client states being hungry.
Ans: B
Feedback:
A bowel movement demonstrates that the nursing outcome of the return to function of
the gastrointestinal track has been met. All of the other options are components of
meeting the outcome of functioning.
31. The nurse is caring for a female postoperative client who is having difficulty voiding.
Which nursing action is most helpful to promote normal voiding?
A) Run water to assist in the let-down reflex.
B) Encourage 8 oz of water.
C) Assist to the bathroom.
D) Offer to catheterize.
Ans: C
Feedback:
The nurse encourages the client to void within 4 hours of surgery to minimize the risk of
a urinary tract infection. Ambulating the client to the bathroom promotes normal body
positioning for urination. Running water is a common psychological strategy to cause
urination, but positioning is a better option. Encouraging water will help fill the bladder
but not urination. Offering to catheterize is a last option.
Page 13
32. The nurse is assessing the postoperative client on the second postoperative day. Which
assessment finding requires immediate physician notification?
A) The client has an absence of bowel sounds.
B) The client's lungs reveal rales in the bases.
C) The client states a moderate amount of pain at the incisional site.
D) A moderate amount of serous drainage is noted on the operative dressing.
Ans: A
Feedback:
A nursing assessment finding of concern on the second postoperative day is the absence
of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may
include abdominal pain and distention as fluids, solids, and gas do not move through the
intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if
general anesthesia was administered. Encourage the client to cough and deep breathe.
Pain is a common symptom following a surgical procedure. Serous drainage on the
postoperative dressing needs to monitored and brought to the physician's attention when
he or she assesses the client.
33. Which teaching point would the nurse stress to decrease the risk of a phlebitis?
A) Massage the calves and thigh.
B) Prop pillows under knees.
C) Encourage ambulation twice daily.
D) Avoid crossing the legs.
Ans: D
Feedback:
Phlebitis is the swelling and inflammation of a vein and is a symptom associated with
thrombophlebitis. To decrease the risk of phlebitis instruct on ways to promote blood
circulation and limiting trauma to the site. Avoiding leg crossing promotes circulation.
Massaging the calves and thighs may cause further swelling and inflammation of the
vein. Propping pillows under the knees decreases circulation. Ambulation is stressed
each hour while awake.
Page 14
34. When planning care for a client in the postoperative period, prioritize nursing diagnoses
in the sequence from highest to lowest priority?
A) Impaired Gas Exchange
B) Risk for Infection
C) Altered Comfort
D) Fluid Volume Deficit
E) Anxiety
Ans: A, B, C, D, E
Feedback:
According to the Maslow's hierarchy of deeds, airway and gas exchange is of the
highest priority. Next would be the deficiency in fluid volume. Altered comfort would
be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a
risk for diagnosis is not a current problem but an important teaching point to reduce the
risk.
Page 15
1. Chapter 15
The nursing instructor is talking with the students about botulism. The instructor tells the
students that when caring for a client with botulism, what condition is most likely to
cause death?
A) Diplopia
B) Dysphagia
C) Paralysis of respiratory muscles
D) Dysarthria
Ans: C
Feedback:
In botulism, paralysis of respiratory muscles poses the greatest potential for lethality.
Diplopia (double vision), dysarthria (difficulty in speaking), and dysphagia (difficulty in
swallowing) are all early signs of botulism.
2. You are an emergency department nurse working triage during a disaster. Why should
you tag a victim after assessment in a disaster situation?
A) To know the victim's name
B) The tag states the triage category of the victim.
C) Someone else does not duplicate the assessment.
D) Call for immediate hospitalization.
Ans: C
Feedback:
The tag is an indication that the victim has been assessed by a nurse. This ensures that
the nurse or another medical person does not spend time assessing the same person
twice. The tag does not name the victim, state the triage category, or contain instructions.
3. You are caring for radiation victims. What is the most important factor that you should
consider to assess a client's chance of survival in acute radiation syndrome (ARS)?
A) Dosage of gamma radiation
B) Concentration of nerve gas
C) Mode of infection
D) Direct physical contact
Ans: A
Feedback:
The chance of surviving ARS depends on the dosage of gamma radiation a person
receives. ARS is not related to chemical (gas) or biologic (infection, contact) disasters.
Page 1
4. The nurse caring for victims of a volcano eruption knows that this disaster is categorized
as a natural disaster. What is the other category of disaster?
A) Man-made
B) Artificial
C) Earthly
D) Human
Ans: D
Feedback:
There are essentially two types of disasters: (1) natural disasters such as earthquakes,
floods, and hurricanes; and (2) human disasters that may be intentionally or
unintentionally caused such as explosions, fires, and acts of terrorism. Options A, B, and
C are simply distractors.
5. You are a nurse caring for clients in the emergency department who have been admitted
from the area surrounding a nuclear power plant. There had been a small explosion at
the plant and a small amount of radiation had escaped. You know that this is what type
of a disaster?
A) Natural
B) Explosive
C) Chemical
D) Radiologic
Ans: D
Feedback:
Radiologic disasters can occur in the following ways: explosion of a dirty bomb,
damage to or human error in a nuclear power plant facility, and nuclear blast. The
scenario does not describe a natural disaster or a chemical disaster. Option B is only a
distractor.
6. An ICU nurse is caring for a radiation victim who is being treated with Prussian blue.
You know that Prussian blue works by doing what?
A) Prevents radioactive iodine from reaching the thyroid gland
B) Attaches to radioactive iodine and promotes its excretion
C) Traps cesium in the intestine to prevent its absorption
D) Prevents cesium from being trapped in the small bowel
Ans: C
Feedback:
Prussian blue is a dye used to treat internal contamination with ingested radioactive
cesium. Prussian blue promotes the excretion of cesium by trapping it in the intestine
and preventing its absorption. It is not given for radioactive iodine contamination and
does not prevent cesium from being trapped in the small bowel.
Page 2
7. You are taking a class on chemical disasters with your local emergency response team.
What toxins would you be learning about? Select all that apply.
A) Blistering agents
B) Psychologic agents
C) Contact emulsifiers
D) Nerve agents
E) Cyanide
Ans: A, D, E
Feedback:
Examples of extremely toxic chemicals include nerve agents, cyanide, respiratory
toxins, and blistering agents. Options B and D are distractors for this question.
8. The nurse is caring for a victim of a chemical disaster. Medications given in the
treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulfate. What
chemical agent does the nurse know this client has been exposed to?
A) Sarin
B) Mustard gas
C) Cyanide
D) Anthrax
Ans: C
Feedback:
They administer one or all of the following antidotes: amyl nitrite, sodium nitrite, and
sodium thiosulfate. Amyl nitrite promotes the formation of methemoglobin, which
combines with cyanide to form nontoxic cyanmethemoglobin. Therefore, options A, B,
and D are incorrect.
9. You are the nurse caring for three clients who have been diagnosed with anthrax. They
were exposed after boarding a flight where a white powdery substance was found in one
of the restrooms. You know that these clients would be classed as being victims of
which of the following?
A) A biologic disaster
B) A natural disaster
C) A radiologic disaster
D) A chemical disaster
Ans: A
Feedback:
Anthrax is a biologic agent that could be the cause of a biologic disaster, one in which
pathogens or their toxins cause harm to many humans and other living species. Anthrax
is not a natural, radiologic, or chemical agent of disaster.
Page 3
10. The nurse is caring for a client who has been exposed to radiation. The client is being
treated with diethylenetriamine pentaacetate (DTPA) to reduce the organ damage from
radiation. The nurse knows that DTPA is administered how?
A) Orally
B) Injection
C) Intravenous
D) Rectally
Ans: B
Feedback:
Diethylenetriamine pentaacetate (DTPA) is an injectable salt or inhalant spray
containing calcium (Ca-DTPA) or zinc (Zn-DTPA) and is used to treat internal
contamination with radioactive substances, such as plutonium. It is most effective if
given within the first 24 hours of exposure, but DTPA may still provide beneficial
effects for days to weeks after contamination.
11. The nurse educator is developing a teaching plan to prepare nurses for a disaster
situation. Which teaching method is best?
A) Develop an online module.
B) Prepare a PowerPoint presentation for review.
C) Coordinate a demonstration of a simulated disaster.
D) Conduct a simulation for the nurses to have a role as participants.
Ans: D
Feedback:
When preparing a teaching plan, it is best to include a simulation where the nurses can
participate. The results of research demonstrate that participation in the activity
increases the students' level of comfort with their assigned roles. The other options are
good for providing background information.
12. The nursing supervisor has been notified of a large industrial fire with multiple injuries
started with an electric short. When notifying the nursing peers, the nurse would classify
this as which type of disaster?
A) A natural disaster
B) A human disaster, intentionally caused
C) A human disaster, unintentionally caused
D) Not classified as a disaster
Ans: C
Feedback:
A fire of an electrical cause is classified as a human disaster of an unintentional cause.
A natural disaster is an earthquake or flood that is caused by nature with no human
influence. A human disaster, intentionally caused is when a fire occurs, and a person
intentionally starts the fire. Because a large industrial fire has injured people, it is
classified as a disaster.
Page 4
13. The nurses are preparing the healthcare facility for clients injured in an explosion. While
understanding the characteristics of explosives, what would be the focus of the facility?
A) Preparing the operating room
B) Arranging a temporary morgue
C) Mobilizing supplies to the emergency department
D) Contacting law enforcement for crowd control
Ans: A
Feedback:
Postexplosion injuries generally cause penetrating and blunt trauma. Preparing the
operating room for victims expedites care to the critically injured. Arranging a
temporary morgue and contacting law enforcement is the responsibility of the
administration. Mobilizing supplies is an important task to be prepared for client care.
14. The nurse, on a mission trip, is caring for a client with internal radiologic contamination
from the fallout. The client states, “I need to get this out of me, and then I will be done
with it.” The nurse is most correct to reply which of the following?
A) “Yes, we need to assure that we clean any debris from your wound which may be
contaminated.”
B) “Yes, but you may have lingering effects from the exposure to your body.”
C) “Yes, but you must also consider further exposure from contaminated food and
water sources.”
D) Yes, we need to continue to document your recovery process and further disease
processes.”
Ans: C
Feedback:
Internal radiologic contamination occurs from exposure to fallout on the skin, in a
wound, inhaled, or consumed through food and water. It is the nurse's responsibility to
advise the client if further harm may occur and ways to decrease the risk.
15. A client, contaminated following exposure to radiation, is brought to the hospital for
assessment. Which nursing action is essential?
A) Assess the client for respiratory concerns.
B) Place the client in strict isolation.
C) Obtain vital signs and lab work.
D) Refer the client to the triage area.
Ans: B
Feedback:
It is important for the nurse to realize that a contaminated person can contaminate others
through contact with body fluids or surfaces which he or she touches. Upon arrival to
the hospital, the client is placed in strict isolation to minimize the exposure of others.
The client will then have vital signs and a complete assessment.
Page 5
16. The nurse researcher has been brought to an area following a radiologic disaster 2 years
before. The nurse will be interviewing individuals regarding their health status. Which
would the nurse document as a long-term effect of exposure? Select all that apply.
A) Heart disease
B) Thyroid cancer
C) Leukemia
D) Cleft lip and palate
E) Stillbirths
F)
Bipolar disorder
Ans: B, C, D, E
Feedback:
The nurse is correct to assess for long-term effects stemming from a radiologic disaster.
Long-term effects include thyroid cancer, leukemia, and non-Hodgkin's lymphoma. In
addition, genetic effects have seen among infants conceived shortly before or after the
radiologic disaster. Some include major congenital defects such as cleft lip and palate,
stillbirths, impaired growth and development, and a shorter life expectancy.
17. The nurse is working the triage, phone answering questions about the radiologic
disaster. When in the fallout period of the disaster, which suggestion is most
appropriate?
A) Stay with friends and family in an outdoor area with good ventilation.
B) Remove all outer garments before entering a house or shelter.
C) Use a fan to circulate air from the outdoors to the inside.
D) Bring all outdoor pets inside to limit their exposure.
Ans: B
Feedback:
During the fallout period when particles are returning to the ground, the main concern is
to limit exposure. To limit exposure, the nurse is most correct to instruct to remain
indoors and prevent the outside air to mix with the indoors. This includes removing all
outer garments before entering a house or shelter. Other considerations include sealing
windows, turning off all fans, placing outdoor clothes and shoes in a plastic bag, and not
having contact with outdoor pets.
Page 6
18. The nurse is caring for a client who is critically ill and has high radiation levels in the
system. When discussing the needs of patient care and the need to protect nursing staff,
which is discussed as the optimal barrier against gamma radiation?
A) A protective face mask and shield
B) Minimal exposure and gloving
C) Maintaining a proximity distance
D) Lead barriers and protective aprons
Ans: D
Feedback:
The optimal barrier against gamma radiation is lead. All other options may also be
incorporated in the plan of care.
19. The nurse is caring for a client prescribed Prussian blue. Which teaching instruction is
most helpful?
A) Prussian blue can lead to joint pain.
B) Prussian blue can turn the mouth, teeth, and stools blue.
C) Prussian blue can provide a blue tinge to the skin resembling cyanosis.
D) Prussian blue can alter the taste buds and decreasing food consumption.
Ans: B
Feedback:
It is most helpful to instruct on changes the client may see with medication
administration so not to alarm the client if it happens. Prussian blue does turn the mouth,
teeth and stools blue. It does not alter taste buds, lead to joint pain, nor turn the skin a
blue tinge.
20. Which isolation category should the nurse use to guide care when caring for a client
with anthrax?
A) Standard precautions
B) Droplet precautions
C) Airborne precautions
D) Contact precautions
Ans: A
Feedback:
Standard precautions, measures for reducing the risk of transmitting pathogens, are
sufficient for caring for clients infected with anthrax. These precautions are for all
patients being cared for in the hospital. Droplet, airborne, and contact precautions
initiate additional measures beyond those for standard precautions.
Page 7
21. The nurse is instructing on bioterrorism agents. Which of the following does the nurse
emphasize as an agent which is transmitted from person to person?
A) Anthrax
B) Botulism
C) Smallpox
D) Varicella
Ans: C
Feedback:
Smallpox is highly contagious and caused by a variola virus. Individuals infected with
the botulinum toxin and anthrax are not at risk to others; there are no reports of person
to person transmission. Varicella, commonly called the chickenpox, is contagious but
not a bioterrorism agent.
22. The nurse is caring for a client diagnosed with botulism. Which medication
classification does the nurse anticipate?
A) An antibiotic
B) An anti-inflammatory
C) Antipyretics
D) Antitoxins
Ans: D
Feedback:
Botulism is a disease that develops from the neurotoxin produced by Clostridium
botulinum. Botulinum antitoxin is the only treatment after exposure to lessen the
severity of symptoms. Antibiotics are used for anthrax. Supportive treatments such as
antipyretics are used for smallpox. Anti-inflammatory medications are not treatments
for botulism.
23. The nurse is advising a community group on hospital procedures established for a
bioterrorism attack. The nurse specifically addresses which agent where victims need a
room under negative air pressure?
A) Anthrax
B) Smallpox
C) Cyanide poisoning
D) Botulism
Ans: B
Feedback:
Clients with smallpox are under strict contact transmission-based precautions in a room
under negative pressure air. Standard precautions are necessary for anthrax. There is no
further precautions for cyanide poisoning or botulism.
Page 8
24. The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a
tutorial on the neurotransmitters and nervous system affected. Which couplet is most
correct?
A) Acetylcholine, parasympathetic nervous system
B) Serotonin, sympathetic nervous system
C) Norepinephrine, sympathetic nervous system
D) Dopamine, parasympathetic nervous system
Ans: A
Feedback:
Nerve agents cause fatal consequences by inhibiting acetylcholinesterase.
Acetylcholinesterase is an enzyme that inactivates acetylcholine, a neurotransmitter of
the parasympathetic nervous system. No other option is correct.
25. The student nurse is completing a simulation where a client is the victim of nerve gas.
The instructions are for the student to set up the room and have all needed supplies
available. Which medication does the student nurse ensure is in the medication
administration system to control seizures?
A) Phenobarbital intramuscular
B) Neurontin tablets
C) Valium intravenous injection
D) Dilantin tablets
Ans: C
Feedback:
The students nurse is correct to have Valium intravenously on hand for seizure activity.
When seizure activity occurs, the intravenous route is the best option to deliver the
medication safely and rapidly into the system. It would be very difficult to administer
medication both orally and intramuscularly.
Page 9
26. The nurse comes across a group (four individuals) overcome by a toxic gas substance
and unconscious. Place the nursing action in order of what the nurse would do first?
(Use all options.)
A) Eliminate the source of the toxic gas.
B) Begin first aid or supportive measures.
C) Assess the clients for spontaneous breathing.
D) Call 911 for emergency assistance.
E) Move the clients to fresh air.
Ans: A, B, C, D, E
Feedback:
The first action is to eliminate the source of the toxic gas. If not, the nurse could be
overcome by the gas also. Next, the nurse would move the clients to fresh air, getting
oxygen into the system, if breathing spontaneously. Next, assess each client's respiratory
status and if spontaneous breathing is present. Provide rescue breathing if breathing is
not present. Call 911 and report client assessment findings and nursing measures already
provided. Begin first aid or supportive measures, as directed, until assistance occurs.
27. The nurse is caring for a client with cyanide poisoning. The nurse is most correct to
assess which systems where manifestation of the poisoning primarily occurs?
A) Cardiovascular and respiratory system
B) Gastrointestinal and musculoskeletal system
C) Cardiovascular and neurological system
D) Sensory and respiratory system
Ans: C
Feedback:
Cyanide poisoning is manifested primarily by the heart/cardiovascular system and
brain/neurological system. Symptoms include tachycardia, cardiac dysrhythmias, low
blood pressure, restlessness, headache, loss of consciousness, and then respiratory
failure.
Page 10
28. The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly
decontaminating the client by showering and bagging all client clothing, what is the
nurse simultaneously assessing for?
A) Neurological compromise
B) Respiratory compromise
C) Cardiovascular compromise
D) Sensory neglect
Ans: B
Feedback:
A person exposed to a blistering agent or vesicant must be decontaminated immediately,
with clothing removed and bagged. Irrigation of the victim's eyes and application of
topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse
is assessing the respiratory system for airway obstruction because blisters from inhaled
toxics can swell obstructing respiratory passages.
29. The nurse is working at a natural disaster scene. A patient requires triage and treatment.
Which category would the patient be assigned to?
A) Expectant
B) Delayed
C) Immediate
D) Minimal
Ans: A
Feedback:
The expectant category provides comfort and emotional support to victim. These clients
will be transported when resources become available. Victims are stabilized via first aid
in the immediate category, which assists the medical personnel when the client gets to
the treatment area. The delayed category is for stable victims who can wait up to 10
hours for care. The minimal category is for minor injuries.
30. The nurse identifies four nursing diagnosis for a client exposed to toxin. Which nursing
diagnosis would be prioritized last?
A) Impaired Skin Integrity
B) Ineffective Coping
C) Fluid Volume Deficit
D) Risk for Contamination
Ans: D
Feedback:
When prioritizing nursing diagnosis, the nurse would place an actual diagnosis ahead of
a “risk for” diagnosis. When identifying a “risk for” diagnosis, the nurse is identifying a
potential problem which needs assessment to prevent or identify early the diagnosis.
Page 11
31. The nurse is evaluating a skin lesion on a client brought to the emergency department.
The nurse notes characteristics of chickenpox but has the physician evaluate the lesion
for which biologic disaster agent?
A) Botulism
B) Smallpox
C) Rubella
D) Anthrax
Ans: B
Feedback:
Smallpox may be mistaken for chickenpox due to the characteristics of the lesions.
Botulism is a neurological toxin. Rubella is a communicable disease. Anthrax is a
spore-forming bacterium that is inhaled or injected.
32. The nursing staff, working in an emergency room, begins to see an influx of clients with
the following condition: acute nausea and vomiting; redness and itchiness of the skin,
leading to open sores; bleeding from the nose, mouth, and gums; and blisters in the
mouth and throat. Which condition is suspected?
A) A food poisoning
B) Acute radiation syndrome
C) Anthrax contamination
D) Manifestations of botulism
Ans: B
Feedback:
The stated symptoms are characteristics of acute radiation syndrome. Food poisoning
produces gastrointestinal symptoms. Anthrax produces respiratory complications when
inhaled, gastrointestinal complications when ingested, and skin manifestations with
direct contact but not the collection of symptoms described. Botulism symptoms include
the 4 Ds being diplopia, dysarthria, dysphonia, and dysphagia.
33. The nurse is instructing community members on understanding the indications of
bioterrorism. Which of the following would be highlighted? Select all that apply.
A) Development of similar symptoms in a community
B) Identification of an individual with unusual symptoms
C) Unexplained deaths of domestic or wild animals in an area
D) Atypical presentation of an illness for the time of year
E) Presence of unexplained mortality
Ans: A, C, D, E
Feedback:
Indications of bioterrorism produce group symptoms, many times, of unusual nature for
the community or time of year. Identification of one individual is an isolated
occurrence.
Page 12
34. The nurse is on a community awareness safety committee. When prioritizing biological
agents according to potential morbidity and mortality, which cluster of biological agents
hold the highest mortality?
A) Hantavirus, tuberculosis
B) Botulism, Salmonella
C) Anthrax, smallpox
D) Escherichia coli, Brucella species
Ans: C
Feedback:
The cluster of agents with the highest mortality includes anthrax and smallpox. The
Hantavirus and tuberculosis agents are not presently used for bioterrorism. Botulism and
Salmonella as well as Escherichia coli and Brucella species are of low mortality.
35. Nurses are learning to administer the smallpox vaccine in the event of needed mass
inoculation. When administering the vaccination, which nursing consideration is
essential?
A) Site of administration
B) Skin preparation
C) Standard precautions following administration
D) Covering site following administration
Ans: B
Feedback:
The nursing consideration most essential is to avoid use of alcohol as a skin disinfectant
because alcohol inactivates the virus. The site of administration is the deltoid. Standard
precautions are used in contact with bodily fluids and infectious diseases. The site is
covered with loose gauge following administration.
Page 13
1. Chapter 16
A nursing instructor is teaching her class about burns. The instructor relates the
following scenario: A nurse is caring for a severely burned client who now has elevated
hematocrit and blood cell counts. What consequences should the nurse expect in this
client?
A) Slow heart rate
B) Kidney stones and blood clots
C) Imbalance in electrolytes
D) Elevated central venous pressure (CVP)
Ans: B
Feedback:
Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated
hematocrit levels and blood cell counts indicate hemoconcentration, which means a high
ratio of blood components in relation to watery plasma. This increases the potential for
blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because
the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte
levels tend to remain normal because they are depleted in proportion to the water loss.
CVP is usually below 4 cm H2O.
2. Which of the following conditions does the nurse need to confirm when he or she taps
the facial nerve of a client who has dysphagia?
A) Hypervolemia
B) Hypercalcemia
C) Hypomagnesemia
D) Hypermagnesemia
Ans: C
Feedback:
If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle,
it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia.
The additional symptom of dysphagia reinforces the possibility of hypomagnesemia
rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia,
hypervolemia, or hypermagnesemia.
Page 1
3. A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous
membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum
sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this
client?
A) Yes, this will correct the sodium deficit.
B) Yes, along with the hypotonic IV.
C) No, start with the sodium chloride IV.
D) No, sodium intake should be restricted.
Ans: D
Feedback:
The symptoms and the high level of serum sodium suggest hypernatremia, (excess of
sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV
can only worsen this condition but may be required in hyponatremia (sodium deficit).
Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
4. You are caring for a client who has been admitted with a possible clotting disorder. The
client is complaining of excessive bleeding and bruising without cause. You know that
you should take extra care to check for signs of bruising or bleeding in what condition?
A) Dehydration
B) Hypokalemia
C) Hypocalcemia
D) Hypomagnesemia
Ans: C
Feedback:
Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this
condition, the nurse should take extra care to check for bruising or bleeding. There is no
such risk in dehydration, hypokalemia, or hypomagnesemia.
5. You are caring for a client with severe hypokalemia. The physician has ordered IV
potassium to be administered at10 mEq/hr. The client complains of burning along his
vein. What should you do?
A) Seek a physician's order to dilute the infusion.
B) Switch to an oral formulation.
C) Increase the speed of transfusion.
D) Change the electrolyte.
Ans: A
Feedback:
Treatment of severe hypokalemia requires treatment with IV infusion of potassium.
Clients may experience burning along the vein with IV infusion of potassium in
proportion to the infusion's concentration. If the client can tolerate the fluid, consult
with the physician about diluting the potassium in a larger volume of IV solution. Oral
potassium may not be enough in severe cases hypokalemia. Hypokalemia requires
treatment with potassium and not any other electrolyte.
Page 2
6. Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115
mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging
by anion gap?
A) Metabolic acidosis
B) Respiratory alkalosis
C) Metabolic alkalosis
D) Respiratory acidosis
Ans: A
Feedback:
The anion gap is the difference between sodium and potassium cations and the sum of
chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates
metabolic acidosis. In this case, the anion gap is (166 + 5) – (115 + 35), yielding 21
mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for
respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.
7. The emergency department (ED) nurse is caring for a client with a possible acid–base
imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the
most important indications of an acid–base imbalance that is shown in an ABG?
A) PaO2
B) PO2
C) Carbonic acid
D) Bicarbonate
Ans: D
Feedback:
Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content
(PaCO2), and bicarbonate. An acid–base imbalance may accompany a fluid and
electrolyte imbalance. PaO2 and PO2 are not indications of acid–base imbalance.
Carbonic acid levels are not shown in an ABG.
8. The nursing instructor is talking with her junior nursing class about fluid and electrolyte
balance. What would the instructor tell her students that the average daily fluid intake
for an adult is?
A) 2000 mL
B) 2500 mL
C) 3000 mL
D) 3500 mL
Ans: B
Feedback:
In healthy adults, oral fluid intake averages about 2500 mL/day; however, it can range
between 1800 and 3000 mL/day, with a similar volume of fluid loss. Options A, C, and
D are incorrect.
Page 3
9. What is one process by which dissolved chemicals from one area of the body to
another?
A) Passive osmosis
B) Free flow
C) Passive elimination
D) Active transport
Ans: D
Feedback:
Active transport requires an energy source, a substance called adenosine triphosphate
(ATP), to drive dissolved chemicals from an area of low concentration to an area of
higher concentration—the opposite of passive diffusion. Options A, B, and C are
incorrect.
10. A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to
complete discharge teaching, which of the following will the nurse teach the client and
his family? Select all that apply.
A) Drink at least eight glasses of fluid each day.
B) Drink caffeinated beverages to retain fluid.
C) Drink carbonated beverages to help balance fluid volume.
D) Drink water as an inexpensive way to meet fluid needs.
E) Respond to thirst.
Ans: A, D, E
Feedback:
In addition, the nurse teaches clients who have a potential for hypovolemia and their
families to respond to thirst because it is an early indication of reduced fluid volume;
consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid
weather; drink water as an inexpensive means to meet fluid requirements; and avoid
beverages with alcohol and caffeine because they increase urination and contribute to
fluid deficits.
11. The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a
class of sixth graders. Which action by bases keeps the blood pH nearly neutral?
A) Bases cast off acids.
B) Bases bind with hydrogen.
C) Bases hold acidic properties.
D) Bases have no contact with acids.
Ans: B
Feedback:
Acids are substances that release hydrogen into fluid, bases are substances that bind
with hydrogen. The delicate balance between acids and bases, as well as fluids and
electrolytes, maintains the nearly neutral blood pH.
Page 4
12. The nurse is caring for a geriatric client in the home setting. Due to geriatric changes
decreasing thirst, the nurse is likely to see a decrease in which fluid location which
contains the most body water?
A) Intracellular fluid
B) Extracellular fluid
C) Interstitial fluid
D) Intravascular fluid
Ans: A
Feedback:
About 60% of the adult human body is water. Most body water is located within the cell
(intracellular fluid). Due to several physiological changes of aging, geriatric clients have
less bodily fluids.
13. The nurse is adding the intake and output results for a client diagnosed with
dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and
intravenous solutions. The output total is calculated as 2800 mL/day from urine output,
emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable
fluid balance?
A) Suggest a fluid restriction.
B) Encourage oral fluids.
C) Remove the Hemovac.
D) Offer a prescribed antiemetic medication.
Ans: D
Feedback:
When calculating the intake and output of a client, it is essential to understand that the
normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL.
Because the client is vomiting, offering a prescribed antiemetic medication would
decrease the output from emesis and increase the input as the client may be more
accepting of oral fluids. The client should be encouraged more oral intake once
vomiting has subsided, but if not possible, intravenous fluids should be increased to
avoid dehydration. A fluid restriction could cause dehydration. Removing the Hemovac
will decrease documented output but may lead to an internal infection from fluid
accumulation.
Page 5
14. The nurse is assessing residents at a summer picnic at the nursing facility. The nurse
expresses concern due to the high heat and humidity of the day. Although the facility is
offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned
about which?
A) Lung function
B) Summer allergies
C) Cardiovascular compromise
D) Insensible fluid loss
Ans: D
Feedback:
Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid
loss through perspiration and vapor in the exhaled air. These losses are noted as
unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be
only able to be outside for a limited period. Those with cardiovascular compromise may
need to alternate outdoor activities with indoor rest.
15. A client is experiencing edema in the tissue. The nurse is correct in anticipating which
tonicity of intravenous fluid?
A) Isotonic fluid
B) No intravenous solution
C) Hypertonic solution
D) Hypotonic solution
Ans: B
Feedback:
There are three types (tonicity) of intravenous fluids, which are isotonic, hypotonic, and
hypertonic solutions. By process of osmosis and diffusion, solutes are moved through
the body. A hypertonic solution is used to pull water back in to circulation as a
hypertonic solution has more particles than the body's water. An isotonic solution is the
same concentration as the body's water and is used as an intravenous volume expander.
A hypotonic solution has fewer particles than the body's water thus shifting water from
the vascular space to the tissue.
Page 6
16. The nurse is correct to state that a client's body needs to have adequate nutrition to
maintain energy. Which type of transport of dissolved substances requires adenosine
triphosphate (ATP)?
A) Osmosis
B) Passive diffusion
C) Facilitated diffusion
D) Active transport
Ans: D
Feedback:
Active transport requires the use of the body's energy molecule (ATP) to meet body
needs for fluid and particle transport. Osmosis is the movement of body fluids through a
semipermeable membrane that allows not all substances to pass through. Passive
diffusion allows the movement of substances from an area of higher concentration to
lower concentration. Facilitated diffusion has certain dissolved substances that require
the assistance from a carrier module to pass through the semipermeable membrane.
17. The nurse is reviewing lab work on a newly admitted client. Which of the following
diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all
that apply.
A) An elevated hematocrit level
B) A low urine specific gravity
C) Electrolyte imbalance
D) Low protein level in the urine
E) Absence of ketones in urine
Ans: A, C
Feedback:
Dehydration is a common primary or secondary diagnosis in healthcare. An elevated
hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an
imbalance as sodium and potassium levels are excreted together in client with
dehydration. The urine specific gravity, due to concentrated particle level, is high.
Protein is not a common sign of dehydration. Ketones are always present in the urine.
Page 7
18. The nurse is conducting a lecture on the difference between hypovolemia and
dehydration. When completing a verbal comparison, which point needs clarified?
A) Similar causes are present in both conditions.
B) Hypovolemia contains only low blood volume.
C) In dehydration, only extracellular is depleted.
D) Both conditions result in abnormal laboratory studies.
Ans: C
Feedback:
In clients diagnosed with dehydration, all fluid compartments including the intracellular
and extracellular compartment are reduced. The other options are correct. Both states
can be from similar disease process such as vomiting, fever, diarrhea and difficulty
swallowing and also have abnormal lab work. It is correct that hypovolemia relates to
low blood volume.
19. Which laboratory result does the nurse identify as a direct result of the client's
hypovolemic status with hemoconcentration?
A) Abnormal potassium level
B) Elevated hematocrit level
C) Low white blood count
D) Low urine specific gravity
Ans: B
Feedback:
When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood
components in relation to watery plasma occurs, thus causing an elevated hematocrit
level. A high white blood cell count and urine specific gravity is also noted. Other
causes of an abnormal potassium level may be present.
20. The nurse is providing nutritional instruction to the client diagnosed with hypovolemia.
Which would the nurse emphasize as something to avoid?
A) Eight to 10 glasses of water per day
B) Foods high in sodium
C) Potassium-rich fruit
D) Beverages with alcohol or caffeine
Ans: D
Feedback:
The nursing management of clients with hypovolemia is to restore fluid balance. The
nurse provides nutritional information and instructs the client to avoid beverages with
alcohol and caffeine, which increases urination and contributes to the fluid deficits. The
clients should drink 8 to 10 glasses of water daily, include sodium in the diet, and eat
potassium-rich fruit.
Page 8
21. The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital
sign is indicative of the disease process?
A) Low heart rate
B) Elevated blood pressure
C) Rapid respiration
D) Subnormal temperature
Ans: B
Feedback:
Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the
excess volume in the system. Respirations are not typically affected unless there is fluid
accumulation in the lungs. Temperature is not generally affected.
22. The nurse is providing afternoon shift report and relates morning assessment findings to
the oncoming nurse. Which daily assessment data is necessary to determine changes in
hypervolemia status?
A) Vital signs
B) Edema
C) Intake and output
D) Weight
Ans: D
Feedback:
Daily weight provides the ability to monitor fluid status. A 2-lb weight gain in 24 hours
indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a
decrease in edema. Vital signs do not always reflect fluid status. Edema could represent
a shift of fluid within body spaces and not a change in weight. Intake and output don't
account for insensible fluid loss.
23. The nurse is documenting assessment findings of a client diagnosed with anasarca.
Which nursing documentation best shows improvement in disease progression?
A) Decreased abdominal girth
B) Increased level of consciousness
C) Weight maintenance
D) Pulse rate decrease
Ans: A
Feedback:
Third-spacing is the translocation of fluid from the intravascular to intercellular space to
tissue compartment. Anasarca is the general edema in the organ cavities such as the
abdomen. Monitoring the abdominal girth provides data on the localization of the fluid
in the interstitial space. A decrease in girth, in particular, notes improvement. Level of
consciousness is not affected unless shock occurs. Weight remains the same as there is a
shifting in fluid; pulse rate could fluctuate according to fluid movement.
Page 9
24. Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to
clients with third-spacing?
A) Initiate an IV of an isotonic solution.
B) Initiate an IV of albumin.
C) Manage an infusion of plasma.
D) Manage an infusion of total parenteral nutrition.
Ans: B
Feedback:
The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin.
Administration of albumin pulls the trapped fluid back into the intravascular space. An
isotonic solution will not pull water from the intercellular space. Blood products are
used for third-spacing management; however, albumin is the product of choice. The
management of total parenteral nutrition is not associated with third-spacing.
25. The nurse is caring for four clients on a medical unit. The nurse is most correct to
review which client's laboratory reports first for an electrolyte imbalance?
A) A 7-year-old with a fracture tibia
B) A 65-year-old with a myocardial infarction
C) A 52-year-old with diarrhea
D) A 72-year-old with a total knee repair
Ans: C
Feedback:
Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency
occurs from an inadequate intake of food, conditions that deplete water such as nausea
and vomiting, or disease processes that cause an excess of electrolyte amounts. The
52-year-old with diarrhea would be the client most likely to have an electrolyte
imbalance. The orthopedic patients will not likely have an electrolyte imbalance.
Myocardial infarction patients will occasionally have electrolyte imbalance, but this is
the exception rather than the rule.
26. The nurse is reviewing client lab work for a critical lab value. Which value is called to
the physician for additional orders?
A) Potassium: 5.8 mEq/L
B) Sodium: 138 mEq/L
C) Magnesium: 2 mEq/L
D) Calcium: 10 mg/dL
Ans: A
Feedback:
Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to
muscle weakness, paresthesias, and cardiac dysrhythmias.
Page 10
27. The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system
assessment would the nurse ask detailed questions?
A) Endocrine system
B) Gastrointestinal system
C) Neurological system
D) Musculoskeletal system
Ans: C
Feedback:
A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely
monitors the client with hypocalcemia for neurological manifestations such as tetany,
seizures, and spasms. If the calcium level continues to decrease, seizure precautions are
necessary. Cardiac dysrhythmias and airway obstruction may also occur.
28. The nurse is caring for a client with multiple organ failure and in metabolic acidosis.
Which pair of organs is responsible for regulatory processes and compensation?
A) Kidney and liver
B) Heart and lungs
C) Lungs and kidney
D) Pancreas and stomach
Ans: C
Feedback:
The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon
dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid
levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate.
The kidneys assist in acid–base balance by retaining or excreting bicarbonate ions.
29. The nurse receives report that a client's pH level is 7.4. Which nursing action would be
most appropriate?
A) Call the physician with the report.
B) Encourage the client to deep breath.
C) Complete a head-to-toe assessment.
D) Obtain an ECG.
Ans: C
Feedback:
The nurse realizes that a pH level of 7.4 is within normal limits. No additional measures
need obtained and the nurse would perform a usual head-to-toe assessment.
Page 11
30. The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease
(COPD) and experiencing respiratory acidosis. The client asks what is making the
acidotic state. The nurse is most correct to identify which result of the disease process
that causes the rise in pH?
A) The lungs are unable to breathe in sufficient oxygen.
B) The lungs are unable to exchange oxygen and carbon dioxide.
C) The lungs have ineffective cilia from years of smoking.
D) The lungs are not able to blow off carbon dioxide.
Ans: D
Feedback:
In clients with chronic respiratory acidosis, the client is unable to blow off carbon
dioxide leaving in increased amount of hydrogen in the system. The increase in
hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas
exchange can occur, it is the lungs ability to remove the carbon dioxide from the system.
Although individuals with COPD frequently have a history of smoking, cilia is not the
cause of the acidosis.
31. The nurse on a surgical unit is caring for a client recovering from recent surgery with
the placement of a nasogastric tube to low continuous suction. Which acid–base
imbalance is most likely to occur?
A) Respiratory alkalosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Metabolic acidosis
Ans: B
Feedback:
Metabolic alkalosis results in increased plasma pH because of an accumulated base
bicarbonate or decreased hydrogen ion concentration. Factors that increase base
bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a
rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as
with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions
in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when
rapid breathing releases more CO2 than necessary.
Page 12
32. Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30
mm Hg; and HCO3, 21 mEq/L for a client with noted acid–base disturbances. Which
acid–base imbalance do both nurses agree is the client's current state?
A) Compensated respiratory alkalosis
B) Uncompensated respiratory alkalosis
C) Compensated metabolic acidosis
D) Compensated metabolic alkalosis
Ans: A
Feedback:
The question states that the client has a history of acid–base disturbance. The nurse
would first note that the pH has returned to close to normal indicating compensation.
The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27
mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite
direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a
metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is
low, the bicarbonate level will be low, also. In this client, the pH is at the high end of
normal, indicating compensation and alkalosis. The PCO2 is low, indicating a
respiratory condition (opposite direction of the pH).
33. The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a
client favorite, will the nurse discourage?
A) A grilled chicken sandwich with mayonnaise
B) A natural fruit salad with nuts
C) A hot dog with catsup
D) A fresh grilled tuna entrée with fresh asparagus
Ans: C
Feedback:
Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast
foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.
34. The nurse is caring for a client with laboratory values indicating dehydration. Which
clinical symptom is consistent with the dehydration?
A) Cool and pale skin
B) Crackles in the lung fields
C) Distended jugular veins
D) Dark, concentrated urine
Ans: D
Feedback:
Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack
of fluid volume. Adding more fluid would dilute the urine. The other options indicate
fluid excess.
Page 13
35. The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client
for postural hypotension. Which of the following symptoms would indicate a potential
diagnosis?
A) A blood pressure elevation upon rising or activity
B) A drop in systolic blood pressure (15 mm Hg) upon rising
C) A pulsating headache
D) A drop in diastolic blood pressure (25 mm Hg) upon rising
Ans: B
Feedback:
Postural hypotension occurs when the client rises from a supine or semi-Fowler's
position to a standing position and the systolic blood pressure drops by 15 mm Hg. The
client has symptoms of dizziness or a near syncopal episode.
Page 14
1. Chapter 17
You are the nurse caring for a client in septic shock. You know to closely monitor your
client. What finding would you observe when the client's condition is in its initial
stages?
A) A rapid, bounding pulse
B) A slow but steady pulse
C) A weak and thready pulse
D) A slow and imperceptible pulse
Ans: A
Feedback:
A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In
case of hypovolemic shock, the pulse volume becomes weak and thready and circulating
volume diminishes in the initial stage. In the later stages when the circulating volume
has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm
changes from regular to irregular.
2. You are caring for a client with shock. You are concerned about hypoxemia and
metabolic acidosis with your client. What finding should you analyze for evidence of
hypoxemia and metabolic acidosis in a client with shock?
A) Serum thyroid level findings
B) Arterial blood gas (ABG) findings
C) Red blood cells (RBCs) and hemoglobin count findings
D) White blood cell count findings
Ans: B
Feedback:
Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis.
Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor
oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid
level findings do not help determine the presence of hypoxemia or metabolic acidosis.
Page 1
3. You are the nurse caring for a client with shock accompanied by lung congestion. How
would you position this client?
A) Completely supine
B) Low Fowler's with legs flat
C) Supine with lower extremities raised to approximately 45º
D) Semi-Fowler's with lower extremities raised to approximately 15º
Ans: D
Feedback:
For a client with shock accompanied by lung congestion, the nurse should raise the
client's upper body to approximately 45º and lower extremities to approximately 15º.
Elevating the upper body lowers the diaphragm and provides more room for lung
expansion and gas exchange. Elevating the head reduces intracranial pressure. Elevating
the legs promotes blood perfusion to the heart, lungs, and brain. Therefore, options A,
B, and C are incorrect.
4. You are a nursing student preparing to care for an ICU client with shock. Your
instructor asks you to name the different categories of shock. Which of the following is
a category of shock?
A) Hypervolemic
B) Distributive
C) Restrictive
D) Cardiotonic
Ans: B
Feedback:
The four main categories of shock are hypovolemic, distributive, obstructive, and
cardiogenic, depending on the cause. This makes options A, C, and D incorrect.
5. You are caring for a client who is in neurogenic shock. You know that this is a
subcategory of what kind of shock?
A) Obstructive
B) Hypovolemic
C) Carcinogenic
D) Distributive
Ans: D
Feedback:
Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There
is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have
subcategories.
Page 2
6. You are a student nurse being precepted in the ICU. You are caring for a client in the
compensatory stage of shock who is hypovolemic. Which compensatory mechanism is
most important in the reabsorption and retention of fluid in the body?
A) Activation of renin-angiotensin-aldosterone system
B) Secretion of epinephrine and norepinephrine
C) Production of antidiuretic hormone and corticosteroid hormones
D) Release of catecholamines
Ans: C
Feedback:
Thus, they play an active role in controlling sodium and water balance. Both ADH and
corticosteroid hormones, then, promote fluid reabsorption and retention. The
renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP)
when circulating volume is diminished. The release of catecholamines stimulates
secretion of epinephrine and norepinephrine.
7. You are assessing a 6-year-old little girl in the emergency department (ED) who was
brought in by her mother. She was stung by a bee and is allergic to bee venom. The
child is now having trouble breathing. She is vasodilated, hypotensive, and has broken
out in hives. What do you suspect is wrong with this child?
A) She is having an allergic reaction and going into cardiogenic shock.
B) She is having an allergic reaction and going into anaphylactic shock.
C) She is having an allergic reaction and going into neurogenic shock.
D) She is having an allergic reaction and going into obstructive shock.
Ans: B
Feedback:
Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to
which a person is extremely sensitive (see Ch. 34). Common allergic substances include
bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic
substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract
to release histamine and other chemicals. The results are vasodilatation, increased
capillary permeability accompanied by swelling of the airway and subcutaneous tissues,
hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and
obstructive shock would not begin with vasodilation, swelling of the airway, and hives.
Therefore, options A, C, and D are incorrect.
Page 3
8. You are caring for a client in the compensation stage of shock. You know that one of the
body's mechanisms of compensation in this stage of shock is the
renin-angiotensin-aldosterone system. What does this system do?
A) Decreases peripheral blood flow
B) Increases catecholamine secretion
C) Increases the production of antidiuretic hormone
D) Restores blood pressure
Ans: D
Feedback:
The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure
(BP) when circulating volume is diminished. It does not decrease peripheral blood flow,
increase catecholamine secretion, or increase the production of antidiuretic hormone.
9. You are caring for a client in shock who is deteriorating. You are infusing IV fluids and
giving medications as ordered. What type of medications are you most likely giving to
this client?
A) Hormone antagonist drugs
B) Antimetabolite drugs
C) Adrenergic drugs
D) Anticholinergic drugs
Ans: C
Feedback:
Adrenergic drugs are the main medications used to treat shock. This makes options A,
B, and D incorrect.
10. A patient presents to the ED in shock. At what point in shock does the nurse know that
metabolic acidosis is going to occur?
A) Compensation
B) Irreversible
C) Early
D) Decompensation
Ans: D
Feedback:
The decompensation stage occurs as compensatory mechanisms fail. The client's
condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes.
As the energy supply falls below the demand, pyruvic and lactic acids increase, causing
metabolic acidosis. Therefore, options A, B, and C are incorrect.
Page 4
11. The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to
the emergency department. The client has numerous fractures, internal abdominal
injuries, and large lacerations on the head and torso. The family arrives and seeks update
on the client's condition. A family member asks, “What causes the body to go into
shock?” Given the client's condition, which statement is most correct?
A) “The client is in shock because the blood volume has decreased in the system.”
B) “The client is in shock because the heart is unable to circulate the body fluids.”
C) “The client is in shock because your loved one is not responding and brain dead.”
D) “The client is in shock because all peripheral blood vessels have massively
dilated.”
Ans: A
Feedback:
Shock is a life-threatening condition that occurs when arterial blood flow and oxygen
delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of
extracellular fluid is significantly diminished due to the loss of or reduced blood or
plasma, frequently occurs with accidents.
12. The nurse is evaluating a client in the intensive care unit to identify improvement in the
client's condition. Which outcome does the nurse note as the result of inadequate
compensatory mechanisms?
A) Liver dysfunction
B) Organ damage
C) Weight loss
D) Unsteady gait
Ans: B
Feedback:
When the body is unable to counteract the effects of shock, further system failure
occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as
one of the organs which fail. Weight fluctuations may occur if the body holds fluid or is
administered a diuretic. Large fluctuations are not noted between shifts. The client is not
able to ambulate.
Page 5
13. A client is in a driving accident creating a spinal cord injury. The nurse caring for a
client realizes that the client is at risk for which type of shock?
A) Anaphylactic
B) Neurogenic
C) Septic
D) Obstructive
Ans: B
Feedback:
Neurogenic shock results from an insult to the vasomotor center of the medulla or to the
peripheral nerves that extend from the spinal cord to the blood vessels. The tone of the
sympathetic nervous system is impaired, resulting in deceased arterial vascular
resistance, vasodilation, and hypotension. Anaphylactic shock has vasodilation also as a
key characteristic, along with increased capillary permeability, swelling of the airway,
hives, and itching. Septic shock is associated with overwhelming bacterial infections.
Obstructive shock is when there is an interference of blood flow in and out of the heart.
14. A client presents to the community health office experiencing rapidly increasing
symptoms of anaphylactic shock. Which nursing action would be completed first?
A) Obtain the name and information of the allergic substance.
B) Administer an epinephrine injection.
C) Notify a physician.
D) Call 911.
Ans: B
Feedback:
The key words in the question are “increasing symptoms.” The first action of the nurse
is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next,
the nurse will call 911.
15. The nurse is reviewing diagnostic lab work of a client developing shock. Which
laboratory result does the nurse note as a key in determining the type of shock?
A) Hemoglobin: 14.2 g/dL
B) Potassium: 4.8 mEq/L
C) WBC: 42,000/mm3
D) ESR: 19 mm/hour
Ans: C
Feedback:
Septic shock has the highest mortality rate and is caused by an overwhelming bacterial
infection; thus, an elevated WBC can indicate this type of shock. The other lab values
are within normal limits.
Page 6
16. A nurse educator is teaching students the types of shock and associated causes. Which
combination of shock type and causative factors are correct? Select all that apply.
A) Hypovolemic shock; blood loss
B) Obstructive shock; kidney stone
C) Cardiogenic shock; myocardial infarction
D) Anaphylactic shock; nuts
E) Septic shock; infection
F)
Neurogenic shock; diabetes
Ans: A, C, D, E
Feedback:
Shock is a life-threatening condition that occurs when arterial blood flow and oxygen
delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the
volume of extracellular fluid is significantly diminished due to the loss of or reduced
blood or plasma. Obstructive shock occurs when there is interfere in blood flow through
the heart. Cardiogenic shock occurs when the heart is ineffective in pumping possibly
due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as
nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an
insult to the vasomotor center in the medulla or peripheral nerves.
17. The nurse is caring for a critically ill client. Which of the following is the nurse correct
to identify as a positive effect of catecholamine release during the compensation stage
of shock?
A) Decreased white blood cell count
B) Increase in arterial oxygenation
C) Decreased depressive symptoms
D) Regulation of sodium and potassium
Ans: B
Feedback:
Catecholamines are neurotransmitters that stimulate responses via the sympathetic
nervous system. A positive effect of catecholamine release increases heart rate and
myocardial contraction as well as bronchial dilation improving the efficient exchange of
oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive
symptoms. They do not regulate sodium and potassium.
Page 7
18. Which compensatory mechanism, during the first stage of shock, is the nurse most
correct to identify as responsible for stabilization of fluid balance?
A) Catecholamines
B) Corticosteroid hormones
C) Renin-angiotensin
D) Aldosterone
Ans: B
Feedback:
Corticosteroids, including mineralocorticoids such as aldosterone, conserve sodium and
promote potassium excretion. This plays an active role in controlling sodium and water
balance. Catecholamines impact the sympathetic nervous system. The
renin-angiotensin-aldosterone system impacts blood volume.
19. The nurse is caring for a client who has progressed to the decompensation stage of
shock. Which intravenous medication does the nurse anticipate as a prophylactic means
to prevent complications?
A) Furosemide
B) Vancomycin
C) Morphine
D) Heparin
Ans: D
Feedback:
As a cell becomes damaged, an inflammatory response ensues. Platelets become sticky,
predisposing the client to microemboli. The nurse anticipates heparin, an anticoagulant,
because it has been found to reduce emboli. The other medications are not anticipated at
this time.
20. The nurse is caring for a client diagnosed with shock. During report, the nurse reports
the results of which assessments that signal early signs of the decompensation stage?
Select all that apply.
A) Vital signs
B) Nutrition
C) Skin color
D) Gait
E) Urine output
F)
Peripheral pulses
Ans: A, C, E, F
Feedback:
Although shock can develop and progress quickly, the nurse monitors evidence of early
signs that blood volume and circulation is becoming compromised. Vital signs, skin
color, urine output related to blood perfusion of the kidneys, and peripheral pulses all
provide assessment data relating blood volume and circulation.
Page 8
21. The nurse is obtaining physician orders which include a pulse pressure. The nurse is
most correct to report which of the following?
A) The difference between an apical and radial pulse
B) The difference between an upper extremity and lower extremity blood pressure
C) The difference between the systolic and diastolic pressure
D) The difference between the arterial and venous blood pressure
Ans: C
Feedback:
The nurse would report the difference between the systolic blood pressure number and
the diastolic blood pressure number as the pulse pressure.
22. The nurse is reporting the current nursing assessment to the physician. Vital signs:
temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute,
blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the
pulse pressure. Which would the nurse report?
A) Within normal limits
B) Thready
C) 24
D) Palpable
Ans: C
Feedback:
The pulse pressure is the numeric difference between systolic and diastolic blood
pressure. By subtracting the two numbers, the physician would be told 24. The pulse
pressure does not report quality of the pulse.
23. The nurse is caring for a client with highly pigmented skin. Which assessment technique
is used to evaluate cyanosis?
A) Blanch the nail beds.
B) Inspect the conjunctiva.
C) Note dullness in skin color.
D) Assess the earlobe.
Ans: B
Feedback:
In clients with highly pigmented skin, cyanosis is more accurately detected by
inspecting the conjunctiva and oral mucous membranes. The other options do not
provide the best assessment for cyanosis.
Page 9
24. The seasoned nurse is instructing the new graduate on information obtained from central
venous pressure and pulmonary artery pressure. Which statement, made by the seasoned
nurse, reflects the most pertinent information regarding circulation?
A) “Central venous pressure reflects the pressure in the right atrium or venae cavae.”
B) “A pulmonary artery pressure provides information about pressure on the left side
of the heart.”
C) “The trend in central venous pressure is more helpful than isolated readings.”
D) “Pulmonary artery pressure and pulmonary capillary pressure is assessed by an
inserted catheter.”
Ans: B
Feedback:
The most pertinent information to share with a new nurse is the information that the
pulmonary artery pressure provides essential information about the effectiveness of left
ventricle. The left ventricle is most pertinent to circulation. The other information is
correct but not as pertinent.
25. The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of
fluid to fluid lost is anticipated?
A) 1:1
B) 2:1
C) 3:1
D) 4:1
Ans: C
Feedback:
Usually, a ratio of 3 L of fluid is administered for every 1 L of fluid lost.
26. The nurse is caring for a client who does not accept blood or blood products. Which
nursing actions conserve blood? Select all that apply.
A) Administer medication to stimulate bone marrow.
B) Draw minimum volume of blood for diagnostic tests.
C) Administer plasma to expand intravascular volume.
D) Reinfuse the client's own blood via closed circuit container.
E) Administer factor VIII to stimulate coagulation process.
F)
Administer blood product only in an emergency.
Ans: A, B, D, E
Feedback:
The client that does not except blood or blood products will accept medications to
stimulate his natural production of cells or cause his current cells to last. Also measures
that use the blood product wisely are stressed. Plasma is a component of the blood so
the client would not permit the infusion and will not consent to blood products in an
emergency.
Page 10
27. The registered nurse is receiving a client from the emergency room on a dopamine drip.
The registered nurse asks the nurse to prepare the room for the client. The practical
nurse obtains an IV pump, sets the bed, arranges the furniture, and places towels and a
gown in the bathroom. Which other piece of equipment is essential?
A) A ventilator
B) Padded side rails
C) A tracheostomy set
D) An automatic blood pressure monitoring machine
Ans: D
Feedback:
A client who is brought from the emergency department on a dopamine drip will need
continuous blood pressure monitoring. An automatic blood pressure monitoring
machine will document and trend the results. It is too early to assume a ventilator is
needed. Padded side rails are used for clients at risk for seizure activity. A tracheostomy
set is needed for a client with airway concerns.
28. The nurse is administering a medication to the client with a positive inotropic effect.
Which action of the medication does the nurse anticipate?
A) Slow the heart rate
B) Increase the force of myocardial contraction
C) Depress the central nervous system
D) Dilate the bronchial tree
Ans: B
Feedback:
The nurse realizes that when administering a medication with a positive inotropic effect,
the medication increases the force of heart muscle contraction. The heart rate increases
not decreases. The central nervous system is not depressed nor is there a dilation of the
bronchial tree.
Page 11
29. The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome
would be the best evidence of an improvement in client condition?
A) A rise in blood count
B) Alertness in level of consciousness
C) Increased heart rate
D) Pulse oxygenation level of 92%
Ans: B
Feedback:
In hypovolemic shock, the volume of extracellular fluid is significantly diminished
because of lost or reduced blood or plasma. Circulation is impaired. Alertness in the
level of consciousness indicates improved circulation and thus oxygenation to the brain.
A documented rise in blood count is promising unless tissue damage has already
occurred. A decrease in heart rate would mean the heart is no longer struggling to
circulate blood to meet tissue needs. A pulse oxygenation level of 92% is a good sign of
available oxygen for the tissue.
30. The nurse is caring for the client with massive blood loss from a gunshot wound. With
little time to spare, which blood type is infused?
A) Type A
B) Type B
C) Type A/B
D) Type O
Ans: D
Feedback:
When in an emergency situation, the safest blood type to infuse in type O, meaning that
there are no antigens on the red blood cell. This is the universal donor blood type, which
is compatible. The other blood types may cause a transfusion reaction.
31. The nurse is performing hourly assessments on a client in the compensation stage of
shock. In documenting the hourly urine output of 40 mL from the Foley catheter, which
nursing action is most appropriate?
A) Reposition the client and make sure there are no kinks in the catheter tubing.
B) Notify the physician of the hourly output and encourage physician assessment.
C) Record 40 mL as the hourly output.
D) Notify the family of the urine output.
Ans: C
Feedback:
Urine output above 35 mL/hour or 500 mL/day indicates adequate kidney perfusion.
The hourly output would be documented in the client record. There is no need to
reposition the client or look for a kink because adequate amounts of urine is collecting
in the tube. There is no need to notify the physician or family.
Page 12
32. The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing
intervention is most helpful to decrease myocardial oxygen consumption?
A) Limit interaction with visitors.
B) Avoid heavy meals.
C) Maintain activity restriction to bedrest.
D) Arrange personal care supplies nearby.
Ans: C
Feedback:
Restricting activity to bedrest provides the best example of decreasing myocardial
oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with
more blood between contractions. The other options may be helpful, but the best option
is limiting activity.
33. The community health nurse finds the client collapsed outdoors. The nurse assesses that
the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor.
Which nursing action is helpful while waiting for the ambulance?
A) Place a cool compress on head.
B) Elevate the legs higher than the heart.
C) Shake the client to arouse.
D) Cover the client with a blanket.
Ans: B
Feedback:
The client has shallow respiration and a weak pulse implying limited circulation and gas
exchange. Most helpful would be to elevate the legs higher than the heart to promote
blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor
would shaking the client to arouse. A client can be covered with a blanket, but this is not
the most helpful.
34. The nurse is assisting the physician with placing a ventricular assist device (VAD).
Which assessment finding would confirm the successful implementation?
A) Respiratory rate decreased
B) Heart rate increased
C) Pedal pulse stronger
D) Temperature within normal limits
Ans: C
Feedback:
The ventricular assist device (VAD) is a medical mechanical device used to improve
cardiac output and redistribute blood. The best evidence to confirm successful
implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory
rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed
oxygen. The temperature within normal limits does not confirm successful
implementation.
Page 13
35. The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining
to the client's family the poor prognosis. Which would the nurse be most accurate to
explain as the rationale for imminent death?
A) Endotoxins in the system
B) Limited gas exchange
C) Brain death
D) Multiple organ failure
Ans: D
Feedback:
In the irreversible stage of shock, significant cells and organs are damaged. The client's
condition reaches a “point of no return” despite treatment efforts. Death occurs from
multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
Page 14
1. Chapter 18
Which of the following advice does the nurse offer clients who are undergoing unsealed
radiation therapy to reduce exposure?
A) Avoid drinking plenty of fluids.
B) Avoid eating for 3 hours after therapy.
C) Avoid applying skin moisturizers.
D) Avoid kissing and sexual contact.
Ans: D
Feedback:
Clients who are undergoing unsealed radiation therapy are advised to avoid kissing and
sexual contact due to the spread of radioactivity. Clients are encouraged to drink plenty
of fluids to help flush radioactive substances. Client may be asked to apply mild
moisturizers and are not asked not to eat after the therapy.
2. The nurse working on a bone marrow unit knows that it is a priority to monitor which of
the following in a client who has just undergone a stem cell transplant?
A) Monitor the client's toilet patterns.
B) Monitor the client closely to prevent infection.
C) Monitor the client's physical condition.
D) Monitor the client's heart rate.
Ans: B
Feedback:
Until transplanted stem cells begin to produce blood cells, these clients have no
physiologic means to fight infection, which makes them very prone to infection. They
are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a
nurse must closely monitor clients and take measures to prevent infection. Monitoring
client's toilet patterns, physical condition, and heart rate does not prevent the possibility
of the client getting an infection.
3. You are an oncology nurse caring for a client who is taking antineoplastic agents. What
adverse symptoms must you monitor for in this client?
A) Symptoms of gout
B) Symptoms of hypertension
C) Symptoms of diarrhea
D) Symptoms of anemia
Ans: A
Feedback:
The nurse monitors the client being administered an antineoplastic agent for symptoms
of gout because they increase uric acid levels, joint pain, and edema. Administering
antineoplastic agents does not cause hypertension, diarrhea, and anemia.
Page 1
4. You are providing client teaching for a client undergoing chemotherapy. What dietary
modifications should you advise?
A) Eat wholesome meals.
B) Avoid spicy and fatty foods.
C) Avoid intake of fluids.
D) Eat warm or hot foods.
Ans: B
Feedback:
The nurse advises a client undergoing chemotherapy to avoid hot and very cold liquids
and spicy and fatty foods. The nurse also encourages the client to have small meals and
appropriate fluid intake.
5. Cancer has many characteristics. What is one of the most discouraging characteristics of
cancer?
A) Large size
B) Carcinogenesis
C) Metastasis
D) Slow growth
Ans: C
Feedback:
Metastasis is one of cancer's most discouraging characteristics because even one
malignant cell can give rise to a metastatic lesion in a distant part of the body. Not all
cancerous tumors are large in size. Carcinogenesis is the process of malignant
transformation, and it is not a characteristic of cancer. Cancer grows rapidly, not slowly.
6. You are a public health nurse giving a talk on the warning signals of cancer to a local
community group. Which of the following are the warning signals of cancer? Select all
that apply.
A) Sores that don't heal
B) Unusual bleeding or discharge
C) Yellow discoloration of body area
D) Tenderness or pain
E) Persistent indigestion
Ans: A, B, E
Feedback:
Seven warning signals of cancer should be familiar to all: (1) a change in bowel habits
or bladder function, (2) sores that do not heal, (3) unusual bleeding or discharge, (4)
thickening or lump in breast or other body parts, (5) persistent indigestion or difficulty
swallowing, (6) a change in a wart or mole, and (7) a persistent nagging cough or
hoarseness.
Page 2
7. Which of the following can be considered carcinogens?
A) Parasites
B) Medical procedures
C) Dietary substances
D) Infective genes
Ans: C
Feedback:
Carcinogens include chemical agents, environmental factors, dietary substances, viruses,
defective genes, and medically prescribed interventions. Therefore, options A, B, and D
are incorrect.
8. While doing a health history, a client tells you that her mother, grandmother, and sister
died of cancer. The client wants to know what she can do to keep from getting cancer.
What would be your best response?
A) “You can't prevent cancer, but you can have your blood analyzed for tumor
markers to see what your risk level is.”
B) “If you eat right, exercise, and get enough rest, you can prevent breast cancer.”
C) “With your family history, there is nothing you can do to prevent getting cancer.”
D) “Cancer often skips a generation, so don't worry about it.”
Ans: A
Feedback:
Specialized tests have been developed for tumor markers, specific proteins, antigens,
hormones, genes, or enzymes that cancer cells release. Options B and C are incorrect,
and giving the client these responses would be giving inaccurate information. Options D
is incorrect because it minimizes and negates the clients concern.
9. The physician recommends that you have your daughter vaccinated with HPV vaccine.
What is this vaccine for?
A) Help prevent lung cancer
B) Help prevent breast cancer
C) Help prevent cervical cancer
D) Help prevent leukemia
Ans: C
Feedback:
The vaccines that are approved for use in the United States include the human papilloma
virus (HPV), which may help prevent women from getting cervical cancer. There are no
vaccines for the prevention of lung cancer, breast cancer, or leukemia.
Page 3
10. A client diagnosed with cancer has his tumor staged and graded based on what factors?
A) How they tend to grow and the cell type
B) How they spread and tend to grow
C) How they differentiate the cell type
D) How they spread and differentiate
Ans: A
Feedback:
Tumors are staged and graded based upon how they tend to grow and the cell type
before a client is treated for cancer.
11. The client is scheduled for a breast lump excision and sentinel node biopsy. What
should the nurse know in planning care for the client with a negative biopsy report?
A) A lump excision is not necessary.
B) A wide excision of lump will be performed.
C) The lump and all axillary lymph nodes will be excised.
D) The entire breast and all regional lymph nodes will be excised.
Ans: B
Feedback:
The sentinel node is the first node in which a tumor will drain; if no malignant cells are
found there, additional excision or radical removal will not be necessary. Excision of the
lump along with a wide margin of cancer-free tissue is standard treatment for malignant
tumors.
12. The nurse performs a breast exam on a client and finds a firm, non-moveable lump in
the upper outer quadrant of the right breast that the client reports was not there 3 weeks
ago. What does this finding suggest?
A) Normal finding
B) Benign fibrocystic disease
C) Malignant tumor
D) Malignant tumor with metastasis to surrounding tissue
Ans: C
Feedback:
A fast-growing lump is suggestive of a malignant tumor. Metastasis can only be
determined by cytology, not by palpation.
Page 4
13. The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the
liver. Which statement made by the client indicates an understanding of the diagnosis?
A) “Once the colon tumor is removed, I will be fine.”
B) “I will be happy once all the cancer is cut out.”
C) “How could I be so unlucky to get cancer twice?”
D) “My cancer has now spread to my liver.”
Ans: D
Feedback:
Response D shows that he has an understanding that he has primary cancer of the colon
with spread to the liver. Choice A does not address the metastasis. Choice B is incorrect
because metastases are not always resectable. Choice C is incorrect because it shows a
lack of understanding about what metastasis is.
14. While completing an admission assessment, the client reports a family history of
ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that
these cancers are most likely associated with what etiology?
A) Inherited gene mutation
B) Smoking and tobacco use
C) Exposure to chemicals and spermicides
D) Increased tumor suppressor genes
Ans: A
Feedback:
Tumor suppressor genes assist the body in normal cell production and death. Tobacco
use and chemical carcinogens can contribute to the development of cancer, but there is
not enough information provided to suggest a common link. Oncogenes are genes that
have mutated and activates out of control cell growth. Inherited gene mutation occurs
when the DNA is passed to the next generation.
15. The nurse is invited to present a teaching program to parents of school-age children.
Which topic would be of greatest value for decreasing cancer risks?
A) Pool and water safety
B) Breast and testicular self-exams
C) Handwashing and infection prevention
D) Sun safety and use of sunscreen
Ans: D
Feedback:
Pool and water safety as well as infection prevention are important teaching topics but
will not decrease cancer risk. While performing breast and testicular self-exams may
identify cancers in the early stage, this teaching is not usually initiated in school-age
children. Severe sunburns that occur in young children can place the child at risk for
skin cancers later in life. Because children spend much time out of doors, the use of
sunscreen and protective clothing/hats can protect the skin and decrease the risk.
Page 5
16. Following surgery for adenocarcinoma, the client learns the tumor stage is T3, N1, M0.
What treatment mode will the nurse anticipate?
A) No further treatment is indicated.
B) Adjuvant therapy is likely.
C) Palliative care is likely.
D) Repeat biopsy is needed before treatment begins.
Ans: B
Feedback:
T3 indicates a large tumor size with N1 indicating regional lymph node involvement.
Although M0 suggest no metastasis, following with adjuvant (chemotherapy or
radiation therapy) treatment is indicated to prevent the spread of cancer outside the
lymph to other organs. The tumor staging of stage IV is indicative of palliative care.
17. A client with a 4-cm breast mass is scheduled for biopsy with frozen section followed
by lumpectomy and possible mastectomy. The client asks the nurse, “Why can't the
doctor tell me specifically whether I will need to have my entire breast removed”?
Which is the best response from the nurse?
A) “The doctor will know which surgery is required, once the tumor is exposed.”
B) “The frozen section will determine presence of cancer and type of surgery
required.”
C) “You need to trust your doctor to provide you with the best of care.”
D) “You seem anxious about your upcoming surgery.”
Ans: B
Feedback:
Although experienced surgeons can often predict the type of tumor upon opening,
seeing the tumor does not determine presence or absence of cancer cells. The client may
be anxious about upcoming surgery, but this response does not address the question
posed by the client. Trusting the surgeon is important, but this response is not
appropriate for the question asked. A frozen section during surgery allows the
pathologist to quickly examine the tissue under microscope allowing the surgeon to
make a decision for best surgical approach.
Page 6
18. A client is recovering from a craniotomy with tumor debulking. Which comment by the
client indicates to the nurse a correct understanding of what the surgery entailed?
A) “I guess the doctor could not remove the entire tumor.”
B) “I am so glad the doctor was able to remove the entire tumor.”
C) “I will be glad to finally be done with treatments for this thing.”
D) “Thank goodness the tumor is contained and curable.”
Ans: A
Feedback:
Debulking is a reference made when a tumor cannot be completely removed, often due
to its extension far into healthy tissue. Without complete removal, this is not a cure and,
the cancer cells will continue to replicate and require adjuvant therapies to prevent
further invasion. The physician, not the nurse, will need to clarify the details of the
surgery.
19. A client who is being treated for bladder cancer expresses his concern of passing cancer
to his wife during intercourse. Which is the best response by the nurse?
A) “You should avoid intercourse until your cancer is cured.”
B) “Cancer is not transferred from person to person via direct contact.”
C) “I understand you are concerned about your wife, but don't worry.”
D) “Perhaps you should have your sperm tested for presence of cancer cells.”
Ans: B
Feedback:
Bladder cancer, depending on staging, is treated over a long period of time. Abstaining
from intercourse may not be realistic and is unnecessary because cancer is not
transferred from person to person via body fluids. It is never appropriate for a nurse to
tell a client not to worry.
20. The client is diagnosed with a benign brain tumor. Which of the following features of a
benign tumor is of most concern to the nurse?
A) Random, rapid growth of the tumor
B) Cells colonizing to distant body parts
C) Tumor pressure against normal tissues
D) Emission of abnormal proteins
Ans: C
Feedback:
Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific
antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors
can compress tissues as it grows, which can result in impaired organ functioning.
Page 7
21. The nurse is providing an educational presentation on dietary recommendations for
reducing the risk of cancer. Which of the following food selections would demonstrate a
good understanding of the information provided in the presentation? Select all that
apply.
A) Egg white omelet with spinach and mushrooms
B) Crispy chicken Caesar Salad
C) Steamed broccoli and carrots
D) Turkey breast on whole wheat bread
E) Smoked salmon
F)
Vegetable and cheddar quiche
Ans: A, C, D
Feedback:
Foods high in fat and those that are smoked or preserved with salt or nitrates are
associated with increased cancer risks. An omelet made of egg whites and vegetables is
a healthy low fat selection as are steamed broccoli/carrots and turkey breast on whole
grain bread. A salad can be a healthy selection but Caesar salads contain much fat from
the dressing and addition of cheeses and fried chicken. Salmon that is not smoked would
be a good selection. Quiche usually contains high-fat milk, crème, eggs, and cheese.
22. Chemotherapy has been used for the past 3 months to treat a client with pancreatic
cancer. The CA 19-9 levels are rising. Which explanation would the nurse attribute as
the most likely cause?
A) It is normal for this antigen to rise for up to 6 months.
B) The client is having an adverse response to the chemotherapy.
C) The chemotherapy is effectively destroying the cancer cells.
D) The cancer is growing despite the chemotherapy treatment.
Ans: D
Feedback:
Elevation of specific tumor markers, such as CA 19-9, is indicative of progression and
proliferation of the cancer cells. If the chemotherapy was successful in the treating of
the pancreatic cancer cells, the tumor marker would be decreased. Increased production
of antibody development is not a usual adverse reaction of chemotherapy.
Page 8
23. A bowel resection is scheduled for a client with the diagnosis of colon cancer with
metastasis to the liver and bone. Which statement by the nurse best explains the purpose
of the surgery?
A) “Removing the tumor is a primary treatment for colon cancer.”
B) “This surgery will prevent further tumor growth.”
C) “Once the tumor is removed, cell pathology can be determined.”
D) “Tumor removal will promote comfort.”
Ans: D
Feedback:
Palliative surgeries, such as bowel resection, may be performed to promote comfort by
relieving pain and pressure on organs within the abdominal cavity. Primary treatment
refers to surgery that is likely to provide a cure, which is not likely in metastatic disease.
With metastasis, primary tumor removal does not prevent further tumor growth in
distant sites. The diagnosis of colon cancer with metastasis suggests cell pathology has
already been determined.
24. The nurse is caring for a thyroid cancer client following oral radioactive iodine
treatment. Which teaching point is most important?
A) Shield your throat area when near others.
B) Flush the toilet twice after every use.
C) Prepare food separately from family members.
D) Use disposable utensils for the next month.
Ans: B
Feedback:
Iodine 131 is a systemic internal radiation that is excreted through body fluids,
especially urine. Flushing the toilet twice after every use will avoid the exposure of
others to radioactive exposure. Shielding the throat area is not effective because this
form of treatment is systemic. Preparing food separately is not necessary, but use of
separate eating utensils will be necessary for the first 8 days.
Page 9
25. When caring for a client who is receiving external beam radiation, which is the key
point for the nurse to incorporate into the plan of care?
A) Time, distance, and shielding
B) The use of disposable utensils and wash cloths
C) Avoid showering or washing over skin markings.
D) Inspect the skin frequently.
Ans: D
Feedback:
Inspecting the skin frequently will allow early identification and intervention of skin
problems associated with external radiation therapy. The external markings should not
be removed, but clients may shower and lightly wash over the skin. Time, distance, and
shielding are key in the management of sealed, internal radiation therapy and not
external beam radiation. The use of disposable utensils and care items would be
important when caring for clients following systemic, unsealed, internal radiation
therapy.
26. Which nursing interventions are most important when implementing care for a client
receiving temporary internal sealed radiation therapy? Select all that apply.
A) Time, distance, and shielding
B) Count wires, threads, or needles every shift
C) Maintain indelible skin markings.
D) Provide rest periods between treatments.
E) Administer treatment through IV access port.
F)
Avoid standing in direct path of implants.
Ans: A, B, F
Feedback:
Internal sealed radiation implants are in the form of needles, seeds, pellets, wires etc.
These forms contain radioactive material and must be counted each shift to ensure
accidental exposure does not occur to staff or others who may come in contact with the
material. Standing in the direct path the implanted forms can increase the exposure to
radiation. Since the radiation implants are placed in a cavity for a specific time limit and
is continuous in treatment modality, rest periods between treatments are not indicated.
Indelible skin marking are only used with external beam radiation. Chemotherapy is the
cancer treatment given through IV access.
Page 10
27. The nurse is caring for a client who is scheduled for chemotherapy. Which is the best
statement the nurse can make about the client experiencing chemotherapy-induced
alopecia?
A) “The hair loss is temporary.”
B) “New hair growth will return without any change to color or texture.”
C) “Clients with alopecia will have delay in grey hair.”
D) “Wigs can be used after the chemotherapy is completed.”
Ans: A
Feedback:
Alopecia associated with chemotherapy is usually temporary and will return after the
therapy is completed. New hair growth may return unchanged, but there is no guarantee
and color, texture, and quality of hair may be changed. There is no correlation between
chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings
can be used by clients at any time during treatment plan.
28. Based on the understanding of the effects of chemotherapy, the nurse would anticipate
which of the following clinical findings in a client 2 weeks posttherapy?
A) Change in hair color
B) Elevated temperature
C) Elevated white blood cells count
D) Ease of bruising
Ans: D
Feedback:
The effects of chemotherapy can include myelosuppression, resulting in anemia or
bleeding tendencies, as exhibited in ease in bruising. Elevated temperature and WBCs
are signs of infection and are anticipated findings after chemotherapy treatment.
Regrowth of hair after alopecia can result in change of hair color but not anticipated 2
weeks posttreatment.
Page 11
29. A client with cancer stage T4, N3, M1 is ordered morphine sulfate 4 mg, subcutaneous
every 3 to 4 hours. Two hours after the last injection, the client rings the call bell to
report a pain scale of 9. Which is the appropriate action by the nurse?
A) Explain to the client that the medication can only be given every 3 to 4 hours.
B) Ignore the call bell and stall until it is time to administer the next dose.
C) Notify the physician of the breakthrough pain in an attempt to obtain additional
orders.
D) Ask the family to attempt diversion activities until the next dose can be given.
Ans: C
Feedback:
Pain is a major problem for clients with metastatic cancer, and control of the pain is a
priority. Explaining to the client is not appropriate and will not correct the issue of pain.
Ignoring the client is a form of neglect and violates the rights of the client to receive
prompt care. Although diversion techniques (meditation, prayer, yoga, music therapy,
etc.) can be used to lessen pain, the family should not be asked to complete nursing care.
30. An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of
survival. The family asks the nurse for advice on whether to tell the client of the
diagnosis or to keep it quiet. Which is the best response from the nurse?
A) “I wouldn't tell, if I were you.”
B) “In my experience, clients who know are more likely to be involved with their
plan of care.”
C) “The shock of learning the diagnosis may be too much stress for an elderly
person.”
D) “This is a private concern that should include the physician, not me.”
Ans: B
Feedback:
Sharing known facts that can enhance client care is advocating for the client and family.
Clients do have the right to know their diagnosis so informed decisions can be made.
Comments A and C are a reflection of personal opinion of the nurse, and opinions
should be avoided. Statement D may leave the family feeling as if the nurse is cold
uncaring.
Page 12
31. When providing care for a client with stage IV cancer, the nurse knows to include which
intervention in the plan of care?
A) Incorporating touching and listening
B) Encouraging the expression of life regrets
C) Assessing signs and symptoms of impending death
D) Discussing ways for the client to handle the dying process
Ans: A
Feedback:
Psychological support can be given via therapeutic touch and through listening to the
concerns and fears associated with the progressive disease. Encouraging the client to
express life regrets suggests the client did not experience a fulfilled life. To discuss how
the client can handle dying is not appropriate, and nurses do not possess the expertise in
this area. Assessing for signs and symptoms of impending death is a part of the nursing
process but not the priority care for this client.
32. A client with advanced cancer makes the following comment to the nurse: “Why are
you bathing me? I am going to die no matter what.” What is the most appropriate
response of the nurse?
A) “A bath will make you feel better.”
B) “Do you want to skip the bath today?”
C) “Would you like to talk about what you are feeling?”
D) “I can give you some medicine to make you feel better.”
Ans: C
Feedback:
By asking the client talk may open the door for further discussion and sharing of
feelings, fears, etc. Statements A and B are matter-of-fact comments and disconnect,
resulting in a shutdown to further communication. Statement D is a quick fix and
demonstrates a nontherapeutic response.
33. When the client complains of increased fatigue following radiotherapy, the nurse knows
this is most likely to be related to which factor?
A) The cancer is spreading.
B) The cancer cells are dying in large numbers.
C) Fighting off infection is an exhausting venture.
D) Radiation can result in myelosuppression.
Ans: D
Feedback:
Fatigue results from anemia associated with myelosuppression and decreased RBC
production. The spreading of cancer can cause many symptoms dependent on location
and type of cancer but not a significant factor to support fatigue with radiotherapy. The
production of healthy cells can increase metabolic rate, but death of cancer cells does
not support fatigue in this case. Fighting infection can cause fatigue, but there is no
evidence provided to support presence of infection in this client.
Page 13
34. A newly diagnosed cancer client is crying and states the following to the nurse: “I
promised God that I will be a better person if I can just get better.” What is the
appropriate assessment of this comment by the nurse?
A) The client is just trying to protect self from potential loss.
B) Anger directed toward nursing staff is not unusual in dealing with cancer clients.
C) The cancer is viewed as a punishment from past actions.
D) Loss is inevitable so client is making final plans.
Ans: C
Feedback:
The comment made by the client is reflective of the bargaining stage of grief in which
the client is bargaining with God to gain time. Denial is the first stage of grief in which
the client uses to protect self, which is not reflective of the comment made. Anger is the
second stage of grief and is not reflective of the statement made. Acceptance of
inevitable loss is the final stage of grief, which is not reflective in the comment made.
35. Which of the following laboratory findings, would be identified by the nurse as the
greatest risk for a cancer client scheduled for implantable port?
A) White blood cell count 10,800/mm3
B) Hemoglobin 10 g/dL
C) Hematocrit 36.0%
D) Platelet count 98,000/mm3
Ans: D
Feedback:
Although the WBC, HGB, and HCT are all slightly outside the normal range, the
platelet count is very low and places the client at risk for bleeding. This is especially a
concern with a surgical procedure.
Page 14
36. A cancer client makes the following statement to the nurse: “I guess I will tell my doctor
to forego the chemotherapy. I do not want to be throwing up all the time. I would rather
die.” Which of the following facts supports the use of chemotherapy for this client?
A) Nausea and vomiting are only a factor for the first 24 hours after treatment.
B) Most clients believe the discomfort is well worth the cure for cancer.
C) Chemotherapy treatment can be adjusted to optimize effects while limiting
adverse effects.
D) Clinical trials are opening up new cancer treatments all the time.
Ans: C
Feedback:
Chemotherapy is not one drug for all clients. The therapy can be specifically designed to
optimize effects while limiting adverse effects with supplemental antiemetics to control
the nausea and vomiting. It is true that nausea and vomiting are most prevalent in the
first 24 hours after each chemotherapy treatment but does not eliminate the fears
expressed by this client. No one can state the worth of any treatment, and a cure is never
promised. Clinical trials open up new options for treatment, but the process is lengthy
and is not a certainty for a client in need of immediate treatment.
37. The nurse is caring for a client is scheduled for chemotherapy followed by autologous
stem cell transplant. Which of the following statements by the client indicates a need for
further teaching?
A) “I hope they find a bone marrow donor who matches.”
B) “The doctor will remove cells from my bone marrow before beginning
chemotherapy.”
C) “I will receive chemotherapy until most of the cancer is gone, and then I will get
my own stem cells back.”
D) “I will need to be in protective isolation for up to 3 months after treatment.”
Ans: A
Feedback:
An autologous stem cell transplant comes from the client not from a donor. The doctor
will remove the stem cells from the bone marrow before beginning chemotherapy and
treat the client until most if not all the cancer is eliminated before reinfusing the stem
cells. Clients are at risk for infection and will be closely monitored for at least 3 months.
Page 15
38. The nurse knows that interferon agents are used in association with chemotherapy to
produce which effects in the client?
A) Suppression of the bone marrow
B) Enhance action of the chemotherapy
C) Decrease the need for additional adjuvant therapies
D) Shorten the period of neutropenia
Ans: D
Feedback:
Interferon agents are a type of biologic response modifiers (BRMs) used in conjunction
with chemotherapy to reduce the risk of infection by shortening the period of
neutropenia through bone marrow stimulation. The suppression of bone marrow creates
the need for interferon use, not a result of the use. Although some BRMs can inhibit
tumor growth, the primary use is for reducing neutropenia. Interferon use does not
replace standard cancer treatments or decrease the need for those treatments.
39. A client is scheduled for a nerve-sparing prostatectomy. The emotional spouse confides
in the nurse that the client will not talk about the cancer and/or upcoming surgery.
Which nursing diagnosis will the nurse choose as primary diagnosis for this client?
A) Sexual Dysfunction
B) Fear
C) Knowledge Deficit
D) Ineffective Coping
Ans: B
Feedback:
Fear of the unknown is probably the major concern for this client. Fear of the diagnosis
of cancer, fear of the effects of the surgery, and fear of loss of control and functioning.
Sexual dysfunction may be one of the fears but not primary at this stage. Knowledge
Deficit is unclear at this time. Ineffective Coping can be illustrated by the client's refusal
to talk about the problem, but no excess or abnormal behavior has been identified at this
time.
Page 16
40. The nurse recognizes which of the following alternative therapies as appropriate in the
care of cancer clients? Select all that apply.
A) Reminiscing
B) Patient-controlled analgesia
C) Hot and cold therapy
D) Epidural stimulators
E) Alternating analgesics
F)
Nonopioid use
Ans: A, C
Feedback:
Distracting techniques, such as reminiscing, can be helpful in taking the focus off pain.
Hot and cold therapy is a holistic approach to restoring natural balance to the body, as
practiced by some cultures. PCA, epidural stimulators, and nonopioid use are
physician-prescribed treatments and not considered a diversion.
41. The client has finished the first round of chemotherapy. Which statement made by the
client indicates a need for further teaching by the nurse?
A) “I will eat clear liquids for the next 24 hours.”
B) “Hair loss may not occur until after the second round of therapy.”
C) “I will use birth control measures until after all treatment is completed.”
D) “I can continue taking my vitamins and herbs because they make me feel better.”
Ans: D
Feedback:
Herbal products are not regulated by the U.S. Food and Drug Administration (FDA);
although some can decrease the risk of cancer, others can have serious side effects and
liver toxicity. Use of vitamins and herbals should be reviewed with the oncologist. Use
of clear liquids is recommended for the client experiencing nausea and vomiting.
Because hair follicles are sensitive to chemotherapy drugs, it is likely for alopecia to
occur especially with consecutive treatments. Chemotherapy includes cytotoxic drugs
that are harmful to rapid dividing cells such as cell development in the fetus. To prevent
damage to the fetus, birth control is recommended during treatment.
Page 17
42. The client is receiving a vesicant antineoplastic for treatment of cancer. Which
assessment finding would require the nurse to take immediate action?
A) Extravasation
B) Stomatitis
C) Nausea and vomiting
D) Bone pain
Ans: A
Feedback:
The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to
prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis,
nausea/vomiting, and bone pain can be symptoms of the disease process or treatment
mode but does not require immediate action.
Page 18
1. Chapter 19
You are caring for a client who is in respiratory distress. The physician orders arterial
blood gases (ABGs) to determine various factors related to blood oxygenation. What
site can ABGs be obtained from?
A) A puncture at the radial artery
B) The trachea and bronchi
C) The pleural surfaces
D) A catheter in the arm vein
Ans: A
Feedback:
ABGs determine the blood's pH; oxygen-carrying capacity; and levels of oxygen, CO2,
and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the
radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter
from which arterial samples are obtained. Blood gas samples are not obtained from the
pleural surfaces or trachea and bronchi.
2. The nurse working in the radiology clinic is assisting with a pulmonary angiography.
The nurse knows that when monitoring clients after a pulmonary angiography, what
should the physician be notified about?
A) Raised temperature in the affected limb
B) Excessive capillary refill
C) Absent distal pulses
D) Flushed feeling in the client
Ans: C
Feedback:
When monitoring clients after a pulmonary angiography, nurses must notify the
physician about diminished or absent distal pulses, cool skin temperature in the affected
limb, and poor capillary refill. Absent distal pulses may indicate damage to the artery or
a clot. When the contrast medium is infused, the client will sense a warm, flushed
feeling.
3. You are a nurse in the radiology unit of your hospital. You are caring for a client who is
scheduled for a lung scan. You know that lung scans need the use of radioisotopes and a
scanning machine. Before the perfusion scan, what must the client be assessed for?
A) Bleeding
B) Iodine allergy
C) Dysrhythmias
D) Inflammation
Ans: B
Feedback:
During lung scans, a radioactive contrast medium is administered intravenously for the
perfusion scan. Before the perfusion scan, nurses must assess the client to check for
allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding
are possible complications of mediastinoscopy.
Page 1
4. The nursing instructor is talking with senior nursing students about diagnostic
procedures used in respiratory diseases. The instructor discusses thoracentesis, defining
it as a procedure performed for diagnostic purposes or to aspirate accumulated excess
fluid or air from the pleural space. What would the instructor tell the students purulent
fluid indicates?
A) Cancer
B) Infection
C) Inflammation
D) Heart failure
Ans: B
Feedback:
Purulent fluid is the recommended diagnosis for infection. Serous fluid may be
associated with cancer, inflammatory conditions, or heart failure.
5. Your client has just had an invasive procedure to assess the respiratory system. What do
you know should be assessed on this client?
A) Watery sputum
B) Loss of consciousness
C) Respiratory distress
D) Masses in pleural space
Ans: C
Feedback:
After invasive procedures, the nurse must carefully check for signs of respiratory
distress and blood-streaked sputum. Masses in the pleural space affect fremitus. General
examination of overall health and condition includes assessing the consciousness of a
client.
6. An 18-month-old child is brought to the emergency department by his parents who
explain that their child swallowed a watch battery. Radiologic studies show that the
battery is in the lungs. Which area of lung is the battery most likely to be in?
A) Right upper lung
B) Left upper lung
C) Right lower lung
D) Left lower lung
Ans: A
Feedback:
Aspiration of foreign objects is more likely in the right main stem bronchus and right
upper lung. The right mainstem bronchus is slightly higher and more vertical than the
left, which is why foreign articles are often aspirated here first.
Page 2
7. What happens to the diaphragm during inspiration?
A) It relaxes and raises.
B) It contracts and flattens.
C) It relaxes and flattens.
D) It contracts and raises.
Ans: B
Feedback:
During inspiration, the diaphragm contracts and flattens, which expands the thoracic
cage and increases the thoracic cavity.
8. You are studying for a physiology test over the respiratory system. What should you
know about central chemoreceptors in the medulla?
A) They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in
the cerebrospinal fluid.
B) They respond to changes in the O2 levels in the brain.
C) They respond to changes in CO2 levels in the brain.
D) They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal
fluid.
Ans: A
Feedback:
Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen
ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not
respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain,
changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.
9. What is the difference between respiration and ventilation?
A) Ventilation is the process of gas exchange.
B) Ventilation is the movement of air in and out of the respiratory tract.
C) Ventilation is the process of getting oxygen to the cells.
D) Ventilation is the exchange of gases in the lung.
Ans: B
Feedback:
Ventilation is the actual movement of air in and out of the respiratory tract. Respiration
is the exchange of oxygen and CO2 between atmospheric air and the blood and between
the blood and the cells. Therefore, options A, C, and D are incorrect.
Page 3
10. Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients
and oxygen. What are the two methods of perfusion?
A) The two methods of perfusion are the bronchial and alveolar circulation.
B) The two methods of perfusion are the bronchial and capillary circulation.
C) The two methods of perfusion are the bronchial and pulmonary circulation.
D) The two methods of perfusion are the alveolar and pulmonary circulation.
Ans: C
Feedback:
The two methods of perfusion are the bronchial and pulmonary circulation. There is no
alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of
which area of the lung they are in.
11. A nurse is caring for a client who has frequent upper respiratory infections. Which
structure is most helpful in protecting against infection?
A) Cilia
B) Sinus cavity
C) Tonsils
D) Turbinates
Ans: C
Feedback:
Tonsils and adenoids do not contribute to respiration but protect against infection.
Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles
and liquid, preventing irritation and contamination of the airway. Sinuses are nasal
cavity structures. Turbinates warm and add moisture to the inspired air.
12. The nurse is suctioning a client who is unable to expectorate respiratory secretions. At
which point does the nurse expect the client to experience coughing?
A) When the catheter reaches the back of the pharynx
B) When the catheter enters the main bronchus of the lung
C) When the catheter reaches the point of the carina
D) When the catheter tickles the uvula
Ans: C
Feedback:
Upon the catheter stimulating the carina, coughing and even bronchospasm may occur.
Productive secretions may be loosened and eliminated via the suction catheter. When
the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated.
The suction catheter does not reach the entrance of the lung.
Page 4
13. A client arrived in the emergency department with a sharp object penetrating the
diaphragm. When planning nursing care, which nursing diagnosis would the nurse
identify as a priority?
A) Acute Pain
B) Potential for Infection
C) Impaired Gas Exchange
D) Ineffective Airway Clearance
Ans: C
Feedback:
The diaphragm separates the thoracic and abdominal cavities. On inspiration, the
diaphragm contracts and moves downward, creating a partial vacuum. Without this
vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia
may occur from the poor availability of oxygen. Although the nursing diagnosis Acute
Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the
least concern because the problem is with ventilation.
14. The nurse is caring for an adolescent client injured in a snowboarding accident. The
client has a head injury, a fractured right rib, and various abrasions and contusions. The
client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and
respirations of 26 breaths/minute. Which laboratory test best provides data on a
potential impairment in ventilation?
A) Blood gases
B) Complete blood count
C) Blood chemistry
D) Serum alkaline phosphate
Ans: A
Feedback:
Blood gases report the partial pressure of oxygen, which is dissolved in the blood.
Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the
nurse recognizes the current ventilation. The complete blood count provides information
regarding number of blood cells, which can relate to the disease processes such as
anemia and infection. The blood chemistry provides information on liver/renal function
and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to
help detect liver disease and bone disorders.
Page 5
15. The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that
the patient's body is working to stabilize?
A) Respirations are increasing.
B) Urine output is decreased.
C) Heart rate is regular.
D) WBC count is within normal limits.
Ans: A
Feedback:
Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid,
causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the
lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to
normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.
16. The nurse is providing health education on the body's ability to exchange oxygen and
carbon dioxide through the alveolar capillary membrane. Which statement, provided by
the nurse, is most correct when asked about diffusion during inspiration?
A) During inspiration, the concentration of oxygen is equal in both the alveoli and the
capillaries.
B) During inspiration, oxygen diffuses from the arterial system through to the
alveolar capillary membrane.
C) During inspiration, carbon dioxide provides the basis for all diffusion gradients.
D) During inspiration, oxygen is greater in the alveoli than in the capillaries.
Ans: D
Feedback:
During inspiration, oxygen-rich air from the environment enters the pulmonary system.
During inspiration, the concentration of inspired oxygen is higher in the alveoli than in
the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the
concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion
from the arterial system after the oxygen diffuses from the alveoli to the capillaries.
Carbon dioxide does not provide the basis for all diffusion gradients.
Page 6
17. The nurse is caring for clients on the neurological unit. Which triad of neurological
mechanisms does the nurse identify as most responsible when there is abnormality in
ventilation control?
A) Medulla oblongata, cerebellum, and heart rate
B) Pons, cerebellum, and oxygen receptors
C) Medulla oblongata, mitral valve, and central receptors
D) Aortic arch, pons, and CO2 receptor sites
Ans: D
Feedback:
Several mechanisms control ventilation. The respiratory center in the medulla oblongata
and pons control rate and depth of respirations. The central chemoreceptors in the
medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for
detecting abnormalities and signal changes to alter the pH and levels of oxygen in the
blood. The other options have an incorrect piece of the triad.
18. The nurse is caring for a client with hypoxemia of unknown cause. Which of the
following oxygen transport considerations does the nurse identify as crucial to circulate
oxygen in the body system? Select all that apply.
A) Oxygen is dissolved.
B) High blood pressure disrupts oxygen transport.
C) Oxyhemoglobin circulates to the body tissue.
D) All systemic oxygen is available for diffusion.
E) Adequate red blood cells are needed for oxygen transport.
Ans: A, C, E
Feedback:
Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining
oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for
oxygen transport. High blood pressure does not disrupt transport unless there is
disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form
which can diffuse across cell membranes.
Page 7
19. The nurse is caring for a client with chronic obstructive pulmonary disease. The client
calls the doctor and states having difficulty breathing and overall feeling fatigued. The
nurse realizes that this client is at high risk for which condition?
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic acidosis
D) Metabolic alkalosis
Ans: B
Feedback:
Respiratory acidosis occurs when the body is unable to blow off CO2 due to the
hypoventilation of disease processes such as COPD. An increase in blood carbon
dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis
is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic
acidosis/alkalosis are disorders that affect the bicarbonate.
20. The nurse is caring for a client with a decrease in airway diameter causing airway
resistance. The client experiences coughing and mucus production. Upon lung
assessment, which adventitious breath sounds are anticipated?
A) Crackles
B) Rhonchi
C) Rubs
D) Wheezes
Ans: D
Feedback:
A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes.
Wheezes are a whistling type of sound relating to the narrowing on the airway. A
wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are
crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a
course rattling sound similar to snoring usually caused by secretion in the bronchial tree.
Rubs are secretions that can be heard in the large airway.
Page 8
21. The client is returning from the operating room following a bronchoscopy. Which
action, performed by the nursing assistant, would the nurse stop if began prior to nursing
assessment?
A) The nursing assistant is assisting the client to a semi-Fowler's position.
B) The nursing assistant is assisting the client to the side of the bed to use a urinal.
C) The nursing assistant is pouring a glass of water to wet the client's mouth.
D) The nursing assistant is asking a question requiring a verbal response.
Ans: C
Feedback:
When completing a procedure which sends a scope down the throat, the gag reflex is
anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex
must be assessed before providing any food or fluids to the client. The client may need
assistance following the procedure for activity and ambulation but this is not restricted
in the post procedure period.
22. The nurse is performing a physical assessment on a client who has a history of a
respiratory infection. Which documentation, completed by the nurse, indicates the
resolution of the infection? Select all that apply.
A) Lung fields documented as clear in the bases.
B) Palpable vibrations over the chest wall when the client speaks.
C) Decreased fremitus when the client speaks “99.”
D) Dull sounds percussed over the lung tissue.
E) Bronchovesicular sounds heard over the upper lung fields.
Ans: A, B, E
Feedback:
The question asks for resolution or clearing of the infection; thus, normal respiratory
status should be assessed. Lungs will return to clear breath sounds. Palpable vibrations
will be felt as there is no blockage in the transmission. Bronchovesicular sounds will be
noted over the upper lung fields. An increased fremitus is noted as the client speaks
“99.” Dull percussed sounds indicate an area of consolidation.
Page 9
23. The student nurse is learning breath sounds while listening to a client in the physician's
office. An experienced nurse is assisting and notes air movement over the trachea to the
upper lungs. The air movement is noted equally on inspiration as expiration. Which
breath sounds would the nurse document?
A) Abnormal vesicular sounds
B) Normal bronchial sounds
C) Normal bronchovesicular sounds
D) Abnormal bronchial sounds
Ans: C
Feedback:
Air movement over the trachea and upper lungs is a normal finding for bronchovesicular
sounds. The air movement is noted equally on inspiration as expiration. The other
choices do not match type of breath sound for the location in question.
24. A client, experiencing respiratory distress, is ordered blood to be drawn for arterial
blood gases (ABGs) via the radial artery. Before the blood is drawn, which circulation is
assessed?
A) Carotid circulation
B) Ulnar circulation
C) Femoral circulation
D) Temporal circulation
Ans: B
Feedback:
Ulnar circulation is assessed using the Allen's test. The Allen's test is completed to
assess blood supply through the ulnar and radial arteries. Noting both circulations is
helpful when using an artery for the ABG draw. It is important to ensure adequate
secondary blood flow to the hand other than through the radial artery in case the artery
were to be damaged. No other circulation is assessed.
25. A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with
PCO2 of 49 mm Hg and a HCO3– of 28 mEq/L. The nurse reports to the physician which
finding?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
Ans: A
Feedback:
Respiratory acidosis would be reported to the physician citing the lab values. Analysis
of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is
the PCO2 above the normal range of 30 to 40 mm Hg. The HCO3– is slightly elevated
because the normal level is 22 to 26 mEq/L.
Page 10
26. The nurse is caring for a client whose respiratory status has declined since shift report.
The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test
should be assessed first?
A) Arterial blood gases
B) Pulmonary function test
C) Pulse oximetry
D) Chest x-ray
Ans: C
Feedback:
Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal
values are 95% and above. Using this diagnostic test first provides rapid information of
the client's respiratory system. All other options vary in amount of time and patient
participation in determining further information regarding the respiratory system.
27. The nurse is caring for a client with an exacerbation of COPD and scheduled for
pulmonary function studies using a spirometer. Which client statement would the nurse
clarify?
A) “My study is scheduled for 10 AM, several hours after I eat.”
B) “I brought comfortable clothes and shoes for the test.”
C) “I am ordered a bronchodilator to note lung improvement following use.”
D) “I will breathe in through my mouth and out through my nose.”
Ans: D
Feedback:
The nurse would clarify the client's statement of improper breathing technique. During a
pulmonary function test using a spirometer, a nose clip prevents air from escaping
through the client's nose when blowing into the spirometer. All other statements are
correct.
Page 11
28. A client presents to the emergency department in respiratory compromise. The client's
temperature is 102.4° F, heart rate 88 beats/minute and regular, and blood pressure
138/76 mm Hg. The client is dyspneic, pale, and expectorating green-tinged sputum.
The physician orders medications including antibiotics, antipyretics, nebulizer
treatments, and IV fluids. A chest x-ray and sputum culture are to be completed. Which
physician order would the nurse complete before beginning antibiotic therapy?
A) Chest x-ray
B) Sputum culture
C) Nebulizer treatments
D) Initiating IV fluids
Ans: B
Feedback:
The nurse would obtain a sputum culture for sensitivity before beginning antibiotic
therapy. Obtaining a sputum culture after beginning antibiotics can skew results. Once
the sputum culture results are returned, the antibiotic can be closely aligned to kill the
organism, if present. The other orders can be prioritized according to client needs.
29. A nurse is obtaining a health history from a client who reports hemoptysis for the past 2
months. The client reports occasional dyspnea. Which imaging study, ordered by the
physician, will view the thoracic cavity while in motion?
A) Fluoroscopy
B) Chest x-ray
C) Magnetic resonance imaging (MRI)
D) Computed tomography (CT) scan
Ans: A
Feedback:
Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in
motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An
x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial
views of the lungs.
Page 12
30. The nurse is instructing the client on the normal sensations, which can occur when
contrast medium is infused during pulmonary angiography. Which statement, made by
the client, demonstrates an understanding?
A) “I will feel a dull pain when the catheter is introduced.”
B) “I will feel light-headed when the contrast medium is introduced.”
C) “I will feel waves of nausea throughout the procedure.”
D) “I will feel warm and an urge to cough.”
Ans: D
Feedback:
During a pulmonary angiography a contrast medium is injected into the femoral artery.
When the medium is infused, the client will feel a sense of warm and flushed with an
urge to cough. The client will feel a pressure when the catheter is inserted. The client
does not typically feel light-headed or nauseated during the procedure.
31. The nurse is working on a busy respiratory unit. In caring for a variety of clients, the
nurse must be knowledgeable of diagnostic studies. With which diagnostic studies
would the nurse screen the client for an allergy to iodine? Select all that apply.
A) Lung scan
B) Chest x-ray
C) Fluoroscopy
D) Pulmonary angiography
E) Bronchoscopy
F)
Pulmonary functions test
Ans: A, C, D
Feedback:
The nurse must be well educated in screening clients before diagnostic procedures
which include contrast medium for an allergy to iodine. A lung scan, fluoroscopy and
pulmonary angiography all require contrast medium.
Page 13
32. The nurse is caring for a client who states, “I am really worried about the thoracentesis.
I know I won't be able to sleep tonight.” Which statement is most helpful to the client at
this time?
A) “Tell me what you are worried about.”
B) “Is there something that I can help you with?”
C) “Is there someone that you would like me to call to be with you?”
D) “The physician will see you before the procedure and can answer any questions.”
Ans: A
Feedback:
A thoracentesis is performed by inserting a needle into the wall under local anesthesia.
The thoracentesis is often done at the bedside. Providing support to the client before,
during, and after the treatment is a nursing responsibility. When the client states that he
is worried, asking an open-ended question promotes communication and is most
therapeutic. Asking if there is something that a nurse can do is a closed-ended question.
Asking about calling someone to be with the patient makes the nurse seem uninterested.
Talking with the physician closes communication with the nurse, making the nurse seem
uninterested.
33. The nurse is caring for a client in the immediate post–thoracentesis period. In which
position is the client placed?
A) In the supine position
B) Lying on the unaffected side
C) In the high Fowler's position
D) Prone with a pillow under the head
Ans: B
Feedback:
Following a thoracentesis, the client remains on bed rest and typically lies on the
unaffected side for at least 1 hour to promote expansion of the lung on the affected side.
Lying flat in a supine position or prone does not promote expansion of the lung.
Page 14
34. The nurse receives an order to obtain a sputum sample from a client with hemoptysis.
When advising the client of the physician's order, the client states not being able to
produce sputum. Which suggestion, offered by the nurse, is helpful in producing the
sputum sample?
A) Tickle the back of the throat to produce the gag reflex.
B) Drink 8 oz of water to thin the secretions for expectoration.
C) Use the secretions present in the oral cavity.
D) Take deep breaths and cough forcefully.
Ans: D
Feedback:
Taking deep breaths moves air around the sputum and coughing forcefully moves the
sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated
into a specimen container. Producing a gag reflex elicits stomach contents and not
respiratory sputum. Dilute and thinned secretions are not helpful in aiding
expectoration. A sputum culture is not a component of oral secretions.
35. A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and
cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is
depressed, especially on inspiration. Crackles are noted in the bases of the lung fields.
Based on inspection, which will the nurse document?
A) The client has a funnel chest.
B) The client has chronic respiratory disease.
C) The client has pneumonia in the bases.
D) The client needs a cough suppressant.
Ans: A
Feedback:
The question asks for a documentation based on inspection. A funnel chest, known as
pectus excavatum, has the sternum depressed from the second intercostal space, and it is
more pronounced on inspiration. The nurse would not diagnose chronic respiratory
disease or pneumonia. The client would also not prescribe a cough suppressant.
Page 15
36. A client arrives at the physician's office stating dyspnea; a productive cough for thick,
green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The
nurse auscultates the lung fields, which reveal poor air exchange in the right middle
lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this
anticipated diagnosis, which sound, heard over the chest wall when percussing, is
anticipated?
A) Tympanic
B) Resonant
C) Hyperresonant
D) Dull
Ans: D
Feedback:
A dull percussed sound, heard over the chest wall, is indicative of little or no air
movement in that area of the lung. Lung consolidation such as in pneumonia or fluid
accumulation produces the dull sound. A tympanic sound is a high-pitched sound
commonly heard over the stomach or bowel. A resonant sound is noted over normal
lung tissue. A hyperresonant sound is an abnormal lower pitched sound that occurs
when free air exists in disease processes such as pneumothorax.
37. A client experiences a head injury in a motor vehicle accident. The client's level of
consciousness is declining, and respirations have become slow and shallow. When
monitoring a client's respiratory status, which area of the brain would the nurse realize is
responsible for the rate and depth?
A) The pons
B) The frontal lobe
C) Central sulcus
D) Wernicke's area
Ans: A
Feedback:
The pons in the brainstem controls rate and depth of respirations. When injury occurs or
increased intracranial pressure results, respirations are slowed. The frontal lobe
completes executive functions and cognition. The central sulcus is a fold in the cerebral
cortex called the central fissure. The Wernicke's area is the area linked to speech.
Page 16
1. Chapter 20
You are caring for a client who is post–sinus surgery. When you assess this client, you
ask him how many fingers you are holding up. Why do you assess postoperative visual
acuity?
A) To assess possible hemorrhage
B) To assess damage to the optic nerve
C) To assess postoperative infection
D) To assess impaired drainage
Ans: B
Feedback:
A client who has undergone a sinus surgery faces a serious risk of damage to the optic
nerve. Therefore, the nurse assesses postoperative visual acuity by asking the client to
identify the number of fingers displayed. To assess possible hemorrhage, the nurse
observes the client for repeated swallowing. The nurse assesses for pain over the
involved sinuses and not a postoperative infection or an impaired drainage.
2. You are caring for a client diagnosed with enlarged adenoids. What condition is
produced by enlarged adenoids?
A) Incrusted mucous membranes
B) Hardened secretions
C) Erosion of the trachea
D) Noisy breathing
Ans: D
Feedback:
Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal
quality to the voice. Incrustation of the mucous membranes in the trachea and the main
bronchus occurs during the postoperative period following a tracheostomy. The
long-term and short-term complications of tracheostomy include airway obstruction.
These are caused by hardened secretions and erosion of the trachea.
Page 1
3. You are performing a preoperative assessment on a client who is scheduled for a
tonsillectomy. Why would you ask the client about the use of herbal supplements?
A) They produce anorexia.
B) They impair the immune system.
C) They prolong bleeding.
D) They lower high-density lipoprotein levels.
Ans: C
Feedback:
The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy
and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal
supplements. The nurse must ask about the use of these supplements because they may
prolong bleeding. A client may experience anorexia because of a diminished sense of
taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune
system and lowers the levels of high-density lipoproteins. These symptoms are not
caused by herbal supplements.
4. A client comes into the emergency department with epistaxis. What intervention should
you perform when caring for a client with epistaxis?
A) Apply a moustache dressing.
B) Provide a nasal splint.
C) Apply direct continuous pressure.
D) Place the client in a semi-Fowler's position.
Ans: C
Feedback:
The severity and location of bleeding determine the treatment of a client with epistaxis.
To manage this condition, the nurse should apply direct continuous pressure to the nares
for 5 to 10 minutes with the client's head tilted slightly forward. Application of a
moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and
placement of the client in a semi-Fowler's position are interventions related to the
management of a client with a nasal obstruction.
Page 2
5. You are presenting about upper respiratory infections at an educational event for a local
community group. What should you be sure to include regarding cold tablets containing
antihistamines?
A) They dilute the nasal secretions.
B) They lead to frequent sinus drainage.
C) They decrease discomfort temporarily.
D) They prolong bleeding.
Ans: C
Feedback:
Some cold tablets contain antihistamines that thicken the nasal secretions. Although this
action may temporarily decrease the discomfort of profuse nasal secretions, thickened
secretions can block the drainage openings of the sinus cavity, leading to the failure of
the sinuses to drain adequately. Aspirin prolongs bleeding.
6. You are caring for a client who is status post nasal polypectomy. What would you
instruct this client to report?
A) Excessive swallowing
B) Nasal stuffiness
C) Diarrhea
D) Coughing
Ans: A
Feedback:
The nurse inspects the nasal packing and dressings frequently for bleeding and asks the
client to report excessive swallowing, which can indicate bleeding. Options B, C, and D
are incorrect. Nasal stuffiness and diarrhea do not indicate postoperative bleeding.
Coughing can loosen or expel scabs on the surgical wounds.
7. You are an occupational health nurse who is presenting a workshop on laryngeal cancer.
What risk factors would you be sure to include in your workshop? Select all that apply.
A) Alcohol
B) Age
C) Tobacco
D) Industrial pollutants
E) Region of country you live in
Ans: A, C, D
Feedback:
Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with
laryngeal cancer.
Page 3
8. You are mentoring a new graduate nurse. Today, the two of you are caring for a client
with a new tracheostomy. The new graduate nurse asks what the complications of
tracheostomy are. What would you respond? Select all that apply.
A) Absence of secretions
B) Aspiration
C) Infection
D) Injury to the laryngeal nerve
E) Penetration of the anterior tracheal wall
Ans: B, C, D
Feedback:
The long-term and short-term complications of tracheostomy include infection,
bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the
laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and
trachea, and penetration of the posterior tracheal wall.
9. You are a nurse caring for a client who has just had a tracheostomy. What should you
monitor frequently?
A) Airway patency
B) Level of consciousness
C) Psychological status
D) Pain level
Ans: A
Feedback:
The nurse monitors for potential complications and checks airway patency frequently.
Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe
respiratory difficulty or death by asphyxiation. The priorities are always airway,
breathing, and then circulation.
10. You are caring for a client who is 42 years old and status post adenoidectomy. You find
the client in respiratory distress when you enter his room. You ask another nurse to call
the physician and bring an endotracheal tube into the room. What do you suspect?
A) Infection
B) Postoperative bleeding
C) Edema of the upper airway
D) Plugged tracheostomy tube
Ans: C
Feedback:
An endotracheal tube is inserted through the mouth or nose into the trachea to provide a
patent airway for clients who cannot maintain an adequate airway on their own. The
scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy
tube.
Page 4
11. The nurse is caring for a client who has recurrent sinusitis. Which consideration could
the nurse suggest to best decrease the frequency of infections?
A) Administer an over-the-counter decongestant.
B) Use an anti-allergy medication to decrease rhinitis.
C) Place a warm cloth over the sinus area of the forehead.
D) Gently blow the nose to eliminate nasal secretions.
Ans: A
Feedback:
The principle causes of sinusitis are the spread of infection from the nasal passages to
the sinus and the blockage of normal sinus drainage. Interference with sinus drainage
predisposes a client to sinusitis. Administering a decongestant opens the nasal passages
for drainage. The other options can be helpful for a sinus infection, but opening the
passages is best.
12. The nurse is caring for a client in the physician's office with a potential sinus infection.
The physician orders a diagnostic test to identify if fluid is found in the sinus cavity.
Which diagnostic test, written by the physician, is specifically ordered for this purpose?
A) CBC with differential
B) Transillumination of the sinus
C) Nasal culture
D) Magnetic resonance imaging (MRI)
Ans: B
Feedback:
Transillumination and x-rays of the sinuses may show a change in the shape of or
confirms that there is fluid in the sinus cavity. CBC with differential can note an
elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture
can note bacteria in the nares. An MRI is an expensive procedure which is not typically
prescribed for a potential infection and not specifically ordered to identify fluid in the
sinus cavity.
Page 5
13. The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus.
Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28
breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client
states a sore throat, moist cough, and watery eyes. The lungs are course in the bases.
Which afternoon assessment finding suggests the advancement to an infectious process?
A) Achiness
B) Headache
C) Temperature rise
D) Increased respiratory rate
Ans: C
Feedback:
Coryza refers to the common cold many times associated with a virus such as the
rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature
is interpreted that the client continues to have a sustained elevated temperature which
suggests a bacterial infection. All viruses can include symptoms of achiness, headache,
and an increase in the respiratory rate. Increased respiratory rate does not always
indicate infection because it can be a sign of a multitude of other problems.
14. The nurse is caring for a geriatric client brought to the emergency department after
being found by her children feeling poorly with an elevated temperature. Laboratory
tests confirm influenza type A, a respiratory virus. Which medical treatment would the
nurse anticipate in the discharge instructions? Select all that apply.
A) Rest
B) Increased fluids
C) Antibiotics
D) Antiemetics
E) Saline gargles
F)
Antitussives
Ans: A, B, E, F
Feedback:
Influenza type A is the most common cause of the flu initiated by a respiratory virus.
Common discharge instructions include rest, increased fluids to thin respiratory
secretions, saline gargles to help prevent a throat infection such a strep throat, and
antitussives if the client is coughing. Antibiotics are not used with a virus unless a
bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting
not commonly associated with a common respiratory virus.
Page 6
15. The nurse is caring for a client in a physician's office whose x-ray of the sinus reveals
exudate in the maxillary sinus. Which equipment must the nurse have present in the
room?
A) Otoscope
B) Ophthalmoscope
C) Irrigation equipment
D) Tuning fork
Ans: C
Feedback:
Note the keyword as “must”. The nurse would have sinus irrigation equipment available
for the physician as saline irrigation of the maxillary sinus is done to remove exudate
and promote drainage. This is most helpful as a condition which could lead to an
infection is documented. An otoscope and tuning fork may be present in the room for
further assessment. An ophthalmoscope is typically not needed.
16. A nurse is caring for a client following nasal surgery. Which assessment finding best
indicates current bleeding?
A) Ruddy colored drainage on the nasal dressing
B) Occasional nonproductive cough
C) Frequent swallowing
D) Pressure in the nasal cavity
Ans: C
Feedback:
Standards of postoperative care include assessment for postoperative bleeding with
symptoms such as repeated swallowing. Swallowing indicates a slow oozing or dripping
down the back of the throat. Ruddy colored drainage indicates old drainage. Occasional
nonproductive cough could possibly indicate a problem but is not as definitive as
swallowing. Pressure in the nasal cavity is to be expected.
17. The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a
red, sore throat. The client has been febrile for 3 days. Which nursing assessment should
be stressed?
A) Lung fields
B) Voiding
C) Joint pain
D) Mentation
Ans: B
Feedback:
A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria.
The most serious bacteria are the group A streptococci, commonly referred to as strep
throat. Strep throat can have serious cardiac and renal complications, including sepsis.
Assessing voiding can be an indication of renal status. Lung fields, joint pain, and
mentation are completed in the head-to-toe assessment.
Page 7
18. The nurse is providing suggestions to a client diagnosed with the effects of coryza.
Which home remedy is appropriate when combined with medical treatment for
pharyngitis?
A) Cool mist humidifier
B) Lavender scent
C) Ice chips
D) Salt water gargle
Ans: D
Feedback:
A salt water or saline gargle combines moisture from the water with sodium from the
salt to treat the infection and aid in associated discomfort. Humidification and ice chips
are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A
lavender scent is relaxing.
19. The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the
postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher
to the bed. The client remains drowsy from anesthesia. In which position would the
nurse instruct the nurse aide to place the client?
A) On a side
B) Supine
C) Semi-Fowler's
D) High-Fowler's
Ans: A
Feedback:
Upon receiving the client in the PACU, the client is drowsy and not fully conscious. A
standard of care to prevent aspiration is to place the client lying on either side with an
emesis basin to catch drainage. Laying the client is a supine position, semi-Fowler's
position, or high-Fowler's position does not provide an easy exit for secretions as the
client is recovering from the anesthesia.
Page 8
20. The nurse initiates the following intervention upon receiving a client back to the clinical
unit after a throat-related procedure, “Elevate the head of the bed 45°.” This assists in
meeting which nursing goal?
A) The client will have decreased pain.
B) The client will remain alert and oriented.
C) The client will have decreased edema.
D) The client will have increased tissue perfusion.
Ans: C
Feedback:
Elevating the head of the bed 45° when the client is fully awake decreases surgical
edema and increases lung expansion. At this point in the recovery, elevating the head of
the bed will not decrease the surgical pain as pain medication will be needed. Elevating
the head of the bed will not affect mentation nor increase the blood supply.
21. The nurse is providing discharge instructions to a client diagnosed with postoperative
tonsillectomy and adenoidectomy. Which discharge instructions would the nurse
include? Select all that apply.
A) Postoperative bleeding most frequently occurs in the hours after surgery.
B) Avoid carbonated fluids.
C) Gradually increase fluids then add soft foods.
D) Apply an ice collar to the neck area.
E) Gargle with warm saline water.
F)
Limit pain medications to the nighttime.
Ans: B, C, D, E
Feedback:
A client may be at risk for postoperative bleeding for several days following the surgical
procedure as the scab may be removed from the surgical site early causing the bleeding.
Clients should avoid carbonated beverages and citrus fluids or foods because these
agents are caustic to the suture line. The client should gradually increase fluids from
thin liquids to thick liquids then soft foods through the recovery process. Applying an
ice collar and gargling with saline decreases swelling and aids in preventing infection.
Pain medication would be appropriate throughout the day, not just at night.
22. The nurse is obtaining a health history from a client with laryngitis. Which causative
factor, stated by the client, is least likely?
A) “I have environmental allergies.”
B) “I smoke a pack of cigarettes a day.”
C) “I used my voice in excess over the weekend.”
D) “I was chewing ice chips all day long.”
Ans: D
Feedback:
Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies,
smoking, and excessive use of the voice causing straining are frequent causes.
Page 9
23. The nurse is obtaining a health history from a client on an annual physical exam. Which
documentation should be brought to the physician's attention?
A) Epistaxis, twice last week
B) Aphonia following a football game
C) Hoarseness for 2 weeks
D) Laryngitis following a cold
Ans: C
Feedback:
Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer
and merits prompt investigation. Epistaxis can be from several causes and has occurred
infrequently. Aphonia and laryngitis are common following the noted activity.
24. The emergency department nurse is assessing a client following a motor vehicle
accident. The nurse notes facial deformities with swelling and bleeding and a clear
drainage coming from the nares. Which diagnostic test is completed to determine if the
clear drainage is cerebrospinal fluid?
A) A serum CBC
B) A Nitrazine paper
C) A Dextrostix
D) A glucometer check
Ans: C
Feedback:
When clear drainage is observed from the nares of a client, a Dextrostix is used to
determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC
would provide information on red and white blood cell count. A low red blood cell
count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to
assess vaginal secretions for the presence of amniotic fluid. A glucometer check will
provide information on serum glucose, not the glucose level in the cerebrospinal fluid.
25. The nurse is caring for a client experiencing laryngeal trauma. Upon assessment,
swelling and bruising is noted to the neck. Which breath sound is anticipated?
A) Rhonchi in the bronchial region
B) Audible stridor without using a stethoscope
C) Crackles in the bases of the lungs
D) Diminished breath sounds throughout
Ans: B
Feedback:
The nurse anticipates hearing audible stridor without needing a stethoscope due to the
neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in
the airways and crackles are heard in the bases of the lungs. Diminished breath sounds
that occur throughout are indicative of airway obstruction and not indicative of
laryngeal swelling.
Page 10
26. The nurse is caring for a client who is demonstrating signs of increased respiratory
distress related to laryngeal obstruction. The nurse is calling the physician to report on
the client's condition. Which of the following will the nurse report? Select all that apply.
A) A decreased respiratory rate
B) Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84
C) Nasal flaring with abdominal retractions
D) Administration of a corticosteroid inhaler for quick relief
E) Lung sounds of stridor
F)
Increased respiratory effort
Ans: B, C, E, F
Feedback:
The nurse would be calling to report signs of respiratory distress. This includes nasal
flaring with abdominal retractions, stridor and an increased respiratory effort. Also
arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory
compromise. An increased respiratory rate occurs in respiratory compromise.
Administration of a corticosteroid decreases inflammation over a period of time.
27. The nurse is caring for the client who presents to the clinic with hoarseness for 2
months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical
neck dissection. When reinforcing information provided by the physician, which nursing
instruction is most correct?
A) Laser surgery is a possibility with limited side effects.
B) The physician removes lymph nodes, muscles and tissue.
C) Once the tissue is removed, no further treatment is necessary.
D) You will be able to speak normally once the swelling subsides.
Ans: B
Feedback:
When the physician prescribes a radical neck dissection, the disease has extended
beyond the larynx. The physician removes lymph nodes, muscle, and tissue. Laser
surgery is completed for early lesions and does not have the ability to remove all of the
structure needed. Chemotherapy and radiation is typically administered. The client will
lose the ability to speak normally.
Page 11
28. A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was
encouraged to attend a support group prior to surgery. The client asked the nurse about
the name of the laryngeal speech method where the client speaks through the wall of the
trachea with a device. The nurse is correct to provide teaching on which method?
A) Esophageal speech
B) An electric larynx
C) A tracheoesophageal puncture
D) An artificial voice box
Ans: C
Feedback:
A tracheoesophageal puncture is the method where a client speaks through a surgical
opening in the posterior wall of the trachea with the assistance of a device. Esophageal
speech occurs from swallowing air and forming words with the lips. An electronic
larynx is a throat vibrator. There is no electronic voice box on the market.
29. The nurse is caring for a client who had a recent laryngectomy. Which of the following
is reflected in the nursing plan of care?
A) Develop an alternate method of communication.
B) Encourage oral nutrition on the second postoperative day.
C) Maintain the client in a low-Fowler's position.
D) Assess the tracheostomy cuff for leaks.
Ans: A
Feedback:
The client with a total laryngectomy is not able to speak. Communication needs to be
established using an alternate method. The client typically has difficulty with
swallowing due to edema in the immediate postoperative period. Alternate forms of
nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head
of the bed is maintained in a semi-Fowler's position to decrease edema.
Page 12
30. A graduate practical nurse is caring for a client who has a tracheostomy tube. A
seasoned nurse is assisting in providing guidance for completing tracheostomy care.
When changing the ties, the client moves and dislodges the tube. Which of the following
does the seasoned nurse do first?
A) Call for the registered nurse to reinsert the tube.
B) Place a dilator in the stoma to maintain the opening.
C) Cover the tracheostomy site with a sterile gauze to prevent infection.
D) Call for an ambulance and transfer the client to the emergency department.
Ans: B
Feedback:
If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the
edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube
must never be forced back into place. Covering the tracheostomy site with gauze can
obstruct the stoma, decreasing ventilation. If needed, an ambulance may be called to
transport the client to the emergency department but not until the airway is stabilized.
31. A nurse is evaluating teaching when discussing care of a new tracheostomy. Which
statement, made by the client, indicates that the client does not accept the new
tracheostomy?
A) “I must carry tissues with me.”
B) “I must give up my love of pool aerobics.”
C) “I will not be able to have the tracheostomy removed.”
D) “Tell my wife about it, I do not want to touch it.”
Ans: D
Feedback:
Not wanting to participate in care and diverting the care to others indicates that the
client has not accepted the tracheostomy. It is correct to carry tissues with the client
because new tracheostomy tubes produce much mucous due to the irritation of the tube
in the throat. Consideration need to be arranged by being in a swimming pool may be
completed as long as water does not surround the new tracheostomy. Stating the reality
of not being able to remove the tracheostomy provides data that the client is accepting
the tracheostomy as part of life.
Page 13
32. The nurse is caring for the client in the intensive care unit immediately after removal of
the endotracheal tube. Which of the following nursing actions is most important to
complete every hour to ensure that the respiratory system is not compromised?
A) Obtain vital signs.
B) Monitor heart rhythm.
C) Auscultate lung sounds.
D) Assess capillary refill.
Ans: C
Feedback:
Major goals of intubation are to improve respirations and maintain a patent airway for
gas exchange. Regular auscultation of the lung fields is essential in confirming that air is
reaching the lung fields for gas exchange. All other options are important to provide
assessment data.
33. The nurse is caring for a client with an endotracheal tube. Which client data does the
nurse interpret as a life-threatening situation?
A) Copious mucous secretions
B) Sudden restlessness
C) Harsh cough
D) Rhonchi in lung fields
Ans: B
Feedback:
Sudden restlessness is indicative of respiratory distress, which may occur from the
obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious
mucous secretions are common from irritation of the endotracheal tube. A harsh cough
and rhonchi in the lung fields is common with the presence of mucous secretions.
34. A client visits the physician's office concerned about possible sleep apnea. The client
states he lives alone and fears that he will not awaken from sleep. The client states that
he has many symptoms which may indicate sleep apnea. Which symptom, stated by the
client, is not a symptom of sleep apnea?
A) “I wake myself up by snoring several times each night.”
B) “I wake up in the morning with a headache.”
C) “I have trouble concentrating throughout the day.”
D) “I have pressure in the middle of my chest at night.”
Ans: D
Feedback:
Signs of pressure in the middle of the chest are not indicative of sleep apnea and require
further instruction and investigation by the nurse. A cardiac or epigastric cause may be
producing the symptoms. All of the other options are symptoms of sleep apnea.
Page 14
35. The nurse is caring for a respiratory client who uses a noninvasive positive pressure
device. Which medical equipment does the nurse anticipate to find in the client's room?
A) A ventilator
B) A face mask
C) A rigid shell
D) A nasal cannula
Ans: B
Feedback:
A face mask or other nasal devices are found in the client's room as this type of
ventilation does not require intubation or a ventilator. A rigid shell is used with a
negative pressure chamber and is not frequently used today. A nasal cannula is not used
with the positive pressure device.
36. The nurse is caring for a client with a new tracheostomy. Which of the following
nursing diagnoses are priorities? Select all that apply.
A) Ineffective Airway Clearance related to increased secretions
B) Risk for Infection related to operative incision and tracheostomy tube placement
C) Knowledge Deficit related to care of the tracheostomy tube and surrounding site
D) Impaired Gas Exchange related to shallow breathing and anxiousness
Ans: A, D
Feedback:
The client with a new tracheostomy tube has increased secretions, which may become
dried and occlude the airway or plug the airway requiring frequent suctioning. Impaired
Gas Exchange is an equally important diagnosis. These are related to airway and
breathing and are priorities.
37. The nurse is caring for a client with an upper respiratory disorder. The client states he
have a hacky, nonproductive cough, which wakens him during the night. Which
over-the-counter medication would the nurse suggest to diminish the cough during the
night?
A) Benadryl
B) Robitussin
C) Pseudoephedrine
D) Flonase
Ans: B
Feedback:
Robitussin acts on the central nervous system to raise the cough threshold and dampen
the cough reflex. Benadryl is an antihistamine which relieves symptoms associated with
allergies. Pseudoephedrine relieves nasal congestion associated with sinusitis, colds, and
allergies. Flonase reduces tissue edema.
Page 15
1. Chapter 21
You are a clinic nurse caring for a client with acute bronchitis. The client asks what may
have caused the infection. What may induce acute bronchitis?
A) Aspiration
B) Drug ingestion
C) Chemical irritation
D) Direct lung damage
Ans: C
Feedback:
Chemical irritation from noxious fumes, gases, and air contaminants induces acute
bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose,
and direct damage to the lungs are factors associated with the development of acute
respiratory distress syndrome.
2. You are an occupational nurse completing routine assessments on the employees where
you work. What might be revealed by a chest radiograph for a client with occupational
lung diseases?
A) Fibrotic changes in lungs
B) Hemorrhage
C) Lung contusion
D) Damage to surrounding tissues
Ans: A
Feedback:
For a client with occupational lung diseases, a chest radiograph may reveal fibrotic
changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues
are possibly caused by trauma due to chest injuries.
3. You are assessing a client's potential for pulmonary emboli. What finding indicates
possible deep vein thrombosis?
A) Pain in the feet
B) Inability to dorsiflex
C) Negative Homan's sign
D) Pain in the calf
Ans: D
Feedback:
When assessing the client's potential for pulmonary emboli, the nurse tests for a positive
Homan's sign. The client lies on his or her back and lifts his or her leg and his or her
foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or
she may have a deep vein thrombosis.
Page 1
4. You are caring for a client who has just been diagnosed with lung cancer. What is a
cardinal sign of lung cancer?
A) Mucopurulent sputum
B) Pain on inspiration
C) Obvious trauma
D) Shortness of breath
Ans: A
Feedback:
For a client with lung cancer, a cough productive of mucopurulent or blood-streaked
sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of
severe pain on inspiration and expiration, obvious trauma, and shortness of breath.
These symptoms may also be caused by other disorders but are not considered
indicative of lung cancer.
5. The local public health department is holding a flu vaccine clinic. The health department
recommends flu vaccinations for healthcare workers and people at high risk for
complications or for those exposed daily to many different people. When using FluMist
(live, attenuated influenza vaccine), what group is not approved?
A) Children between 6 and 12 years of age
B) People with hypersensitivity to milk products
C) Adolescents who regularly take aspirin
D) Adults 30 to 40 years of age
Ans: C
Feedback:
FluMist is a live and attenuated influenza vaccine administered intranasally. It is not
approved for various categories of people, including adolescents who regularly take
aspirin, children younger than 5 years of age, adults above 50 years of age, and people
with a hypersensitivity to eggs.
Page 2
6. You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke
inhalation. You know that this client is at increased risk for which of the following?
A) Acute respiratory distress syndrome
B) Lung cancer
C) Bronchitis
D) Tracheobronchitis
Ans: A
Feedback:
Factors associated with the development of ARDS include aspiration related to near
drowning or vomiting; drug ingestion/overdose; hematologic disorders such as
disseminated intravascular coagulation or massive transfusions; direct damage to the
lungs through prolonged smoke inhalation or other corrosive substances; localized lung
infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as
chest contusions, multiple fractures, or head injury; any major surgery; embolism; and
septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and
tracheobronchitis.
7. You are preparing a client for emergency thoracic surgery. What would you document
in your assessment?
A) Emergency contacts
B) IV fluids ordered
C) General statement of the client's condition
D) Detailed physical assessment
Ans: C
Feedback:
If the surgery is an emergency, physical assessment may be limited to a general
statement of the client's condition, a list of emergency measures and treatments done,
and vital signs. You would not document emergency contacts or a detailed physical
assessment. You would document the IV fluids running and not any that are ordered.
8. What is the reason for chest tubes after thoracic surgery?
A) Draining secretions, air, and blood from the thoracic cavity is necessary.
B) Chest tubes allow air into the pleural space.
C) Chest tubes indicate when the lungs have reexpanded by ceasing to bubble.
D) Draining secretions and blood while allowing air to remain in the thoracic cavity
is necessary.
Ans: A
Feedback:
After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is
necessary to allow the lungs to expand. This makes options B, C, and D incorrect.
Page 3
9. What are the conditions that make up Virchow's triad? Select all that apply.
A) Hypercoagulability
B) Disruption of the vessel lining
C) Hypocoagulability
D) Edema
E) Venostasis
Ans: A, B, E
Feedback:
Three conditions, referred to as Virchow's triad, predispose a person to clot formation:
venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part
in Virchow's triad.
10. The nurse caring for a 2-year-old near-drowning victim monitors for what possible
complication?
A) Atelectasis
B) Acute respiratory distress syndrome
C) Metabolic alkalosis
D) Respiratory acidosis
Ans: B
Feedback:
Factors associated with the development of ARDS include aspiration related to near
drowning or vomiting; drug ingestion/overdose; hematologic disorders such as
disseminated intravascular coagulation or massive transfusions; direct damage to the
lungs through prolonged smoke inhalation or other corrosive substances; localized lung
infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as
chest contusions, multiple fractures, or head injury; any major surgery; embolism; and
septicemia. Options A, C, and D are incorrect.
11. Which of the following provides the best example of documentation for a client who is
presenting with acute bronchitis?
A) Physical activity seems to increase incidence of paroxysmal coughing.
B) Expectorating moderate amounts of thick, green mucus.
C) Dry, frequent cough with occasional production of sputum.
D) Less crackles today. No cough or mucus noted.
Ans: B
Feedback:
Moderate amount of thick, green mucus provides amount of sputum and description.
Physical activity seems to increase is a judgment not an observation. Dry, frequent
cough is descriptive, but the sputum is not described. Less crackles today does not
provide enough detail and is not measureable.
Page 4
12. The client, with a lower respiratory airway infection, is presenting with the following
symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis
best supports the assessment by the nurse?
A) Risk for Infection
B) Impaired Gas Exchange
C) Ineffective Airway Clearance
D) Ineffective Breathing Pattern
Ans: C
Feedback:
The symptom of wheezing indicates a narrowing or partial obstruction of the airway
from inflammation or secretions. Risk for Infection is a real potential because the client
is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange
may occur, but no symptom listed supports poor exchange of gases. No documentation
of respiratory rate or abnormalities is listed to justify this nursing diagnosis.
13. A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which
statement from the nurse best explains the rationale for this vaccine?
A) “Getting the flu can complicate pneumonia.”
B) “Influenza vaccine will prevent typical pneumonias.”
C) “Influenza is the major cause of death in the United States.”
D) “Viruses, like influenza, are the most common cause of pneumonia.”
Ans: D
Feedback:
Influenza type A is the most common cause of pneumonia. Therefore, preventing
influenza lowers the risk of pneumonia. Viral URIs can make the client more
susceptible to secondary infections, but getting the flu is not a preventable action.
Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that
is used to prevent a viral infection. Influenza is not the major cause of death in the
United States. Combined influenza with pneumonia is the major cause of death in the
United States.
14. The client has been self-medicating with antitussives. Which assessment finding would
alert the nurse to an adverse effect of this medication?
A) Crackles in the bases
B) Increased coughing
C) Temperature 101° F
D) Nausea and vomiting
Ans: A
Feedback:
The indiscriminate use of antitussives can cause more harm by suppressing the cough
mechanism and allowing secretions to pool in the bases of the lungs. Antitussives
decrease coughing and do not have antipyretic properties. Nausea and vomiting is a
common adverse effect for many drugs but is not a finding that places the nurse on alert.
Page 5
15. Which is a primary nursing intervention in caring for a client with the diagnosis of
bronchiectasis?
A) Postural drainage
B) Droplet precautions
C) Preventative antibiotic use
D) Administration of antitussives
Ans: A
Feedback:
Management of bronchiectasis focuses on postural drainage and the movement of
secretions out of the dilated sacs of the bronchioles. Bronchiectasis is not contagious or
spread through droplets. The presence of infection is treated with selective antibiotics,
but long-term preventative treatment with antibiotics is not protocol. Suppressing the
cough mechanism with use of antitussives would be counterproductive in the
management of bronchiectasis.
16. Upon assessing a client with emphysema, the nurse notes increased difficulty with
inspiration. What is the likely cause of this finding?
A) Prolonged tobacco use
B) Rigid chest cage
C) Saccular dilatation
D) Inflammation of the bronchioles
Ans: B
Feedback:
Fibrous scarring in the alveolar walls occurs with progressive emphysema and results in
a rigid chest cage and inspiration difficulty. Smoking can contribute to the destruction of
lung function but is not significant for the difficulty in inspiration. Saccular dilation is a
symptom of bronchiectasis. Emphysema is a chronic disease not an inflammatory
condition.
17. Which action should the nurse take first in caring for a client during an acute asthma
attack?
A) Obtain arterial blood gases.
B) Send for STAT chest x-ray.
C) Administer bronchodilator as ordered.
D) Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.
Ans: C
Feedback:
Administering bronchodilator will dilate the airway and allow oxygen to reach the
lungs. Although ABGs and chest x-ray are valid diagnostic tests for lung disorders,
immediate action to restore gas exchange is a priority in an acute attack. The
administration of oxygen is indicated, but without open bronchioles, the action will not
be effective in an acute attack.
Page 6
18. Which statement would indicate that the parents of child with cystic fibrosis understand
the disorder?
A) “Early treatment can stop the progression of the disease.”
B) “The mucus-secreting glands are abnormal.”
C) “There are fibrous cysts in the lungs.”
D) “Allergic reactions cause inflammation in the lungs.”
Ans: B
Feedback:
Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions
present in the lungs. Early treatment can improve symptoms and extend the life of
clients, but a cure for this disorder is presently not available. Allergens are responsible
for allergic asthma and not associated with cystic fibrosis.
19. The nurse is obtaining data from a client with a respiratory disorder. Which information
would be considered a part of the functional assessment and assist in the diagnosis of an
occupational lung disease?
A) Cough and dyspnea
B) Black-streaked sputum
C) Tenacious secretions
D) Barrel chest
Ans: B
Feedback:
A functional assessment provides data on the lifestyle, living environment, and work
environment of the client, which can contribute to lung disorders. A black-tinged
sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious
secretions are vague respiratory symptoms that are not specific to occupational lung
disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a
prolonged period of time.
Page 7
20. In the prevention of silicosis, the nurse would direct preventative teaching to which
high-risk occupations? Select all that apply.
A) Baker
B) Banker
C) Rock quarry worker
D) Nurse
E) Welder
F)
Mechanic
Ans: A, C, E
Feedback:
A baker is exposed to dust from flour. A quarry worker is exposed to rock dust and
silica. A welder is exposed to gases and fumes that can be inhaled and result in silicosis.
A banker, nurse, and mechanic may have work hazards but not specific to the
development of silicosis.
21. A client with pulmonary hypertension asks the nurse to explain the heart changes that
can occur with this disorder. Which is the best response?
A) “I will ask your physician to discuss this with you.”
B) “Blood pressure is high as it leaves the heart.”
C) “The right side of the heart enlarges as pressure backs from the lungs.”
D) “The left side of the heart is not pumping well and blood backs into the lungs.”
Ans: C
Feedback:
In primary pulmonary hypertension, there is increased resistance and pressure in the
pulmonary vascular bed, which places strain on the right ventricle and causes
enlargement. To increase understanding of a disorder, the nurse should take time to
answer questions presented. The blood pressure is highest in the pulmonary arteries and
right ventricle of the heart, not on the left side of the heart or where the blood enters the
general circulation.
22. Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The
nurse suspects a pulmonary embolus that originated from which site?
A) Deep veins of the legs
B) Bone marrow
C) Myocardial tissue
D) Superior vena cava
Ans: B
Feedback:
A fat embolus usually occurs after a fracture or repair to the long bones. Pulmonary
emboli may arise from the endocardium of the right side of the heart, but a myocardial
infarction has not been identified in this client. The deep veins of the legs are a common
site for emboli formation especially with prolonged inactivity or thrombophlebitis,
which does not apply to this client.
Page 8
23. The client admitted with a deep vein thrombosis (DVT) is now complaining of chest
pain and dyspnea. Which is the primary intervention for the nurse to take?
A) Apply oxygen via face mask.
B) Assess and rate the chest pain.
C) Apply compression stockings.
D) Prepare for ventilation-perfusion scan.
Ans: A
Feedback:
Maintaining patency of the airway and promoting oxygen concentration to the tissues of
the lung are paramount in the management of pulmonary embolus. Managing the pain is
important but not the primary intervention. The client may be ordered a
ventilation-perfusion scan and pulmonary angiography but not the priority intervention.
Application of compression stockings is ideal for preventing pulmonary emboli in
high-risk clients but not an intervention after occurrence.
24. The nurse identifies which finding to be most consistent prior to the onset of acute
respiratory distress?
A) Normal lung function
B) Loss of lung function
C) Chronic lung disease
D) Slow onset of symptoms
Ans: A
Feedback:
Acute respiratory failure occurs suddenly in clients who previously had normal lung
function.
25. A client with chronic respiratory failure presents with a pH 7.28, PCO2 54 mm Hg, and
HCO3– 25 mEq/L. The nurse recognizes this to indicate which finding?
A) Respiratory alkalosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Metabolic acidosis
Ans: C
Feedback:
A pH of less than 7.35 indicates acidosis. With a high PCO2 and normal HCO3–
indicates the lungs are the cause of the acidosis—respiratory acidosis. In metabolic
acidosis, the PCO2 would be normal, but the HCO3– would be low.
Page 9
26. The client with acute respiratory distress syndrome (ARDS) presents with severe
hypoxemia, in spite of oxygen administration via face mask. The nurse would anticipate
and prepare for which intervention?
A) Intermittent positive pressure breathing
B) Insertion of endotracheal tube
C) Increasing oxygen to 12 to 15 L flow
D) Insertion of chest tube
Ans: B
Feedback:
To maintain airway, an endotracheal tube or tracheostomy tube will be inserted for
administration of mechanical ventilation. Mechanical ventilation uses positive
end-expiratory pressure (PEEP), not IPPB. Because the lungs are not collapsed, a chest
tube is not indicated for reinflation. Increasing the oxygen flow rate via mask does not
maintain patency of the airway and can place the client at risk for ocular damage.
27. The nurse knows the mortality rate is high in lung cancer clients due to which factor?
A) Increase in women smokers
B) Increased incidence among the elderly
C) Increased exposure to industrial pollutants
D) Few early symptoms
Ans: D
Feedback:
Because lung cancer produces few early symptoms, its mortality rate is high. Lung
cancer has increased in incidence due to increase in number of women smokers,
growing aging population, and exposure to pollutants but not indicative of mortality
rates.
28. A client is brought to the emergency department following a motor vehicle accident.
Which of the following nursing assessment is significant in diagnosing this client with
flail chest?
A) Respiratory acidosis
B) Paradoxical chest movement
C) Chest pain on inspiration
D) Clubbing of fingers and toes
Ans: B
Feedback:
Flail chest occurs when two or more adjacent ribs fracture and results in impairment of
chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur
with flail chest but is not as significant in the diagnosis as paradoxical chest movement.
Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
Page 10
29. A client is admitted to the emergency department with a stab wound and is now
presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration.
The nurse should care for the wound in which manner?
A) Clean the wound and leave open to the air.
B) Apply vented dressing.
C) Apply airtight dressing.
D) Apply direct pressure to the wound.
Ans: C
Feedback:
The client has developed a pneumothorax, and the best action is to prevent further
deflation of the affected lung by placing an airtight dressing over the wound. A vented
dressing would be used in a tension pneumothorax, but because air is heard moving in
and out, a tension pneumothorax is not indicated. Applying direct pressure is required if
active bleeding is noted.
30. The client asks the nurse to explain the reason for a chest tube insertion in treating a
pneumothorax. Which is the best response by the nurse?
A) “Chest tube will allow air to be restored to the lung.”
B) “The tube will drain secretions from the lung.”
C) “Chest tubes provide a route for medication instillation to the lung.”
D) “The tube will drain air from the space around the lung.”
Ans: D
Feedback:
Negative pressure must be maintained in the pleural cavity for the lungs to be inflated.
An injury that allows air into the pleural space will result in a collapse of the lung. The
chest tube can be used to drain fluid and blood from the pleural cavity and to instill
medication, such as talc, to the cavity.
31. The nurse is caring for a client with a closed chest drainage system. While repositioning
the client, the chest tube dislodges. What is the immediate nursing intervention?
A) Reinsert the chest tube.
B) Notify the physician.
C) Cover the exit site.
D) Apply oxygen via face mask.
Ans: C
Feedback:
Air entering the cavity will allow further collapse of the lung. Applying a dressing or
covering the site will minimize the amount of air entering the cavity. The nurse would
notify the physician for reinsertion of the tube but not the immediate action to take.
Applying oxygen may be necessary to eliminate symptoms of hypoxia after wound is
sealed.
Page 11
32. Which nursing assessment would alert a nurse to the development of a mediastinal shift,
in a client with tension pneumothorax?
A) Fluctuation of the fluid in the water-seal chamber
B) Shift of rib cage toward affected side
C) Sucking sound heard on inspiration and expiration
D) Shift of trachea, esophagus, heart, and great vessels
Ans: D
Feedback:
In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape.
The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward
the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected
finding. There may be a paradoxical movement of the ribs but not a shifting to the side.
A sucking sound may be heard with a pneumothorax, but air moves in and cannot
escape out.
33. When the nurse monitors the water-sealed drainage system, which finding suggests the
system is working properly?
A) Fluid rises and falls with respirations.
B) Level of fluid is lowered in suction chamber.
C) Fluid is bubbling vigorously.
D) Fluid appears white and frothy.
Ans: A
Feedback:
Fluctuation of fluid in the water-sealed chamber is initially present with each
respiration. The level of fluid in the suction chamber should be maintained to initial
level. Excessive or vigorous bubbling can indicate a leak in the system. The fluid in the
chamber is clear.
34. While caring for a client with a chest tube, which nursing assessment would alert the
nurse to a possible complication?
A) Skin around tube is pink.
B) Bloody drainage is seemed in the collection chamber.
C) Absence of bloody drainage in the anterior/upper tube
D) Crackling is heard when skin around tube is touched.
Ans: D
Feedback:
Subcutaneous emphysema is the result of air leaking between the subcutaneous layers
not serious complication but is notable and reportable. Pink skin and blood in the
collection chamber are normal findings. When two tubes are inserted, the posterior or
lower tube drains fluid, whereas the anterior or upper tube is for air removal.
Page 12
35. When managing the postoperative pain after a pneumonectomy, the nurse is most
concerned about which assessment data?
A) Blood pressure 100/60 mm Hg
B) Temperature 97.8° F
C) Heart rate 100 beats/minute
D) Respirations 10 breaths/minute
Ans: D
Feedback:
The use of narcotics can further depress respirations. Respirations below 10
breaths/minute should be reported immediately to the physician, and the nurse would
hold the medication for pain. Blood loss during surgery can result in symptoms of
tachycardia and lower blood pressure, but these findings are not outside the range of
what is expected outcome. A lower body temperature may be a result of anesthesia and
environmental factors from the operating suite and are not outside the expected norm for
this situation.
Page 13
1. Chapter 22
You are caring for a client with right-sided heart failure. When assessing the respiratory
rate of this client, what is an indication that the client is having difficulty breathing?
A) Not using the abdominal muscles during breathing
B) Using accessory muscles during respiration
C) Barely palpable, thready pulse volume
D) Combination of noisy and quiet respiration
Ans: B
Feedback:
When assessing the respiratory rate of a client with a cardiovascular disorder, the nurse
observes the character of the respirations, noting whether the client's breathing is easy,
labored, or dyspneic; deep or shallow; and noisy or quiet. The use of accessory muscles
such as neck or abdominal muscles during respiration is an indication that the client is
having difficulty breathing. Pulse volume is described as feeling full, weak, or thready,
meaning barely palpable.
2. You are teaching a group of nursing students about adventitious heart sounds. You
explain that auscultation of the heart requires familiarization with normal and abnormal
heart sounds. What would you tell these students a ventricular gallop indicates in an
adult?
A) Heart failure
B) Hypertensive heart disease
C) Normal functioning
D) Pericarditis
Ans: A
Feedback:
A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3,
normal in children, often is an indication of heart failure in an adult. An extra sound
before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with
hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound
that is an indication of pericarditis or inflammation of the pericardium.
Page 1
3. One of your students asks what the consequences of uncorrected, left-sided heart failure
would be. What would be your best response?
A) Distention of the jugular vein
B) Effort to lie down to breathe
C) Right-sided heart failure
D) Blood congestion in neck veins
Ans: C
Feedback:
If uncorrected, left-sided heart failure is followed by right-sided heart failure because
the circulatory system is a continuous loop. With left-sided congestive heart failure,
auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are
accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart
fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may
inspect the distention of external jugular vein.
4. A student nurse is caring for a client with suspected cardiovascular disease. The nursing
instructor asks the student what side effects a client may experience when undergoing a
magnetic resonance imaging (MRI) test. What should the student respond?
A) Swollen feet
B) Sweating
C) Rapid heart rate
D) Sluggishness
Ans: C
Feedback:
Side effects that a client may experience when undergoing an MRI test include chest
pressure, rapid heart rate, and hypotension. Swollen feet, sweating, and sluggishness are
not the side effects of an MRI test.
5. The nurse notes that the client has had a change in mental status. Why would it be
important for the nurse to report extremes in the thought process of a client with
cardiovascular disorder to the physician?
A) It is an indication of an impending heart failure.
B) The client may develop anxiety disorder.
C) It may indicate a problem with oxygenation.
D) It creates anxiety during the diagnostic testing.
Ans: C
Feedback:
The nurse should report extremes in thought processes to the physician because such
effects may interfere with the client's safety and prescribed therapy. Chest pain and
impaired breathing may create anxiety. Extremes of emotions or disturbances in thought
processes are not the indications of an impending heart failure. The client will not
develop any anxiety disorder.
Page 2
6. You are caring for a client with a damaged tricuspid valve. You know that the tricuspid
valve is held in place by which of the following?
A) Chordae tendineae
B) Atrioventricular tendons
C) Semilunar tendineae
D) Papillary tendons
Ans: A
Feedback:
Attached to the mitral and tricuspid valves are cordlike structures known as chordae
tendineae, which in turn attach to papillary muscles, two major muscular projections
from the ventricles. Options B, C, and D are distractors for the question.
7. You are discharging a client after a cardiac catheterization. What would you include in
your discharge teaching?
A) Eat only soft foods for the next 12 hours.
B) Report any numbness, tingling, or sharp pain in the extremity.
C) Restrict your intake of water until the dye is out of your system.
D) You can move around whenever you feel like getting up.
Ans: B
Feedback:
Instructions for the client and family include the following: Keep the extremity straight
for several hours and avoid movement; report any warm, wet feeling that may indicate
oozing blood, numbness, tingling, or sharp pain in the extremity; and drink a large
volume of fluid to relieve thirst and promote the excretion of the dye. There is no need
to eat only soft foods after a cardiac catheterization.
8. The nurse caring for a client who is suspected of having cardiovascular disease has a
stress test ordered. The client has a comorbidity of multiple sclerosis, so the nurse
knows the stress test will be drug induced. What drug will be used to dilate the coronary
arteries?
A) Thallium
B) Ativan
C) Diazepam
D) Dobutrex
Ans: D
Feedback:
Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine
(Dobutrex) may be administered singularly or in combination by the IV route. The drugs
dilate the coronary arteries, similar to the vasodilation that occurs when a person
exercises to increase the heart muscle's blood supply. Options A, B, and C would not
dilate the coronary arteries.
Page 3
9. Your client is being prepared for echocardiography when he asks you why he needs to
have this test. What would be your best response?
A) “This test will find any congenital heart defects.”
B) “This test can tell us a lot about your heart.”
C) “Echocardiography is a way of determining the functioning of the left ventricle of
your heart.”
D) “Echocardiography will tell your doctor if you have cancer of the heart.”
Ans: C
Feedback:
Echocardiography uses ultrasound waves to determine the functioning of the left
ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue
layers of the heart. All answers are correct. Option C is the best answer because it
addresses the client's question without making him anxious or minimizing the question.
10. A patient needs additional information about her heart condition. The patient states to
the nurse, “What is considered the pacemaker of the heart?”
A) The AV node
B) The bundle of HIS
C) The Purkinje fibers
D) The SA node
Ans: D
Feedback:
The SA node is called the pacemaker of the heart because it initiates the electrical
impulses that cause the atria and ventricles to contract. Normally, it produces between
60 and 100 impulses per minute; the average is approximately 72 impulses per minute.
Therefore, options A, B, and C are incorrect.
11. The healthcare team is caring for a client with early atherosclerotic changes within the
blood vessels. The physician orders diagnostic testing, and the nurse provides
cardiovascular teaching. Which primary goal is the healthcare team working toward?
A) Preserving the natural heart by avoiding further heart disease
B) Preventing age-related changes which could jeopardize health
C) Monitoring cardiovascular status and current health needs
D) Increasing client knowledge base for independent care
Ans: A, C
Feedback:
A primary focus of the health team is to care for and educate the client to maintain
current status, or improve if possible, or to avoid further disease. In addition, monitoring
status is proactive to make lifestyle changes to abort the progression of atherosclerotic
changes. Age-related changes are difficult to avoid because the changes are a part of the
natural aging process. Increasing the knowledge base is helpful, but a higher priority
and goal is preserving the heart function.
Page 4
12. The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion.
Which area of the heart would the nurse anticipate being compromised?
A) Right atrium
B) Pulmonary artery
C) Right ventricle
D) Aorta
Ans: C
Feedback:
There are four chambers to the heart. The right and left ventricles is the heart's major
pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The
left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are
not of the heart.
13. The nurse is assessing the cardiovascular status of a client who was found unresponsive
in a lobby area. Following transfer of the client, the family asks how blood circulates
through the body. The nurse is most correct to state the proper circulation as which?
Place the pattern of circulation in the correct order beginning in the right atrium. Use all
options.
A) Pulmonary vein
B) Right ventricle
C) Left ventricle
D) Pulmonary artery
E) Left atrium
F)
Aorta
Ans: A, B, C, D, E, F
Feedback:
The pathway of blood flow from the right atrium includes the right ventricle. The blood
flows to the lungs via the pulmonary artery and returns to the heart in an oxygenated
state via the pulmonary vein. The oxygenated blood then enters the left atrium then left
ventricle pump through the aorta to the systemic circulation.
14. The nurse is explaining the three layers of tissue which make up the heart wall. As the
nurse draws the layers in different colors to highlight the layers, which color would the
nurse use for the heart valves?
A) Blue, the same color as the pericardium
B) Green, a mix of the pericardium and myocardium
C) Purple, the same color as the myocardium
D) Orange, the same color as the endocardium
Ans: D
Feedback:
Folds of the endocardium, the innermost layer, form the heart valves. Pericardial tissue
is the outer layer. Myocardial tissue is the middle layer muscle tissue.
Page 5
15. The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth
intercostal space and lateral to the sternum. At which cardiac valve would the nurse
document this murmur?
A) Mitral valve
B) Tricuspid valve
C) Aortic valve
D) Pulmonic valve
Ans: B
Feedback:
The tricuspid valve is at the left fourth intercostal space and lateral to the sternum. The
mitral valve is heard at the left fifth intercostal space and midclavicular line. The aortic
valve is heard at the right second intercostal space, lateral to the sternum. The pulmonic
valve is left second intercostal space, lateral to the sternum.
16. The nurse is assessing a client who has dyspnea and considering the process of gas
exchange. Which structural characteristic of capillaries best enables gas exchange at the
cellular level?
A) Capillaries are one cell–layer thick.
B) Capillaries form a complex network.
C) Capillaries transport blood back to the heart.
D) Capillaries are elastic structures.
Ans: A
Feedback:
Capillaries are one cell–layer thick and in direct contact with the cells of all tissues. This
allows easy of gas exchange. Capillaries do form a complex network; however, it is the
one cell structure that facilitates gas exchange. Venules and veins transport blood back
to the heart. Arteries are elastic.
17. The nurse is reviewing lab work for a client whose blood CO2 level is elevated. The
nurse is most correct to suspect an impairment of which?
A) Alveoli
B) Bronchi
C) The pulmonary artery
D) The pulmonary vein
Ans: A
Feedback:
Gas exchange occurs in the lung where oxygen in inspired air exchanges for CO2 in the
venous blood. The CO2 is then transferred to the alveoli to be exhaled. No gas exchange
occurs in the bronchi. The pulmonary artery carries deoxygenated blood to the lungs,
and the pulmonary vein brings oxygenated blood back to the heart to be pumped to the
tissues.
Page 6
18. The nurse is caring for a client who is diagnosed with an infarction of the posterior wall
of the right atrium. Which assessment finding would the nurse anticipate relating to the
infarction location?
A) Respiratory compromise
B) Chronic chest pain
C) Irregular heart rate
D) Cyanosis
Ans: C
Feedback:
The posterior wall of the right atrium is the location of the sinoatrial node (SA node),
which is the pacemaker of the heart. Damage to this location may result in an irregular
heart rate due to a disturbance of electrical pulse initiation. Depending on muscle
damage, the client may have respiratory compromise, chest pain, and/or cyanosis.
19. A client is experiencing an irregular heartbeat. The client asks the nurse how a heartbeat
occurs. The nurse explains the conduction system of the heart beginning with the
sinoatrial node (SA node). Place the conduction sequence of the heart in order beginning
with the SA node. Use all options.
A) Purkinje fibers
B) AV node
C) Atrial cell stimulation
D) Bundle of His
E) Bundle branches
Ans: A, B, C, D, E
Feedback:
In the normal sequence, the impulse starts in the SA node. The waves of stimulation
spread through the atria to the AV node. The impulse then travels from the AV node to
the bundle of His, then to the right and left bundle branches, and eventually to the
Purkinje fibers.
20. When caring for a client with dysfunction in the conduction system, at which period
would the nurse note that cells are resistant to stimulation?
A) During polarization
B) During depolarization
C) During repolarization
D) During the refractory period
Ans: D
Feedback:
The refractory period is the time when cells are resistant to electrical stimulation.
Repolarization is when the ions realign themselves to wait for an electrical signal.
Depolarization occurs during muscle contraction when positive ions move inside the
myocardial cell membrane and negative ions move outside. Before an impulse is
generated, the cells are in a polarized state.
Page 7
21. The nurse is caring for a client with an elevated blood pressure and no previous history
of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood
pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood
pressure to which structure?
A) Chemoreceptors
B) Sympathetic nerve fibers
C) Baroreceptors
D) Vagus nerve
Ans: C
Feedback:
Baroreceptor sense pressure in nerve endings in the walls of the atria and major blood
vessels. The baroreceptors respond accordingly to raise or lower the pressure.
Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers
increase the heart rate. The vagus nerve slows the heart rate.
22. Which of the following suggestions can the nurse provide to a client to reduce
sarcopenia?
A) Maintain hydration.
B) Eat green, leafy vegetables.
C) Increase vitamin C.
D) Increase exercise.
Ans: D
Feedback:
Sarcopenia refers to changes in composition of muscle tissue that can occur in aging as
a result of deconditioning. Increasing exercise helps to improve muscle strength,
including the heart. The other options directly improve muscle strength.
23. A nurse is caring for a dying client following myocardial infarction. The client is
experiencing apnea with a falling blood pressure of 60 per palpation. Which
documentation of pulse quality does the nurse anticipate?
A) Bounding pulse
B) Weak pulse
C) Thready pulse
D) A pulse deficit
Ans: C
Feedback:
The nurse is most correct to anticipate a thready (barely palpable) pulse quality. A
bounding pulse indicates a strong cardiac output. A weak pulse indicates a lower pulse
quality. A pulse deficit occurs when the pulses between the apex of the heart differs
from the radial pulse.
Page 8
24. The nurse is providing discharge instructions to a client with unstable angina. The client
is ordered Nitrostat 1/150 every 5 minutes as needed for angina. Which side effect,
emphasized by the nurse, is common especially with the increased dosage?
A) Rash
B) Nausea
C) Dry mouth
D) Orthostatic hypotension
Ans: D
Feedback:
A common side effect of Nitrostat, especially at higher dosages, is orthostatic
hypotension. The action of the medication is to dilate the blood vessels to improve
circulation to the heart. The side effect of the medication is orthostatic hypotension. A
rash, nausea, and dry mouth are not common side effects.
25. The nurse is caring for a client on a monitored telemetry unit. During morning
assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which
action would the nurse do first?
A) Call the physician with a report.
B) Assess the client.
C) Assess for mechanical dysfunction.
D) Reposition the client.
Ans: B
Feedback:
When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to
assess the client. After client assessment, the nurse is able to make an informed decision
on the next nursing action.
26. The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets
0.125 mg daily for a cardiac dysrhythmias. Which of the following assessment
considerations is essential when caring for this age-group?
A) Digoxin level
B) Cardiac output
C) Activity level
D) Dyspnea
Ans: A
Feedback:
The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate
is essential prior to administration in all clients. Due to decreased perfusion common in
geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels
in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea
are also important assessment considerations for all clients.
Page 9
27. The critical care nurse is caring for clients in an emergency department. When caring
for a variety of clients, when is the presence of a third heart sound normal?
A) In clients with heart valve replacement
B) In geriatric clients
C) In clients with an indwelling pacemaker
D) In pediatric clients
Ans: D
Feedback:
When caring for a variety of clients, it is important to consider that a third heart sound is
normal in children. In adults, a third heart sound may signify heart failure. There is no
correlation between third heart sounds with heart valve replacement and an indwelling
pacemaker.
28. The nurse is assessing an African American client for signs of cyanosis. Which
assessment finding is documented as cyanosis?
A) A grayish cast to the skin
B) A bluish tinge to the hands and feet
C) Paleness of the internal lid of the eye
D) Bluish tinged to the nail beds
Ans: A
Feedback:
In dark-skinned clients, a grayish cast to the skin indicates cyanosis. A bluish tinged to
the hands and feet as well as nail beds is a sign of cyanosis in light-skinned clients
where the blue tinge can be noted. Paleness of the internal eye lid is consistent with
anemia.
29. The nurse is assessing the client newly prescribed Lasix 20 mg daily for 3+ pitting
edema. To evaluate the effectiveness of diuretic therapy, which of the following would
be documented?
A) Weight
B) Blood pressure
C) Edema
D) Urine output
Ans: C
Feedback:
The best method to evaluate the effectiveness of diuretic therapy is to note a decrease in
edema. Weight, blood pressure, and urine output all are affected by diuretic therapy, but
the therapeutic goal is to decrease the edema.
Page 10
30. The nurse is caring for an elderly client with left-sided heart failure. When auscultating
lung sounds, which adventitious sound is expected?
A) Wheezes
B) Rhonchi
C) Crackles
D) Coarseness
Ans: C
Feedback:
When the heart is pumping inefficiently, blood backs up into the pulmonary veins and
lung tissue. Auscultation reveals a crackling sound. Possible wheezes and gurgles are
also possibilities.
31. The nurse is caring for a client on the cardiac unit. Which change of condition may
indicate potential increasing of right-side heart failure? Select all that apply.
A) Edema changed from a 3+ to a 1+
B) Jugular vein distention
C) Increased dyspnea
D) One-pound weight loss
E) Increased palpitations
F)
Increased weakness on ambulation
Ans: B, C, E, F
Feedback:
A change in assessment finding may indicate an increase in heart failure. Right-sided
heart failure symptoms include jugular vein distention, increased dyspnea, increased
palpitations, and an increased weakness on ambulation. Edema is a common sign of
right-sided heart failure, but changing from a 3+ to 1+ is improvement in condition.
Weight loss is also improvement in condition.
32. The nurse is caring for a client with ECG changes consistent with a myocardial
infarction. Which of the following diagnostic test does the nurse anticipate to confirm
heart damage?
A) Fluoroscopy
B) Nuclear cardiology
C) Serum blood work
D) Chest radiography
Ans: B
Feedback:
Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest
radiography and fluoroscopy determine the size and position of the heart and condition
of the lungs. Serum blood work notes elevations in enzymes suggesting muscle damage.
Page 11
33. The nurse is caring for a client anticipating further testing related to cardiac blood flow.
Which statement, made by the client, would lead the nurse to provide additional
teaching?
A) “The first test I am getting is an echocardiography. I am glad that it is not
painful.”
B) “My niece thought that I would be ordered a magnetic resonance imaging even
though I have a pacemaker.”
C) “I had an ECG already. It provided information on my heart rhythm.”
D) “I am able to have a nuclide study because I do not have any allergies.”
Ans: B
Feedback:
A magnetic resonance imaging (MRI) test is prohibited on clients with various metal
devices within their body. External metal objects must be removed. All other options are
correct statements not needing clarification.
34. The following clients are in need of exercise electrocardiography. Which client would
the nurse indicate as most appropriate for a drug-induced stress test?
A) A 48-year-old policemen with history of knee replacement 4 years ago
B) A 68-year-old housewife with history of osteoporosis
C) A 72-year-old retired janitor obtaining a cardiac baseline
D) A 55-year-old recovering from a fall and broken femur
Ans: D
Feedback:
An exercise electrocardiography or stress test monitors the electrical activity of the heart
while the client walks on a treadmill. If a client has a sedentary lifestyle or physical
disability, cardiac medications may be administered to stress the heart similar to
activity. Even though the client is middle aged at 55 years old, the client is recovering
from a broken femur thus would be unable to have vigorous exercise. None of the other
clients have a history which precludes them from exercise electrocardiography.
35. The nurse is caring for a post–cardiac catheterization client in the recovery room. Which
of the following is a priority nursing consideration?
A) Dressing assessment
B) Monitor temperature
C) Encourage fluids
D) Supine positioning
Ans: A
Feedback:
Following cardiac catheterization, the client has a pressure dressing over the catheter
site. The nurse's priority is to monitor the site for bleeding. The client is instructed to
report any warm, wet feeling that may indicate bleeding. The other options are also
completed in the recovery room and the nursing unit.
Page 12
1. Chapter 23
The nurse is performing client teaching with a client who has just been diagnosed with
cardiomyopathy. What instructions should the nurse provide a client with
cardiomyopathy to avoid pulmonary complications that may compromise
cardiopulmonary function?
A) Stay within the level of exercise tolerance.
B) Receive yearly vaccinations.
C) Eat a diet high in sodium.
D) Keep appointments for medical follow-up.
Ans: B
Feedback:
The nurse should instruct the client to receive the pneumonia vaccine and yearly
influenza vaccinations to avoid pulmonary complications that may compromise
cardiopulmonary function. Staying within the level of exercise tolerance does not help to
avoid pulmonary complications. Eating a diet high in sodium causes water retention and
therefore makes the client at risk for pulmonary edema, pneumonia, etc. The client
should keep appointments for medical follow-up to evaluate the status of the disease and
symptom control.
2. The instructor is talking with a nursing student who is caring for a client with
pericarditis. The instructor asks the student to name the main characteristic of
pericarditis. What should be the student's answer?
A) Precordial pain
B) Dyspnea
C) Fever
D) Respiratory symptoms
Ans: A
Feedback:
Precordial pain is the main characteristic of pericarditis. Dyspnea, fever, and respiratory
symptoms are not the main characteristics of pericarditis.
3. The nurse is instructing a new graduate nurse. Together, they are caring for a client with
infective endocarditis. What is a sign of infective endocarditis?
A) Homan's sign
B) Splinter hemorrhage
C) Precordial pain
D) Heart murmur
Ans: B
Feedback:
Splinter hemorrhage, black longitudinal lines, can be seen in the nails of the clients with
endocarditis. Homan's sign is found in the clients with thrombophlebitis. A heart
murmur is the first abnormal sign detected in clients with cardiomyopathy. Precordial
pain is the main characteristic of pericarditis.
Page 1
4. A young mother brings her 4-year-old in to the pediatric clinic with a mild fever and a
red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm
is abnormal. The mother states the child has been healthy until about 3 weeks ago when
the child had a sore throat. You suspect rheumatic carditis. What organism causes
rheumatic carditis?
A) Group A beta-hemolytic strep
B) Staphylococcus aureus
C) Streptococcus viridians
D) Epstein-Barr virus
Ans: A
Feedback:
The inflammatory symptoms of rheumatic carditis are believed to be induced by
antibodies originally formed to destroy the group A beta-hemolytic streptococcal
microorganisms. Staphylococcus aureus and Streptococcus viridians are associated with
infectious endocarditis. The Epstein-Barr virus is associated with myocarditis.
5. You are caring for a client with thrombophlebitis. When assessing this client, what
would be most important to assess for?
A) Chest pain and dyspnea
B) Leg pain and swollen calf
C) Mottled coloring of leg and foot
D) Capillary refill of extremity
Ans: A
Feedback:
Consult with the client about chest pain and dyspnea, which are hallmarks of PE, a
complication of thrombophlebitis. All answers are correct, however, assessing for chest
pain and dyspnea, signs of a PE, would be most important.
6. The nurse is caring for a client with infective endocarditis. The nurse teaches the client
that he will have to take antibiotics periodically for the rest of the client's life. The client
wants to know why. What would be the nurse's best answer to the client?
A) “Just to be on the safe side.”
B) “You will be vulnerable to infective endocarditis for the rest of your life.”
C) “Your heart has been weakened, and it will need extra help so you can live a long
life.”
D) “You will be susceptible to infections from all kinds of germs now.”
Ans: B
Feedback:
The nurse informs clients that periodic antibiotic therapy is a lifelong necessity because
they will be vulnerable to the disease for the rest of their lives. Options A, C, and D are
incorrect. Option A minimizes the client's question and does not answer the question.
Options C and D are partially correct but are not the best answer.
Page 2
7. Which type of cardiomyopathy is associated with syncope?
A) Restrictive
B) Dilated
C) Arrhythmic
D) Hypertrophic
Ans: D
Feedback:
Hypertrophic cardiomyopathy is associated with syncope (sudden loss of consciousness)
or near-syncopal episodes, which the client may describe as “graying out”. Dilated
cardiomyopathy, the most common type, is accompanied by dyspnea on exertion and
when lying down. Restrictive cardiomyopathy has symptoms of exertional dyspnea,
dependent edema in the legs, ascites (fluid in the abdomen), and hepatomegaly
(enlarged liver). Arrhythmic cardiomyopathy is inherited.
8. You are caring for a client who is scheduled for a sympathectomy. In what disease
process would a sympathectomy be performed to relieve vasospasm?
A) Thromboangiitis obliterans
B) Restrictive cardiomyopathy
C) Rheumatic carditis
D) Thrombophlebitis
Ans: A
Feedback:
Sympathectomy, the surgical interruption or suppression of some portion of the
sympathetic nerve pathway, is performed to relieve vasospasm. None of the other
answers would require a sympathectomy to relieve vasospasm.
9. The nursing instructor is teaching a class on thrombophlebitis. What should the nurse
tell the students about the inflammatory response in thrombophlebitis?
A) The inflammatory response is caused by the irritation of the clot.
B) The inflammatory response is caused by accumulated waste products in the
blocked vessel.
C) The inflammatory response is caused by an excess for fibrin in the blocked vessel.
D) The inflammatory response is caused by the irritation of blood trying to flow
through the vessel.
Ans: B
Feedback:
Accumulated waste products in the blocked vessel irritate the vein wall, initiating an
inflammatory response. Options A, C, and D are incorrect because they do not cause the
inflammatory response in thrombophlebitis.
Page 3
10. You are caring for a client with Buerger's disease. You know that most of the care for
this disease is carried out at home. What would be important to teach a client with
Buerger's disease?
A) The need for adhering to the correct diet
B) The importance of joining a support group
C) The need to cooperate with the home health nurse
D) The importance of smoking cessation
Ans: D
Feedback:
The nurse teaches the client self-care techniques and stresses the importance of smoking
cessation and performing prescribed exercises consistently. Options A, B, and C are
incorrect. Eating a healthy diet, joining a support group, or cooperating with a home
health nurse might be important to teach some clients. However, smoking cessation is
very important to a client with Buerger's disease.
11. The nurse is caring for a pediatric client diagnosed with rheumatic carditis. The parents
ask what is causing the inflammation. The nurse is correct to answer which of the
following?
A) “The inflammation is attributed to the group A beta-hemolytic streptococcal
microorganism.”
B) “The inflammation is from the antibodies formed to destroy the streptococcal
microorganism.”
C) “The inflammation is from the systematic infection.”
D) “The inflammation is from the structural damage.”
Ans: B
Feedback:
The inflammatory symptoms of rheumatic carditis are believed to be induced by
antibodies originally formed to destroy the group A beta-hemolytic streptococcal
microorganism. It is not the microorganism or infection that causes the inflammation. It
is not structural damage that causes inflammation.
Page 4
12. The nurse is obtaining a history from a client brought to the emergency department
following a motor vehicle accident. The client states having a history of rheumatic heart
disease as a child. Which long-standing changes of rheumatic heart disease are
evaluated for?
A) Valvular changes
B) Dysrhythmias
C) Heart failure
D) Pulmonary hypertension
Ans: A
Feedback:
After the acute episode of rheumatic fever, many of the symptoms cease and the client
recovers, but valvular changes remain. Dysrhythmias occur in the acute period and may
lead to heart failure. Pulmonary hypertension is not noted during this time.
13. The school nurse is providing care to a child with a sore throat. With any sign of throat
infection, the nurse stresses which of the following?
A) Warm, salt water gargling
B) Fluid increase to 2500 cc
C) Obtaining a throat culture
D) Administering antiseptic lozenges
Ans: C
Feedback:
When a child has a sore throat and symptoms of a possible infection occur, it is essential
that a culture is obtained. A culture can identify group A beta-hemolytic streptococcal
infection, which needs to be eliminated with use of an antibiotic. Warm, salt gargles;
increasing fluids; and administering antiseptic lozenges are helpful for symptom control.
Obtaining a throat culture is a priority.
14. The nurse is reviewing the results of a client's diagnostic test indicating a positive strep
culture. Which prescription medication does the nurse anticipate?
A) Prednisone
B) Amoxicillin
C) Acetaminophen
D) Xanax
Ans: B
Feedback:
The prescription medication anticipated as it is the drug of choice is a penicillin drug
such as amoxicillin. Prednisone is a corticosteroid and not typically prescribed.
Acetaminophen is used for pain relief but not a prescription medication. Xanax is an
antianxiety medication and not typically prescribed for a positive strep culture.
Page 5
15. When caring for an adolescent client recovering from rheumatic fever, which
diversional activity would the nurse advise against?
A) Video games
B) Exercise
C) Listening to music
D) Having friends over
Ans: B
Feedback:
When advising proper diversional activity, activities suggested would be those which
require minimal activity to reduce the work of the myocardium. Exercise, a popular
activity of adolescents, would be too much activity in the recovery process. All the other
activities would be acceptable.
16. The nurse is reviewing the lab work of a client diagnosed with infective endocarditis.
Which diagnostic study confirms the diagnosis?
A) Complete blood count
B) Positive blood culture
C) Serum cardiac antigens
D) Immunosuppressant assay
Ans: B
Feedback:
A positive blood culture identifies the microorganism circulating in the blood. Slight
leukocytosis is common but can be associated with other disease processes. Serum
cardiac antigens and immunosuppressant assay are not typical diagnostic studies.
17. The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood
culture results. The client asks, “Where did I pick up these bacteria?” The nurse is most
safe to speculate which of the following?
A) From droplets from a cough
B) From the fecal–oral route
C) From ingestion of a food
D) From a break in the skin
Ans: D
Feedback:
The microorganisms that cause infective endocarditis include bacteria and fungi.
Streptococci and staphylococci are the bacteria most frequently responsible for this
disorder. Both bacteria are abundantly found on the skin. These organisms are not found
in the other locations.
Page 6
18. The nurse is planning care for a client with history of rheumatic carditis. Which nursing
intervention would be most helpful in preventing further complications?
A) Assess temperature, pulse, respirations, and blood pressure every 4 hours.
B) Use clean technique or sterile technique, when applicable, for any invasive
procedure.
C) Instruct on adequate rest, at least 8 hours, per day.
D) Encourage a diet of lean meat and fish in a weekly meal plan.
Ans: B
Feedback:
A nurse considers that clients with a history of rheumatic carditis may be at risk for
further complications. Considering care (clean or sterile) during invasive procedures
reduces the portals of entry for causative microorganisms. This is most helpful in
preventing further complications. All other options are appropriate interventions when
considering standards of care.
19. The nurse is caring for a client with cardiac compromise related to mitral valve
impairment. Which outcome of the eroding of the mitral valve is most significant?
A) Presence of a heart murmur
B) Heart failure
C) Activity intolerance
D) Pulmonary congestion
Ans: B
Feedback:
The most significant outcome of the eroding of the mitral valve is heart failure. Blood
leaking between the heart chambers diminishes the hearts ability to circulate blood
efficiently. Eventually, the heart cannot keep up with the body's metabolic need, and
heart failure occurs.
20. The nurse is documenting assessment findings as a client is being admitted to a medical
unit. Which of the following conditions, present with a diagnosis of infectious
endocarditis, is correct to be documented as petechiae?
A) Purplish, painful nodules
B) Black longitudinal lines in the nails
C) White areas in the retina surrounded by areas of hemorrhage
D) Reddish hemorrhagic spots on the skin
Ans: D
Feedback:
Petechiae is documented when tiny, pinpoint, reddish hemorrhagic spots on the skin and
mucous membranes are noted. Purplish, painful nodules are Osler nodes. Black
longitudinal lines in the nails are splinter hemorrhages. White areas in the retina
surrounded by areas of hemorrhage are Roth's spots.
Page 7
21. Which would the nurse stress as a lifelong necessity for a client managing infectious
endocarditis?
A) Antibiotic therapy
B) Antihypertensive medication
C) Exercise regimen
D) Potassium replacement
Ans: A
Feedback:
The nurse informs the client that periodic antibiotic therapy is a lifelong necessity
because the client will be vulnerable to diseases for the rest of his life. Antihypertensive
therapy is not always prescribed. Limited activity is stressed. Potassium replacement is
typical when combined with diuretic therapy.
22. The nurse is working on a telemetry unit at a local hospital. The nurse obtains report on
a client with symptoms of sharp chest pain and tachycardia. The nurse begins to collect
and critical think through assessment data. Which client symptom distinguishes between
a myocardial infarction and myocarditis?
A) Pulse deficit
B) White frothy sputum
C) +3 Peripheral edema
D) Relief of pain when sitting up
Ans: D
Feedback:
Clients may complain of sharp, stabbing discomfort that resembles a myocardial
infarction; however, sitting up relieves the pain. There is no correlation between white
frothy sputum, peripheral edema, or a pulse deficit and the disease processes.
23. The nurse is caring for a client newly diagnosed with myocarditis. Which diagnostic test
would the nurse find most helpful in confirming the diagnosis?
A) Echocardiography
B) Cardiac isoenzyme level
C) Myocardial biopsy
D) Radionuclide study
Ans: C
Feedback:
When choosing a definitive diagnostic test for myocarditis, a myocardial biopsy is most
helpful. All of the other diagnostic tests provide information about the heart but is not as
definitive as actually testing the heart muscle.
Page 8
24. The nurse is caring for a client with manifestations of dilated cardiomyopathy. When
planning care, which consideration would the nurse make?
A) Place bed in a high or semi-high Fowler's position as needed.
B) Assist client to bathroom every 2 hours.
C) Instruct client to avoid strenuous activity.
D) Assess abdominal girth daily.
Ans: A
Feedback:
Dilated cardiomyopathy has clinical manifestations of dyspnea on exertion and when
lying down. Depending on level of dyspnea, placing the client in an upright Fowler's
position is helpful. Clients with hypertrophic cardiomyopathy have syncopal episodes
and can collapse following strenuous activity. Assistance with ambulation to avoid falls
is helpful. Restrictive cardiomyopathy includes manifestations of ascites and assessment
of abdominal girth.
25. Which common assessment question does the nurse use when admitting all clients that
helps to screen for cardiomyopathy?
A) What brought you to the emergency department today?
B) Have you ever had a close family member die unexpectedly?
C) When was the last time you had any nausea or heartburn?
D) Did you have any common childhood diseases?
Ans: B
Feedback:
Having a client's close family member die unexpectedly can indicate cardiomyopathy.
Many individuals with cardiomyopathy are asymptomatic with the disorder not
discovered until the affected person becomes acutely ill or dies.
26. The nurse is caring for a five-client assignment on a cardiac unit. In caring for which
client would the nurse be most correct to assess for an effusion?
A) A client with chest pain
B) A client with chest trauma
C) A client with aortic stenosis
D) A client with mitral valve prolapse
Ans: B
Feedback:
An effusion, which is the accumulation of fluid between two layers of tissue, commonly
occurs with pericarditis, which is the inflammation of the pericardium. Common causes
of pericarditis include endocarditis, myocarditis, chest trauma, post heart surgery, or a
myocardial infarction. Clients with chest pain, aortic stenosis, and mitral valve prolapse
have conditions without current inflammation.
Page 9
27. The nurse is caring for clients on a busy cardiac unit. Following morning assessment,
the nurse would notify the physician with which of the following symptoms?
A) Dyspnea when ambulating from the bathroom
B) A noted irregular pulse rate prior to Lanoxin (digoxin) administration
C) Cyanosis with a pulse oximetry level of 92%
D) Pulsus paradoxus on vital sign assessment
Ans: D
Feedback:
Pulsus paradoxus is a difference of 10 mm Hg or more between the first Korotkoff
sound noting systolic blood pressure heard during expiration and the first that is heard
during inspiration. Pulsus paradoxus can signal a deteriorating condition including
diminished stroke volume, compromised cardiac output, and death. This would be of
high priority to notify the physician.
28. The nurse is caring for a client with a deep vein thrombosis in the popliteal vein. Which
component of a head-to-toe assessment is crucial?
A) Lung sounds
B) Level of consciousness
C) Amount of pain
D) Peripheral edema
Ans: A
Feedback:
Thrombi that form above the popliteal vein of the leg are at higher risk for migration
toward the pulmonary circulation. Assessing lung sounds can identify changes quickly.
A pulmonary embolus can be a life-threatening condition. The other options do not
reflect on the most crucial assessment for this critical complication of DVT.
29. The nurse is caring for a client following cardiac valve replacement. Which nursing
action is correct when obtaining a Homan's sign to screen for thrombophlebitis?
A) Adduction of the lower extremity
B) Assess the pulse on the dorsal aspect of the foot
C) Dorsiflexion of the foot noting calf pain
D) Rotation of the knee noting pain
Ans: C
Feedback:
The correct action to obtain a Homan's sign is to dorsiflex the foot noting calf pain.
Heat, redness, and swelling also develops along the length of the vein. The other options
are part of a circulation and musculoskeletal assessment but not the action for a
Homan's sign.
Page 10
30. The nurse is caring for a client who has history of thrombosis. The client asks, “I never
want to have another pulmonary embolus in the lung again. Is there something that can
be done to prevent them?” Which options would the nurse state and encourage
discussion with the physician? Select all that apply.
A) Anticoagulant therapy
B) A vena caval filter
C) Thrombolytic therapy
D) A vena caval plication
E) A thrombectomy
Ans: A, B, D
Feedback:
Prevention of thrombus development and moving to the lung is key. Prevention of
thrombus development in the system can be obtained from anticoagulant therapy which
interrupts the clotting cascade. Once a thrombus has formed, the vena caval filter and
vena caval plication can interrupt the movement to the lungs. Thrombolytic therapy
breaks a clot apart current thrombus travel through the system or wedged in a vessel,
and a thrombectomy is a surgical procedure to remove a thrombus from a vessel. Both
are following thrombus movement.
31. The home health nurse is monitoring anticoagulant therapy by assessing prothrombin
time (PT) laboratory values. Which action, made by the nurse, is the correct response
anticipated for a PT level of 21 seconds?
A) No change is dosage.
B) Increase the amount of Coumadin to obtain therapeutic blood level.
C) Decrease the amount of Coumadin to obtain therapeutic blood level.
D) Hold Coumadin therapy until further blood levels are drawn.
Ans: A
Feedback:
Frequent monitoring of the prothrombin time (PT) is essential for clients taking oral
anticoagulants. The PT levels should be 1.5 to 2.5 times the control value of 12 to 15
seconds. A value of 21 falls into the therapeutic range; thus, the nurse would anticipate
no change in dosage.
Page 11
32. The nurse is completing a nursing diagnosis of Pain for a client with thromboangiitis
obliterans. Which of the following nursing instructions are most beneficial in decreasing
the pain? Select all that apply.
A) Elevate the extremity.
B) Apply ice.
C) Apply a warm compress.
D) Stop smoking.
Ans: A, B, C, D
Feedback:
Thromboangiitis obliterans is an inflammation of the blood vessels associated with clot
formation and fibrosis of the blood vessel wall. It affects primarily the small arteries and
veins of the legs. All of the options have therapeutic benefits.
33. The nurse is evaluating the expected outcomes following thrombolytic therapy for a
right leg deep vein thrombosis. Which of the following findings confirms a positive
outcome? (Select all that apply.)
A) Pedal pulse thready
B) Client denies pain
C) Right extremity pink
D) Homan's sign positive
E) Right extremity comparable in size to left
F)
No bleeding or bruising noted
Ans: B, C, E, F
Feedback:
Evaluation of the expected outcome of thrombolytic therapy includes restoring blood
flow to the extremity. Findings include no pain from impaired circulation, a pink
extremity of comparable size, and no bleeding from complications of the thrombolytic
medication. A thready pulse would indicate impaired circulation, and a positive
Homan's sign would indicate a continuing thrombus.
Page 12
1. Chapter 24
When assessing a client, what sign would you know is an early sign of an impending
heart failure?
A) S1 heart sound
B) S3 heart sound
C) Heart murmur
D) Crackles
Ans: B
Feedback:
An S3 heart sound, if heard, is an early sign of impending heart failure. The S1 heart
sound is normal. Heart murmur is not a sign of impending heart failure. Moist lung
sounds could be indicative of either heart failure or pneumonia.
2. Your client is complaining of severe dizziness and drowsiness. Upon assessment, you
find the client has bradycardia and a bluish discoloration of the palms and fingernails.
What do these signs and symptoms indicate?
A) Cinchonism
B) Overdosage
C) Hypokalemia
D) Hypertension
Ans: B
Feedback:
These signs and symptoms indicate overdosage of a drug. The nurse should inform the
care provider immediately if these symptoms appear. These are not the signs and
symptoms of cinchonism, hypokalemia, or hypertension.
3. Your client is scheduled for a percutaneous balloon valvuloplasty. The client asks you
how long it takes for the opening to close after the procedure. What would be your best
response?
A) Within 1 week
B) Within 1 month
C) Within 6 months
D) Within 1 year
Ans: C
Feedback:
The opening usually closes within 6 months of a percutaneous balloon valvuloplasty.
Therefore, options A, B, and D are incorrect.
Page 1
4. The nurse is caring for a client with a valvular disorder of the heart. What intervention
should the nurse perform before administering the prescribed beta-blockers to clients
with valvular disorders of the heart?
A) Monitor the prothrombin time.
B) Monitor for episodes of bleeding.
C) Take the client's apical pulse.
D) Monitor for bluish discoloration of the palms.
Ans: C
Feedback:
Before administering beta-blockers, the nurse should take the client's apical pulse. If the
heart rate is less than 60 beats/minute, the nurse should withhold the drug and inform
the primary healthcare provider. Oral anticoagulant therapy requires close monitoring of
prothrombin time or INR. The nurse should also closely monitor clients receiving oral
anticoagulants for episodes of bleeding. Overdosage of beta-blockers indicates bluish
discoloration of the palms.
5. The nurse is caring for a client with a valvular disorder. The client is at risk for
decreased cardiac output. What nursing intervention should a nurse perform for this
client?
A) Perform exercises consistently.
B) Keep legs horizontal.
C) Auscultate lung and heart sounds.
D) Measure urine output.
Ans: D
Feedback:
The nurse should monitor urine output every 8 hours or more often if it is less than 500
mL/day. Renal output reflects the heart's ability to perfuse the renal arteries. The client
should not perform any exercises and should be on bed rest. Keeping the client's legs
horizontal and auscultating lung and heart sounds will not help in this condition.
6. A client with aortic valve regurgitation is asking about his disease process. What would
you, as the nurse, tell the client is the first sign of aortic valve regurgitation?
A) Tachycardia
B) Left-sided heart failure
C) Pain
D) Dysrhythmias
Ans: A
Feedback:
Tachycardia is one of the first signs. When valve damage affects the left ventricle, the
client becomes aware of forceful heart contractions (palpitations). At first, palpitations
occur only when lying flat or on the left side. Aortic valve regurgitation does not
produce left-sided heart failure, pain, or dysrhythmias as the first symptom of disease.
Page 2
7. What disease process is mitral regurgitation associated with?
A) Aortic stenosis
B) Cellulitis
C) Pulmonary fibrosis
D) Rheumatic carditis
Ans: D
Feedback:
Mitral regurgitation is associated with rheumatic carditis and mitral valve prolapse. It is
not associated with aortic stenosis, cellulitis, or pulmonary fibrosis. Aortic stenosis is a
narrowing of the aortic valve, not related to the mitral valve. Cellulitis is inflammation
in tissue, and pulmonary fibrosis is a scarring in the tissue of the lung.
8. What is the best technique to identify structural changes in the mitral valve?
A) Chest radiography
B) Cardiac catheterization
C) Transthoracic echocardiogram
D) Cardiac stress test
Ans: C
Feedback:
Standard transthoracic or transesophageal echocardiography is the best technique to
identify structural changes in the mitral valve because the performance of the valve
during the cardiac cycle can be evaluated. Options A, B, and D do not show you similar
detail. Chest radiography shows structures in the chest. Cardiac catheterization evaluates
patency of arteries and measures pressures in cardiac chambers. Cardiac stress testing
shows areas of the heart muscle that may become ischemic with exercise.
9. You are caring for a client with a valvular disorder. What nutritional intervention would
be appropriate for a client with a valvular disorder?
A) Limit sodium intake.
B) Eat six small meals a day.
C) Limit caloric intake to maintain optimal weight.
D) Increase intake of B and C vitamins.
Ans: A
Feedback:
Clients with valvular disorders often need to limit sodium intake because decreasing the
volume of blood decreases cardiac workload. Eating six small meals daily, limiting
caloric intake, and increasing the intake of B and C vitamins would not help a client
with a valvular disorder.
Page 3
10. The nursing instructor is teaching the junior nursing students about aortic regurgitation.
What classification of drugs are used to treat aortic regurgitation?
A) Antihypertensives
B) Anticoagulants
C) Cardiac glycosides
D) Antiarrhythmics
Ans: C
Feedback:
Because aortic regurgitation is mild and only slowly progressive in most people, clients
are sustained with cardiac glycosides or beta-blockers and diuretics. Antihypertensives,
anticoagulants, and antiarrhythmics are not the type of drugs used to treat aortic
regurgitation.
11. A client reports a family history of aortic stenosis. Which assessment finding would the
nurse identify as the most likely contributing factor?
A) High blood pressure
B) Missing aortic cusp
C) Unidirectional blood flow
D) Chest pain
Ans: B
Feedback:
In young adults, aortic stenosis usually is a consequence of a congenital defect in which
the valve has two instead of three cusps. High blood pressure and chest pain are
symptoms that can be exhibited in aortic stenosis. Unidirectional blood flow is the
normal flow of blood through the heart.
12. What must the nurse be assessing for in order to determine adequate care for a client
with aortic stenosis?
A) Increased systolic pressure
B) Calcification of aortic valve
C) Angina
D) Systolic murmur
Ans: C
Feedback:
Angina indicates insufficient nourishment of the myocardium, which can increase the
risk for mortality. The systolic blood pressure increases to force blood through the
narrowed opening, and systolic murmurs can be identified in some clients, but are not
the most important factors. Calcification of the aortic valve is a cause for the disorder.
Page 4
13. A client with aortic stenosis is scheduled for a balloon valvuloplasty. Which statement
made by the client indicates a need for further teaching?
A) “No chest incision is necessary for this procedure.”
B) “I understand this is a bridge procedure.”
C) “The balloon is used to stretch my valve open.”
D) “I'll be able to lead a normal life after the procedure.”
Ans: D
Feedback:
Because the stretched valve opening tends to narrow again in 6 to 12 months, this
procedure is considered a bridge to valve replacement or temporary treatment that is
performed via catheter insertion in a peripheral vessel.
14. A client with aortic regurgitation is experiencing dyspnea and chest pain with activity.
The nurse knows that the cause of the symptoms can be best determined by which
diagnostic test?
A) Radionuclide scan
B) Electrocardiogram (ECG)
C) Transesophageal echocardiogram (TEE)
D) Magnetic resonance imaging (MRI)
Ans: A
Feedback:
Because the symptoms occur with activity, a radionuclide scan could compare the blood
flow through the heart at rest and during activity, giving valuable information about the
severity of the diseased valve. ECG, TEE, and MRI are diagnostic tests used in the
diagnosis of cardiac disease but less specific for exercise evaluation.
15. A mechanical prosthetic heart valve client is admitted with leukopenia and abdominal
pain. Which diagnostic lab data would the nurse access first?
A) Complete blood count (CBC)
B) Prothrombin time and international normalized ratio (PT/INR)
C) Blood urea nitrogen (BUN)
D) Sodium (Na++) and potassium (K+) level
Ans: B
Feedback:
The nurse must first know that mechanical valves increase the risk for emboli formation
requiring clients to be placed on anticoagulants. Leukopenia and abdominal pain are
symptoms associated with anticoagulant use, such as seen in ASA overdose. PT and
INR are tests that will determine the risk for bleeding. CBC should also be reviewed but
not the first priority. BUN provides review of renal function and not significant. Na++
and K+ levels are significant for electrolyte balance but not a first priority.
Page 5
16. A client is scheduled for transcatheter aortic valve implantation (TAVI). Which
statement from the nurse, best explains this procedure to family members?
A) “A small incision in the chest wall will allow for valve repair.”
B) “A catheter is used for partial replacement of the valve.”
C) “A small window incision is made so a pig valve can replace the diseased valve.”
D) “A complete aortic valve replacement is the best surgical treatment.”
Ans: B
Feedback:
TAVI procedure is a minimally invasive procedure (no incision) that uses balloon
valvuloplasty, stent, and partial replacement of the diseased valve using a portion of a
pig valve. The TAVI is mostly used in older adults who are at high risk for the complete
aortic valve replacement and helps to relieve recurring symptoms.
17. The nurse is providing teaching to a post–valve replacement client. Which of the
following activities would require prophylactic antibiotic use? Select all that apply.
A) Vision screening
B) Dental care
C) Echocardiogram
D) MRI
E) Colonoscopy
F)
Chelation therapy
Ans: B, E
Feedback:
Dental cleaning/care and colonoscopy are invasive procedures that can disturb the
normal bacteria located in residence and place a valve replacement client at risk for
infective endocarditis. Vision screening, echocardiogram, MRI, and chelation therapy
are not invasive procedures and do not mobilize bacteria.
18. The client has been diagnosed with aortic regurgitation. Which nursing data is most
significant in identifying cause for this disorder?
A) Obesity
B) Tobacco use
C) Fen-Phen diet
D) Lack of exercise
Ans: C
Feedback:
The incidence of mitral and aortic regurgitation increased by as much as 36% in 1997,
due to the use of fenfluramine with phentermine (Fen-Phen) for weight loss. Obesity,
tobacco use, and lack of exercise have been identified as risk factors for heart disease
but not a significant identified cause for aortic regurgitation.
Page 6
19. A client with diagnosed aortic stenosis is exhibiting fatigue, shortness of breath on
exertion, and systolic murmur. Which of the following would the nurse list as the most
concerning nursing diagnosis?
A) Decreased Cardiac Output
B) Activity Intolerance
C) Fatigue
D) Ineffective Breathing Pattern
Ans: A
Feedback:
Activity Tolerance, Fatigue, and Ineffective Breathing Pattern are all appropriate
nursing diagnosis but the primary concern is Decreased Cardiac Output due to narrowed
valve and insufficient nourishment to the myocardium and other organs.
20. Which symptom is most important in determining the diagnosis and nursing care for a
client experiencing pulmonary hypertension?
A) Increased stroke volume
B) Bradycardia
C) Frothy sputum
D) High systolic pressure
Ans: C
Feedback:
Tachycardia, low systolic pressure, and decreased stroke volume are symptoms
associated with pulmonary hypertension. A productive cough with pink-tinged frothy
sputum can indicate progression of the disorder and need for treatment.
21. A mechanical prosthetic valve client is receiving oral anticoagulant therapy. The nurse
is monitoring the diagnostic labs and finds international normalized ratio (INR) of 3.3.
Which course of action should the nurse take?
A) Notify the physician.
B) Hold the next dose of anticoagulant.
C) Anticipate the injection of vitamin K.
D) Continue anticoagulant therapy.
Ans: D
Feedback:
The American College of Chest Physicians recommends an INR of 2.5 to 3.5 in clients
with mechanical prosthetic valves. Because the client's INR is reported at 3.3, this is
within the recommended range. The nurse may choose to notify the physician but not
necessary. Vitamin K would reverse the effects of the anticoagulant and could place the
client at risk for emboli. Holding the next dose of the anticoagulant would lower the
INR values but could place the client at risk for emboli.
Page 7
22. A client is being evaluated for mitral stenosis versus mitral insufficiency. Which of the
following symptoms would the nurse find in either condition?
A) Angina
B) Syncope
C) Murmur
D) High blood pressure
Ans: C
Feedback:
Mitral stenosis and mitral insufficiency both create regurgitation of blood back through
the mitral valve which can be heard as a murmur. Angina and syncope are not common
and would only be exhibited if decrease nourishment of the cardiac muscle and organs
occur. Hypertension may be an underlying condition but not necessarily associated with
both of these disorders.
23. The nurse is assessing the murmur on a client with mitral stenosis. Which is the best
position for the client to take for this evaluation?
A) Supine
B) Prone
C) Right lateral
D) Left lateral
Ans: D
Feedback:
The murmur can be best heard when the client takes a left lateral position. The
placement of the stethoscope over the mitral valve (fourth intercostal area left of
midline) while leaning the client forward allows for best sound discernment. The
murmur can be heard in supine, prone, or right lateral positioning but not as loud.
24. Which client symptom change would most likely indicate, to the nurse, a progression of
mitral stenosis?
A) Decreased systolic pressure
B) Increased systolic pressure
C) Widening pulse pressure
D) Normal diastolic pressure
Ans: A
Feedback:
As mitral stenosis progresses, the systolic blood pressure will decrease due to the
reduction of the cardiac output. Widening pulse pressure with normal diastolic pressure
is associated more with aortic regurgitation.
Page 8
25. Following percutaneous balloon valvuloplasty, for the treatment of mitral stenosis, the
best action of the nurse is to assess for which finding?
A) Rejection of porcine graft
B) Mitral regurgitation
C) Infection at incision site
D) Blood shunting from right to left atrium
Ans: B
Feedback:
The balloon valvuloplasty stretches the valve and can impair the papillary muscles,
resulting in regurgitation of blood back through the mitral valve. A percutaneous
balloon valvuloplasty does not have an incision and does not use a porcine graft. The
septum is perforated and can allow shunting of blood but the shunting, if occurs, will
move from left to right.
26. A client with mitral stenosis develops a productive cough with pink, frothy sputum. The
best interpretation made by the nurse would be to further evaluate for which
complication?
A) Pulmonary edema
B) Congestive failure
C) Thrombophlebitis
D) Cardiogenic shock
Ans: A
Feedback:
Cough with productive, pink, frothy sputum and crackles in the bases of the lungs are
signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive
failure, thrombophlebitis, or cardiogenic shock.
27. Which historical fact is of greatest value to a nurse who is interviewing a client being
admitted for possible mitral regurgitation?
A) Congenital neural tube defect
B) Rheumatic fever
C) One-pack-a-day smoker for 20 years
D) Pacemaker inserted 2 years ago
Ans: B
Feedback:
Rheumatic fever and subsequent heart disease is the prominent cause of valvular
insufficiency. Congenital neural tube defect is associated with spina bifida not mitral
regurgitation. Smoking and insertion of pacemaker are significant to heart disorders but
not of greatest value as rheumatic fever.
Page 9
28. The nurse identifies a heart murmur in an adult client. Which of the following
age-related changes would be the most likely cause?
A) Stiffness of heart valves
B) Stretching and dilation of veins
C) Decreased elasticity of the heart muscle
D) Arterial stiffening
Ans: A
Feedback:
Heart valves that are stiff do not allow the valve to close properly, resulting in a
murmur. Stretching and dilation of veins are referred to as varicosities and do not result
in murmurs. Decreased elasticity of the heart muscle can result in decreased cardiac
output but not significant to murmurs. Arterial stiffening is related to changes in
connective tissue and elastic fibers as associated with arteriosclerosis and does not result
in murmurs.
29. Which assessment finding would cause the greatest concern in providing nursing care to
a client with mitral stenosis?
A) Decreased pulmonary pressure
B) Increased cardiac output
C) Decreased right ventricular pressure
D) Increased left atrial pressure
Ans: D
Feedback:
A damaged mitral valve leads to incomplete emptying of the left atrium and
accumulation of blood resulting in increased pressure. As the backup of blood
continues, pressure is increased into the lungs and right ventricle and cardiac output
decreases.
30. Before invasive procedures, clients with valvular disease are usually prescribed
antibiotics. The nurse understands the reason for this preventative action is to avoid
which of the following complications?
A) Infective endocarditis
B) Rheumatic heart disease
C) Congestive failure
D) Septic shock
Ans: A
Feedback:
Infective endocarditis can compound valvular damage and can be minimized with the
preventative use of antibiotics before invasive procedure and dental work. Rheumatic
heart disease is associated with the original cause of valve disease and is not prevented
with prophylactic antibiotic use. Congestive failure is not associated with infection.
Septic shock is a systemic inflammatory response to infection and can be caused by
ruptured cusp or muscles in valvular disease clients.
Page 10
31. Before administering digoxin to a client with valvular disease, the nurse assesses the
apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72
beats/minute. Which is the best action for the nurse to take?
A) Hold the digoxin.
B) Recheck the apical pulse in 30 minutes.
C) Administer the digoxin.
D) Notify the physician.
Ans: C
Feedback:
A heart rate of 62 beats/minute falls within the normal range for administration of this
drug. Holding the medication would not be recommended unless specific orders were
detailed to do so. The nurse may decide to recheck the pulse but not required. Notifying
the physician of normal findings is not efficient use of time/resources.
32. The client with diabetes is taking a beta-adrenergic blocker for the management of
valvular disorder. Which statement made by the client indicates a need for further
teaching?
A) “I should avoid taking OTC cold medicines.”
B) “I should stop taking the medicine if I get dizzy.”
C) “I should take the medicine before meals.”
D) “I will need to check my blood sugar more often.”
Ans: B
Feedback:
The client should report dizziness to the PCP but should NOT stop the medication until
an evaluation of therapeutic effects has been decided. Abrupt withdrawal of
beta-blockers can lead to rebound sympathetic overactivity. OTC medications, such as
cold remedies, can interfere with beta-blockers should be avoided. Beta-blockers should
be taken before meals because food delays peak effects. Clients with diabetes should
monitor blood sugars regularly because beta-blockers can mask signs of hypoglycemia
and hyperglycemia.
Page 11
33. A client with progressive mitral valve prolapse is experiencing sympathetic nervous
system symptoms in addition to prolapse symptoms. Which teaching point should be
stressed by the nurse in an effort to minimize these effects?
A) Antibiotic therapy before invasive procedures
B) Low-dose aspirin daily
C) Avoid caffeine.
D) Decrease fluid and sodium intake.
Ans: C
Feedback:
The symptoms associated with sympathetic nervous response (anxiety, agitation,
nervousness, and palpitations) are often managed with antianxiety medications and
advisement to avoid caffeine and over-the-counter medications that contain stimulants.
Periodic antibiotic therapy use before an invasive procedure is not associated with
sympathetic nervous system symptoms. Low-dose aspirin is used to prevent thrombus
formation. Decreasing fluid and sodium intake is indicated for the control of congestive
failure.
34. The client with suspected mitral valve prolapse asks the nurse about tests that will be
done to confirm the diagnosis. Which is the best response by the nurse?
A) “A halter monitor will be used to confirm diagnosis.”
B) “An echocardiogram along with clinical symptoms will assist in diagnosis.”
C) “A chest x-ray will reveal a prolapse if present.”
D) “An ECG that presents a notched P wave will assist with diagnosis.”
Ans: B
Feedback:
The echocardiogram shows abnormal movement of mitral valve leaflets during systole
and can assist in the diagnosis of mitral valve prolapse when used along with clinical
symptoms. A notch in the P wave on ECG shows that the left atrium takes longer to
depolarize and can assist in the diagnosis of mitral stenosis. A 24-hour ECG via halter
monitor is used essentially to eliminate an MI and other causes of chest pain. A chest
x-ray can be used to visualize the size and location of the heart but not as significant as
echocardiogram.
Page 12
35. The client with valvular disorder is ordered a preoperative dose of penicillin G 600,000
units to be given IV q4h. Penicillin G is supplied in a vial labeled as, “Add 4 mL diluent
to yield 250,000 units per mL.” How many milliliters will the nurse need to withdraw
from the vial to provide the ordered dose?
______________________
Ans: 2.4 mL
Feedback:
600, 000 units
250, 000 units × 1 mL
600, 000 units
250, 000 units = 2.4 mL
Page 13
1. Chapter 25
You are caring for a client with coronary artery disease (CAD). What is an appropriate
nursing action when evaluating a client with CAD?
A) Assess the client's mental and emotional status.
B) Assess the skin of the client.
C) Assess the characteristics of chest pain.
D) Assess for any kind of drug abuse.
Ans: C
Feedback:
The nurse should assess the characteristics of chest pain for a client with CAD.
Assessing the client's mental and emotional status, skin, or for drug abuse will not assist
the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating
for adequate blood flow to the heart.
2. The nurse is caring for a client with Raynaud's disease. What is an important instruction
for a client who is diagnosed with this disease to prevent an attack?
A) Report changes in the usual pattern of chest pain.
B) Avoid situations that contribute to ischemic episodes.
C) Avoid fatty foods and exercise.
D) Take over-the-counter decongestants.
Ans: B
Feedback:
Teaching for clients with Raynaud's disease and their family members is important.
They need to understand what contributes to an attack. The nurse should instruct the
clients to avoid situations that contribute to ischemic episodes. Reporting changes in the
usual pattern of chest pain or avoiding fatty foods and exercise does not help the client
to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse
advises clients to avoid over-the-counter decongestants.
3. You are caring for a client at risk for thrombosis. What is an appropriate nursing action
when evaluating this client?
A) Examine the client's mental and emotional status.
B) Examine the legs for color, capillary refill time, and tissue integrity.
C) Examine for pain around the shoulder and neck region.
D) Examine the extremities for skin lesions.
Ans: B
Feedback:
The nurse examines the extremities and assesses skin color, temperature, capillary refill
time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining
the client's mental and emotional status or examining for pain around the shoulder and
neck region will not assist the nurse in evaluating a client with thrombosis.
Page 1
4. A client has had oral anticoagulation ordered. What should you monitor for when your
client is taking oral anticoagulation?
A) Prothrombin time (PT) or international normalized ratio (INR)
B) Hourly IV infusion
C) Vascular sites for bleeding
D) Urine output
Ans: A
Feedback:
The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular
sites for bleeding, urine output, and hourly IV infusions are generally monitored in all
clients.
5. The nurse is working with a client who has just been diagnosed with an aneurysm. What
advice should the nurse provide to this client?
A) Minimize bowel movements and coughing.
B) Avoid situations that contribute to ischemic episodes.
C) Avoid straining during bowel movements and coughing.
D) Wear wool socks and mittens during cold weather.
Ans: C
Feedback:
The nurse advises the client with an aneurysm to avoid straining during bowel
movements and coughing. Coughing and straining increase the risk of rupture. The
client with Raynaud's disease is asked to avoid situations that contribute to ischemic
episodes and to wear wool socks and mittens during cold weather.
6. You are presenting a workshop at the senior citizens center about how the changes of
aging predispose clients to vascular occlusive disorders. What would you name as the
most common cause of peripheral arterial problems in the older adult?
A) Arteriosclerosis
B) Coronary thrombosis
C) Atherosclerosis
D) Raynaud's disease
Ans: C
Feedback:
Atherosclerosis is the most common cause of peripheral arterial problems in the older
adult. The disease correlates with the aging process. The other choices may occur at any
age.
Page 2
7. A patient presents to the emergency room with characteristics of atherosclerosis. What
characteristics would the patient display?
A) Fatty deposits in the lumen of arteries
B) Cholesterol plugs in the lumen of veins
C) Blood clots in the arteries
D) Emboli in the veins
Ans: A
Feedback:
Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits
called plaque. Therefore, options B, C, and D are incorrect.
8. A client comes to the emergency department (ED) complaining of precordial chest pain.
In describing the pain, the client describes it as pressure with a sudden onset. What
disease process would you suspect in this client?
A) Coronary artery disease
B) Raynaud's disease
C) Cardiogenic shock
D) Venous occlusive disease
Ans: A
Feedback:
The classic symptom of CAD is chest pain (angina) or discomfort during activity or
stress. Such pain or discomfort typically is manifested as sudden pain or pressure that
may be centered over the heart (precordial) or under the sternum (substernal). Raynaud's
disease in the hands presents with symptoms of hands that are cold, blanched, and wet
with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive
disease occurs in the veins, not the arteries.
9. You are caring for a client who is suspected of having coronary artery disease. The
client is scheduled to have a nuclear stress test using thallium. When would the thallium
be injected to determine narrowing of the coronary arteries?
A) During and a few hours after exercise electrocardiography
B) Before and during exercise electrocardiography
C) Before and a few hours after exercise electrocardiography
D) Before, during, and a few hours after exercise electrocardiography
Ans: A
Feedback:
A nuclear stress test using a radionuclide, such as thallium, may be injected
intravenously (IV) during and a few hours after exercise electrocardiography, followed
by a heart scan. Narrowing of one or more coronary arteries is documented during
coronary arteriography. Therefore, options B, C, and D are incorrect.
Page 3
10. The nurse is caring for a client who is status postoperative from a vein stripping. What
would the nurse monitor for?
A) Swelling in the inoperative leg
B) Blood on the dressing on the inoperative leg
C) Warm, pink toes in the inoperative leg
D) Swelling in the operative leg
Ans: D
Feedback:
When the client returns from surgery with a gauze dressing covered by elastic roller
bandages on the operative leg, the nurse monitors for swelling in the operative leg(s)
and its effect on circulation.
11. Understanding atherosclerosis, the nurse identifies which of the following to be both a
risk factor for the development of the disorder and an outcome?
A) Hyperlipidemia
B) Hypertension
C) Glucose intolerance
D) Obesity
Ans: B
Feedback:
Increases in diastolic and systolic blood pressure are associated with an increased
incidence of atherosclerosis, often an inherited factor. Elevation of blood pressure
results when the vessels cannot relax and impairs the ability of the artery to dilate.
Hyperlipidemia, diabetes, and obesity are all risk factors for atherosclerosis but do not
result from the disorder.
12. The client asks the nurse to explain the difference between arteriosclerosis and
atherosclerosis. Which is the best explanation provided by the nurse?
A) “Arteriosclerosis is a condition that produces structural changes in the arteries,
and atherosclerosis is a specific type of arteriosclerosis.”
B) “Arteriosclerosis and atherosclerosis are the same disorder. The terms are
interchangeable.”
C) “Atherosclerosis and arteriosclerosis are disorders in which the lining of the
vessels become narrowed due to plaque formation.”
D) “Arteriosclerosis is when the vessels become dilated and weakened, whereas
atherosclerosis is the deposit of fatty substances in the vessel lining.”
Ans: A
Feedback:
Arteriosclerosis is a complex condition that produces structural changes to the arteries
usually associated with loss of elasticity. Atherosclerosis is a specific type and most
common cause of arteriosclerosis. Both disorders affect the ability of the vessels to
deliver blood and are considered occlusive disorders, but the causes differ. Vessels that
become dilated and weakened are referred to as aneurysms, not arteriosclerosis.
Page 4
13. A study published in the American Journal of Physiology, Endocrinology, and
Metabolism (You et al., 2005), reported findings that suggest inflammation increases the
risk of heart disease. Which modifiable factor would the nurse target in teaching clients
about prevention of inflammation that can lead to atherosclerosis?
A) Smoking
B) Inactivity
C) Obesity
D) Blood pressure control
Ans: C
Feedback:
The American Journal of Physiology, Endocrinology, and Metabolism (You et al.,
2005) indicated a relationship between body fat and the production of inflammation that
is associated with heart disease. This information suggests decreasing obesity and body
fat stores may help to reduce the risk. Smoking, inactivity, and uncontrolled blood
pressure are risk factors associated with heart disease but not specific to inflammatory
protein production.
14. Which of the following nursing assessment findings are suggestive of increased risk for
coronary artery disease? Select all that apply.
A) Arcus senilis
B) Pear-shaped body
C) Plump ear lobes
D) Xanthelasma
E) Sensory loss
F)
Motor changes
Ans: A, D
Feedback:
Arcus senilis is the opaque ring seen around the cornea that results from deposit of fat
granules, and xanthelasma is raised yellow plaque on the eyelids. Both of these findings
are suggestive of lipid accumulation that can increase the risk of CAD. An apple-shaped
body carries a higher risk. Diagonal creases in the earlobe have been suggestive of
CAD. Sensory and motor changes are more associated with CVA than CAD.
Page 5
15. A client is being evaluated for coronary artery disease (CAD) and is scheduled for an
electron beam computed tomography. The nurse understands that the primary advantage
of this radiologic test is which of the following?
A) Less exposure to radiation
B) Clear images
C) Less invasive procedure
D) Quantifies calcified plaque
Ans: D
Feedback:
The primary advantage of EBCT is to detect and quantify calcified plaque in the
coronary arteries even before symptoms arise. EBCT is noninvasive and provides
clearer images with less exposure to radiation than a CT scan but not the primary reason
for use.
16. In the treatment of coronary artery disease (CAD), medications are often ordered to
control blood pressure in the client. Which of the following is a primary purpose of
using beta-adrenergic blockers in the nursing management of CAD?
A) To dilate coronary arteries
B) To decrease workload of the heart
C) To decrease homocysteine levels
D) To prevent angiotensin II conversion
Ans: B
Feedback:
Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial
oxygen by reducing heart rate and workload of the heart. Nitrates are used for
vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease
homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.
Page 6
17. A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the
nurse why the patch is removed at bedtime. Which is the best response by the nurse?
A) “Nitroglycerine causes headaches, but removing the patch decreases the
incidence.”
B) “You do not need the effects of nitroglycerine while you sleep.”
C) “Removing the patch at night prevents drug tolerance while keeping the benefits.”
D) “Contact dermatitis and skin irritations are common when the patch remains on all
day.”
Ans: C
Feedback:
Tolerance to antiangina effects of nitrates can occur when taking these drugs for long
periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common
regime to remove transdermal patches at night. Common adverse effects of
nitroglycerine are headaches and contact dermatitis but not the reason for removing the
patch at night. It is true that while you rest, there is less demand on the heart but not the
primary reason for removing the patch.
18. Clients taking vasodilator drugs can be a greater risk for postprandial hypotension.
Which of the following is the best nursing explanation for this phenomenon?
A) Gravity pulls blood to the lower extremities while sitting.
B) Blood is being diverted to the gastrointestinal tract.
C) Decreased peripheral blood flow results.
D) Bronchospasms are increased when food enters the stomach.
Ans: B
Feedback:
During digestion, blood is diverted to the GI tract which decreases cerebral blood flow
and increases potential of orthostatic hypotension. Although gravity does pull blood to
the lower extremities while sitting, this is not the primary concern with postprandial
hypotension. Decreased peripheral blood flow does not result in postprandial
hypotension. Bronchospasms are associated more with asthma not diversion of blood
flow.
Page 7
19. A client with a strong family history of coronary artery disease asks the nurse how to
reduce the risk of developing the disorder. Which is the best response by the nurse?
A) “Moderation is the key to everything.”
B) “Ask your physician to prescribe the new reverse lipid drug.”
C) “Increase the soy in your diet.”
D) “Exercise, keep your cholesterol in check, and manage your stress.”
Ans: D
Feedback:
Although moderation is the key, this does not provide specific options for this client
such as regular exercise and managing stress and cholesterol levels. The reverse lipid
drug sounds good but is not available or approved by the FDA. Soy products have
limited benefits for cholesterol control.
20. A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA),
has received discharge instructions. Which statement by the client would indicate the
need for further teaching by the nurse?
A) “I should avoid taking a tub bath until my catheter site heals.”
B) “I should expect a low-grade fever and swelling at the site for the next week.”
C) “I should avoid prolonged sitting.”
D) “I should expect bruising at the catheter site for up to 3 weeks.”
Ans: B
Feedback:
Fever and swelling at the site are signs of infection and should be reported to the
physician. Showers should be taken until the insertion site is healed. Prolonged sitting
can result in thrombosis formation. Bruising at the insertion site is common and may
take from 1 to 3 weeks to resolve.
21. Which nursing actions would be of greatest importance in the management of a client
preparing for angioplasty?
A) Inform client of diagnostic tests.
B) Remove hair from skin insertion sites.
C) Assess distal pulses.
D) Withhold anticoagulant therapy.
Ans: D
Feedback:
The nurse knows to withhold the anticoagulant therapy to decrease chance of
hemorrhage during the procedure. The nurse does inform the client of diagnostic test,
will assess pulses, and prep the skin prior to the angioplasty, but this is not the most
important action to be taken.
Page 8
22. Dysrhythmias can be fatal to a client during the acute phase following a myocardial
infarction. The nurse understands that the primary cause of this event is due to which of
the following?
A) Effects on depolarization and repolarization of the myocardial cells
B) Arterial spasms are common after a myocardial infarction.
C) After a myocardial infarction, leukocytosis occurs.
D) Scar tissue has replaced healthy cardiac tissue.
Ans: A
Feedback:
Dysrhythmias during the acute phase occur because the affected areas are electrically
unstable due to the shifting of electrolytes and accumulation of lactic acid, which affect
the depolarization and repolarization of the myocardial cells. Arterial spasms can be a
cause of MI, not a result. Leukocytosis does occur after a MI but not the cause of
dysrhythmias. Scar tissue formation takes weeks to form and does not occur in the acute
phase.
23. The nurse knows that women and the elderly are at greater risk for a fatal myocardial
event. Which factor is the primary contributor of this cause?
A) Chest pain is typical
B) Vague symptoms
C) Decreased sensation to pain
D) Gender bias
Ans: B
Feedback:
Often, women and elderly do not have the typical chest pain associated with a
myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which
can lead to misdiagnosis. Some older adults may experience little or no chest pain.
Gender is not a contributing factor for fatal occurrence but rather a result of symptoms
association.
Page 9
24. Severe chest pain is reported by a client during an acute myocardial infarction. Which of
the following is the most appropriate drug for the nurse to administer?
A) Isosorbide mononitrate (Isordil)
B) Meperidine hydrochloride (Demerol)
C) Morphine sulfate (Morphine)
D) Nitroglycerin transdermal patch
Ans: C
Feedback:
Morphine not only decreases pain perception and anxiety but also helps to decrease
heart rate, blood pressure, and demand for oxygen. Nitrates are administered for
vasodilation and pain control in clients with angina–type pain, but oral forms (such as
Isordil) have a large first-pass effect, and transdermal patch is used for long-term
management. Demerol is a synthetic opioid usually reserved for treatment of
postoperative or migraine pain.
25. After 2-hour onset of acute chest pain, the client is brought to the emergency department
for evaluation. Elevation of which diagnostic findings would the nurse identify as
suggestive of an acute myocardial infarction at this time?
A) Troponin I
B) Myoglobin
C) WBC (white blood cell) count
D) C-reactive protein
Ans: B
Feedback:
Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the
gold standard for determining heart damage, but troponin I levels due not rise until 4 to
6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
26. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA)
immediately following confirmed diagnosis of acute myocardial infarction. The client is
overtly anxious and crying. Which response by the nurse is most appropriate?
A) “Everything will be fine. Your family is here for you.”
B) “Don't cry; you have the best team of doctors.”
C) “Would you like something to calm your nerves?”
D) “Tell me what concerns you most.”
Ans: D
Feedback:
Allowing the client to share feelings tends to relieve or reduce emotional distress.
Telling a client that everything is fine negates the feelings they are expressing. Telling a
client not to cry can be viewed as insensitive to the feelings being expressed. Providing
a prescribed sedative may be helpful but does not address the fears and concerns of the
client.
Page 10
27. Following a percutaneous transluminal coronary angioplasty (PTCA), which of the
following nursing assessments would be considered as primary for this client?
A) Evaluate for signs of infection.
B) Monitor gag reflex.
C) Assess peripheral pulses in affected extremity.
D) Monitor for signs of fluid volume deficit.
Ans: C
Feedback:
The PTCA is inserted and threaded through a peripheral artery. If a complication occurs
at the site of insertion, impaired circulation to the affected limb can occur. Fluid volume
deficit is not a primary concern. PTCA is an invasive, nonsurgical procedure in which
general anesthesia is not required, making monitoring for impaired gag reflex a
nonpriority. Signs of infection should be monitored post-PTCA but not in the immediate
postprocedure time frame.
28. A client, who is resting in bed, presents with symptoms of poikilothermy, bilateral lower
extremity edema, and pallor. Which is the best nursing measure to initiate?
A) Elevate the legs.
B) Apply cool compresses.
C) Smoking cessation class.
D) Lower the legs.
Ans: D
Feedback:
These are symptoms of peripheral artery disease. By lowering the legs, blood flow will
be increased to the lower extremities. Elevation of the legs would be helpful in the
management of impaired venous blood return. Smoking cessation is paramount but not
the initial action to be taken, and cool compresses stimulate vasoconstriction and further
impede blood flow.
29. Which nursing diagnosis is most significant in planning the care for a client with
Raynaud's disease?
A) Acute Pain
B) Disturbed Sensory Perception
C) Self-Care Deficit
D) Activity Intolerance
Ans: A
Feedback:
The hallmark symptom of Raynaud's Disease is pain related to the arterial insufficiency.
Disturbed Sensory Perception associated with paresthesia can occur but is less
significant than pain. Self-Care Deficit and Activity Intolerance can occur but less
significant than Acute Pain.
Page 11
30. A client with Raynaud's disease complains of cold and numbness in the fingers. Which
of the following would the nurse identify as an early sign of vasoconstriction?
A) Cyanosis
B) Gangrene
C) Pallor
D) Clubbing of the fingers
Ans: C
Feedback:
Pallor is the initial symptom in Raynaud's followed by cyanosis and aching pain.
Gangrene can occur with persistent attacks and interference of blood flow. Clubbing of
the fingers is a symptom associated with chronic oxygen deprivation to the distal
phalanges.
31. A client with venous insufficiency is instructed to exercise, apply elastic stockings, and
elevate the extremities. Which is the primary benefit for this nursing management
regime?
A) Improve arterial flow
B) Strengthen venous valves
C) Increase venous congestion
D) Improve venous return
Ans: D
Feedback:
The major goal in management of venous insufficiency is to promote venous
circulation. Arterial flow improvement is not the goal of treatment for this disorder.
Venous valves that are incompetent cannot be strengthened. Venous congestion is a
complication of venous insufficiency.
32. In providing nursing management to a client post–varicose vein surgery, the nurse
would include which of the following teaching measures? Select all that apply.
A) Exercise
B) Cool compresses
C) Elastic stockings
D) Lower the extremities.
E) Stand rather than sit.
F)
Take warm showers in the morning.
Ans: A, C
Feedback:
Movement/exercise and use of elastic stocking aid in venous return. Cool compresses
can cause vasoconstriction, which can diminish arterial blood flow. Elevation of legs
can be helpful in aiding venous return. Standing or sitting for prolonged periods of time
should be avoided. Showers in the morning can dilate blood vessels and contribute to
venous congestion and edema.
Page 12
33. Which of the following factors would the nurse identify as a modifiable risk factor for
the development of varicose veins?
A) Mother and maternal grandmother had varicose veins
B) Employed as over-the-road truck driver
C) Weight gained during past pregnancies
D) History of thrombophlebitis in both extremities
Ans: B
Feedback:
Over-the-road truckers sit for long periods of time, and because prolonged sitting should
be avoided, employment change could modify the risk associated with varicose vein
aggravation. Varicose veins have a familial tendency, but this cannot be modified.
Weight gained during previous pregnancies and history of thrombophlebitis cannot be
changed.
34. Which assessment finding by the nurse is the most significant finding suggestive of
aortic aneurysm?
A) High blood pressure
B) Severe back pain
C) Abdomen bruit
D) Nausea and vomiting
Ans: C
Feedback:
A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic
aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms
associated with aortic aneurysm but not as independently suggestive.
35. The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which
assessment finding is most likely to indicate a dissection of the aneurysm?
A) Severe back pain
B) Hematemesis
C) Rectal bleeding
D) Hypertensive Crisis
Ans: A
Feedback:
Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be
exhibited as severe back pain. A decrease in blood pressure will result as the client goes
into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with
rupture of AAA.
Page 13
1. Chapter 26
You are caring for a client who has premature ventricular contractions. What sign or
symptom is observed in this client?
A) Fluttering
B) Nausea
C) Hypotension
D) Fever
Ans: A
Feedback:
Premature ventricular contractions usually cause a flip-flop sensation in the chest,
sometimes described as “fluttering.” Associated signs and symptoms include pallor,
nervousness, sweating, and faintness. Symptoms of premature ventricular contractions
are not nausea, hypotension, and fever.
2. A pacemaker is the treatment of choice for what cardiac dysrhythmia?
A) Supraventricular tachycardia
B) Atrial flutter
C) Ventricular fibrillation
D) Complete heart block
Ans: D
Feedback:
Pacemaker insertion is the treatment for complete heart block. Treatments for
supraventricular tachycardia include Valsalva maneuver, unilateral carotid massage,
immersion of face in ice water, administration of IV adenosine, cardioversion, and
radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of
atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or
followed with epinephrine.
3. The staff educator is teaching a class in dysrhythmias. What statement is correct for
defibrillation?
A) It is a scheduled procedure 1 to 10 days in advance.
B) The client is sedated before the procedure.
C) It is used to eliminate ventricular dysrhythmias.
D) It uses less electrical energy than cardioversion.
Ans: C
Feedback:
The only treatment for a life-threatening ventricular dysrhythmia is immediate
defibrillation, which has the same effect as cardioversion, except that defibrillation is
used when there is no functional ventricular contraction. It is an emergency procedure
performed during resuscitation. The client is not sedated but is unresponsive.
Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.
Page 1
4. Your client has just been diagnosed with a dysrhythmia. The client asks you to explain
normal sinus rhythm. What would you explain is the characteristic of normal sinus
rhythm?
A) Heart rate between 60 and 150 beats/minute.
B) Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 second.
C) The ventricles depolarize in 0.5 second or less.
D) The sinoatrial (SA) node initiates the impulse.
Ans: D
Feedback:
The characteristics of normal sinus rhythm are heart rate between 60 and 100
beats/minute, the SA node initiates the impulse, the impulse travels to the AV node in
0.12 to 0.2 second, the ventricles depolarize in 0.12 seconds or less, and each impulse
occurs regularly.
5. You are taking a pre–nursing pharmacology class. Today, you are learning about
antidysrhythmic drugs. What drug is a potassium channel blocker?
A) Cordarone
B) Lidocaine
C) Tambocor
D) Isuprel
Ans: A
Feedback:
Potassium channel blockers include Cordarone and Bretylol. Lidocaine and Tambocor
are sodium channel blockers. Isuprel is a beta-blocker.
6. You are caring for a client with atrial fibrillation. What procedure would be
recommended if drug therapies did not control the dysrhythmia?
A) Defibrillation
B) Maze procedure
C) Pacemaker implantation
D) Elective cardioversion
Ans: D
Feedback:
Atrial fibrillation also is treated with elective cardioversion or digitalis if the ventricular
rate is not too slow. Defibrillation is used for a ventricular problem. A Maze procedure
is only a distractor for this question. Pacemakers are implanted for bradycardia.
Page 2
7. Elective cardioversion is similar to defibrillation except that the electrical stimulation
waits to discharge until an R wave appears. What does this prevent?
A) Disrupting the heart during the critical period of atrial repolarization
B) Disrupting the heart during the critical period of ventricular repolarization
C) Disrupting the heart during the critical period of ventricular depolarization
D) Disrupting the heart during the critical period of atrial depolarization
Ans: B
Feedback:
It is similar to defibrillation. One difference is that the machine that delivers the
electrical stimulation waits to discharge until it senses the appearance of an R wave. By
doing so, the machine prevents disrupting the heart during the critical period of
ventricular repolarization. Therefore, options A, C, and D are incorrect.
8. You enter your client's room and find him pulseless and unresponsive. What would be
the treatment of choice for this client?
A) IV lidocaine
B) Chemical cardioversion
C) Immediate defibrillation
D) Electric cardioversion
Ans: C
Feedback:
Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation,
and asystole (cardiac arrest) when no identifiable R wave is present.
9. Your client has just been admitted with bradycardia and scheduled for the insertion of a
pacemaker. You notify the physician that the client's heart rate has dropped into the 40
beats/minute range. The physician orders a temporary pacemaker. You know that there
are different types of temporary pacemakers. What types of temporary pacemakers are
there? Select all that apply.
A) Transatrial
B) Transcutaneous
C) Transvenous
D) Transthoracic
E) Transabdominal
Ans: B, C, D
Feedback:
The three types of temporary pacemakers are transcutaneous, transvenous, and
transthoracic. Therefore, options A and E are incorrect.
Page 3
10. Your client has returned to the floor with a transthoracic pacemaker ready to be
connected. You know that a transthoracic pacemaker is a temporary pacemaker used in
what situation?
A) Transthoracic pacemakers are used in a client who has had open heart surgery.
B) Transthoracic pacemakers are used when a client has an MI.
C) Transthoracic pacemakers are used after a coronary bypass graft surgery.
D) Transthoracic pacemakers are used for tachyarrhythmias.
Ans: A
Feedback:
The leads of a transthoracic pacemaker are inserted during open heart surgery. They
extend from the chest incision. If the client requires cardiac pacing during postoperative
recovery, the leads are connected to a temporary pacing unit.
11. The nurse is caring for clients on a telemetry unit. Which nursing consideration best
represents concerns of altered rhythmic patterns of the heart?
A) Altered patterns frequently turn into life-threatening arrhythmias.
B) Altered patterns frequently produce neurological deficits.
C) Altered patterns frequently cause a variety of home safety issues.
D) Altered patterns frequently affect the heart's ability to pump blood effectively.
Ans: D
Feedback:
The best representation of a nursing concern related to a cardiac arrhythmia is the
inability of the heart to fill the chambers and eject blow flow efficiently. Lack of an
efficient method to circulate blood and bodily fluids produces a variety of complications
such as tissue ischemia, pulmonary edema, hypotension, decreased urine output, and
impaired level of consciousness. The other options can occur with dysrhythmias, but the
cause stemming from the altered pattern is the best answer.
12. The nurse is caring for a client with a dysrhythmia. While assessing the data in the
history of the chart, the nurse anticipates the cause of the dysrhythmia to be which of the
following?
A) Peripheral vascular disease
B) Ischemic heart disease
C) Aortic stenosis
D) Atherosclerotic heart disease
Ans: B
Feedback:
The nurse realizes that the most common cause of dysrhythmias is ischemic heart
disease. When the heart does not obtain sufficient blood to meet demands, the heart
works harder to circulate body fluids and becomes inefficient in the process. Problems
with the peripheral vessels, narrowing of the aorta and plaque buildup in the vessels
may be a component of the disease process but not the best answer.
Page 4
13. The nurse is caring for a client on the cardiac unit. The licensed practical nurse on the
previous shift reported the following vital signs/assessment information: temperature,
100.6° F; pulse, 56 beats/minute; respirations 24 breaths/minute; blood pressure, 116/60
mm Hg; pulse oximetry reading, 92%; and with 2+ edema noted in the lower
extremities. Prior to 9 AM antidysrhythmic medication administration, which of the
following will the nurse reassess?
A) Temperature
B) Pulse
C) Blood pressure
D) Edema
Ans: B
Feedback:
Of the vital signs noted, the pulse rate is found to be abnormal, below 60 beats/minute.
Before administering an antidysrhythmic medication, which often slows the heart rate
further, the pulse rate would be reassessed, and a rate of 60 beats/minute would need to
be obtained.
14. The licensed practical nurse is co-assigned with a registered nurse in the care of a client
admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the
accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client
appears anxious and states not feeling well. The licensed practical nurse confirms the
monitor reading. When consulting with the registered nurse, which of the following is
anticipated?
A) The registered nurse stating to administer Lanoxin (digoxin)
B) The registered nurse administering atropine sulfate intravenously
C) The registered nurse stating to hold all medication until the pulse rate returns to 60
beats/minute
D) The registered nurse stating to administer all medications accept those which are
cardiotonics
Ans: B
Feedback:
The licensed practical nurse and registered nurse both identify that client's bradycardia.
Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a
dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under
60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing
intervention or administering additional medications until the imminent concern is
addressed.
Page 5
15. The nurse is caring for a client with a resting heart rate of 120 beats/minute. Which
nursing intervention would be the highest priority in plan of care?
A) Arrange periods of activity with periods of rest.
B) Instruct to sit on the edge of the bed before rising.
C) Place a pillow under the feet and ankles.
D) Maintain strict intake and output.
Ans: B
Feedback:
Safety is always a high priority. Instructing the client to sit on the edge of the bed before
rising helps to prevent falls related to hypotension and dizziness. Cardiac output drops
dangerously low in clients with tachycardia due to the client's heart not having sufficient
time to fill with blood. Alternating periods of rest with periods of activity and
maintaining strict intake and output are appropriate nursing interventions but not the
highest priority. Placing a pillow under the feet and ankles is used for individuals with
edema where the nurse wants to improve venous blood return.
16. A client presents to the emergency department via ambulance with a heart rate of 210
beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most
correct to alert the medical team of the presence of a client with which disorder?
A) Asystole
B) Premature ventricular contraction
C) Atrial flutter
D) Ventricular fibrillation
Ans: C
Feedback:
Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes
the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node
conducts only some impulses to the ventricle, resulting in a ventricular rate slower than
the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the
absence of cardiac function and can indicate death. Premature ventricular contraction
indicates an early electric impulse and does not necessarily produce an exceedingly
rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and
indicative of a dying heart.
Page 6
17. Which of the following medication classifications is more likely to be expected when
the nurse is caring for a client with atrial fibrillation?
A) Diuretic
B) Anticoagulant
C) Antihypertensive
D) Potassium supplement
Ans: B
Feedback:
Clients with persistent atrial fibrillation are prescribed anticoagulation therapy to reduce
the risk of emboli formation associated with ineffective circulation. The other options
may be prescribed but not expected in most situations.
18. The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor
of the client admitted following a myocardial infarction. The nurse notes that every
other beat includes a premature ventricular contraction (PVC). The nurse notes which of
the following in the permanent record?
A) Bigeminy
B) Couplets
C) Multifocal PVCs
D) R-on-T phenomenon
Ans: A
Feedback:
The nurse is correct to note bigeminy on the permanent record when every other beat is
a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one
location. R-on-T phenomenon occurs when the R wave falls on the T wave.
19. Which of the following medications does the nurse anticipate administering to a client
preparing for cardioversion?
A) Atropine
B) Lanoxin
C) Vasotec
D) Valium
Ans: D
Feedback:
Prior to cardioversion, cardiac medications are held, and the client is sedated with a
medication such as Valium.
Page 7
20. The nurse and student nurse are observing a cardioversion procedure completed by a
physician. At which time is the nurse most correct to identify to the student when the
electrical current will be initiated?
A) During stimulation of the SA node
B) During repolarization of the heart
C) During ventricular depolarization
D) During the QRS complex
Ans: C
Feedback:
The electrical current is initiated at the R wave when ventricular depolarization occurs.
The electrical current completely depolarizes the entire myocardium with the goal of
restoring the normal pacemaker of the heart. The other options focus on an incorrect
timing that will not restore the normal electrical conduction.
21. The nurse is assigned the following client assignment on the clinical unit. For which
client does the nurse anticipate cardioversion as a possible medical treatment?
A) A new myocardial infarction client
B) A client with poor kidney perfusion
C) A client with third-degree heart block
D) A client with atrial dysrhythmias
Ans: D
Feedback:
The nurse is correct to identify a client with atrial dysrhythmias as a candidate for
cardioversion. The goal of cardioversion is to restore the normal pacemaker of the heart,
as well as, normal conduction. A client with a myocardial infarction has tissue damage.
The client with poor perfusion has circulation problems. The client with heart block has
an impairment in the conduction system and may require a pacemaker.
22. The licensed practical nurse is setting up the room for a client arriving at the emergency
department with ventricular arrhythmias. The nurse is most correct to place which of the
following in the room for treatment?
A) A suction machine
B) A defibrillator
C) Cardioversion equipment
D) An ECG machine
Ans: B
Feedback:
The nurse is most correct to place a defibrillator close to the client room if not in the
room. The nurse realizes that clients with ventricular dysrhythmias are at a high risk for
fatal heart dysrhythmia and death. A suction machine is used to remove respiratory
secretions. Cardioversion is used in a planned setting for atrial dysrhythmias. An ECG
machine records tracings of the heart for diagnostic purposes. Most clients with history
of cardiac disorders have an ECG completed.
Page 8
23. The nurse is in the mall and observes a client slump to the floor. The nurse assesses the
client and notes no pulse. The nurse calls for assistance to others in the mall and
requests which piece of equipment?
A) A blood pressure cuff
B) A cell phone to call 911
C) An automatic external defibrillator
D) A stethoscope
Ans: C
Feedback:
Most malls in the United States now have automatic external defibrillators in common
areas. These defibrillators can easily be applied and obtain electrical confirmation of no
ventricular contraction or R wave. The machine allows an electrical stimulation when
the discharge button is depressed. A blood pressure cuff and stethoscope will not
provide the equipment needed to save the client's life. The 911 can be called by a
bystander, but the priority is to obtain the life-saving equipment. If defibrillation is
performed within the first 3 minutes of cardiac arrest, the potential for survival is 74%.
24. The nurse is providing instruction to a group of new nurses orienting on the unit,
highlighting the benefits of the automatic implanted cardioverter defibrillator (AICD).
While pointing at a diagram of the heart, at which location would the nurse identify the
placement of the electrical lead?
A) On the right atrium near the SA node
B) In the right ventricle near the septum
C) At the left atrium on the anterior wall
D) On the left ventricle on the posterior wall
Ans: B
Feedback:
The nurse is correct to explain that an AICD consists of a generator with a battery and
one or two electrical leads that resemble a wire. The generator is placed under the skin,
and the lead wire is inserted transvenously through the subclavian or cephalic vein to the
apex or septum of the right ventricle. The other options are incorrect.
Page 9
25. The nurse is instructing on home care after placement of an automatic implanted
cardioverter defibrillator (AICD). Which statement, made by the client, needs
clarification by the nurse?
A) “I need to notify my cardiologist if I feel frequent kicks to the chest.”
B) “I can continue to work with my power tools.”
C) “I need to stay away from microwaves.”
D) “I should opt for a hand search at the airport instead of metal detector scan.”
Ans: C
Feedback:
Similar to hand tools, microwaves have shields or are grounded, making them safe for
clients with AICDs. There is no restriction from microwave use. All of the other options
are correct.
26. Which of the following does the nurse recognize as the therapeutic goal of
radiofrequency catheter ablation for a client with cardiac dysrhythmias?
A) Reperfusion of ischemic heart tissue
B) Dilation of arterial blood vessels
C) Destruction of errant tissue
D) Stimulation of the impulse center
Ans: C
Feedback:
The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue, in
hopes of allowing impulse conduction to travel over appropriate pathways. The goal
does not include dilation of blood vessels or reperfusion of heart tissue. There is no
stimulation of the heart.
27. The nurse is reviewing morning lab work for a client with dysrhythmias and notes a
digoxin level of 0.5 ng/mL. Which nursing action is correct?
A) Hold the 9 AM digoxin dose and notify the physician.
B) Administer the 9 AM digoxin dose and notify the physician.
C) Administer the 9 AM digoxin; no physician notification is required.
D) Administer the 9 AM digoxin dose and repeat lab work after 1 hour.
Ans: B
Feedback:
A digoxin level of 0.5 ng/mL is subtherapeutic. The physician will most likely assess
the client and increase the dose to obtain a therapeutic blood level. Although the dose
may be adjusted, the nurse should give the prescribed dose until another dose is
prescribed. Communication between the nurse and the physician include the amount of
medication currently in the system, last dose given, and how and when the physician
would like to increase the dose.
Page 10
28. A client is unconscious on arrival to the emergency department. The nurse in the
emergency department identifies that the client has a permanent pacemaker due to
which characteristic?
A) Scar on the chest
B) “Spike” on the rhythm strip
C) Quality of the pulse
D) Vibration under the skin
Ans: B
Feedback:
Confirmation that the client has a permanent pacemaker is the characteristic “spike”
identified by a thin, straight stroke on the rhythm strip. The scar on the chest is
suggestive of pacer implantation but not definitive. There should be no change in pulse
quality, and no vibration under the skin.
29. The nurse reports to the cardiac nurse practitioner that the client is consistently
exhibiting a normal sinus rhythm. What characteristics are understood? Select all that
apply.
A) Heart rate 106 beats/minute
B) Upright P wave before each QRS complex
C) Each impulse occurs regularly.
D) Impulse travels to the SA node from the AV node.
E) Wave ends with a T wave
F)
Ventricles depolarize in the QRS complex.
Ans: B, C, E, F
Feedback:
Characteristics of normal sinus rhythm include a regular impulse originating in the SA
node and with impulses continuing to the AV node. There is a P wave initially with
depolarization at the QRS complex and ending with a T wave. Normal heart rate is
between 60 to 100 beats/minute.
30. Two clients in cardiac rehabilitation are discussing the differences between scheduled
cardioversion and unexpected defibrillation. Which difference will the nurse confirm?
A) Both procedures sedate the clients.
B) Cardioversion uses less electrical energy.
C) Both used to eliminate ventricular dysrhythmias.
D) Machine determines when electrical energy is delivered.
Ans: B
Feedback:
Cardioversion uses less electrical energy (50 to 100 joules) than defibrillation (200 to
360 joules). All of the other statements are correct.
Page 11
31. The nurse is caring for a client who has been resistant to past antidysrhythmic therapy.
Which cardiac dysrhythmic medication is administered for ventricular dysrhythmias
when other mediations have failed?
A) Bretylium tosylate (Bretylol)
B) Lidocaine hydrochloride (Xylocaine)
C) Procainamide hydrochloride (Pronestyl)
D) Flecainide (Tambocor)
Ans: A
Feedback:
Bretylium tosylate (Bretylol), a class III antidysrhythmics, inhibits the release of
norepinephrine and is used for dysrhythmias resistant to other agents. The other
medications are class I antidysrhythmics: sodium channel blockers.
32. The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing
action precedes the nurse pressing the discharge button?
A) Placing gel on the chest
B) Checking the ECG rhythm
C) Shouts, “All clear”
D) States, “Charging”
Ans: C
Feedback:
Preceding pressing the discharge button, the nurse shouts “All clear” to ensure that no
one is in contact with the client. The other options are correct but not the nursing action
immediately preceding.
33. The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which
waveform pattern needs attention first?
A) Sustained asystole
B) Supraventricular tachycardia
C) Atrial fibrillation
D) Ventricular fibrillation
Ans: D
Feedback:
Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs
attention first because there is no cardiac output, and it is an indication for CPR and
immediate defibrillation. Sustained asystole either is from death, or the client is off of
the cardiac monitor. Supraventricular tachycardia and atrial fibrillation is monitored and
reported to the physician but is not addressed first.
Page 12
34. Which diagnostic study best evaluates different medications ability to restore normal
heart rhythm?
A) Elective electrical cardioversion
B) Electrocardiogram (ECG)
C) Electrophysiology study
D) Echocardiogram
Ans: C
Feedback:
An electrophysiology study is a procedure that enables the physician to examine the
electrical activity of the heart, produce actual dysrhythmias, and determine the best
method for care. Cardioversion uses synchronized electricity to change the rhythm
pattern. Electrocardiogram and echocardiograms provide diagnostic information.
Page 13
1. Chapter 27
A client has just been diagnosed with prehypertension. What would the nurse instruct
this client to do to restore his blood pressure below hypertensive levels?
A) Increase iodine intake.
B) Decrease sodium intake.
C) Increase fluid intake.
D) Avoid over-the-counter decongestants.
Ans: B
Feedback:
The nurse should instruct clients with prehypertension to avoid or decrease sodium and
iodine intake. Increasing fluid intake raises circulating blood volume and systemic
vascular resistance. Over-the-counter decongestants decrease pulmonary congestion and
not hypertension.
2. The nurse is caring for a client with malignant hypertension. What would be an
appropriate nursing intervention for this client?
A) Monitor the client's mental and emotional status every hour.
B) Monitor the blood pressure (BP) every few minutes by applying an automatic BP
recording machine.
C) Monitor the client's blood sugar every hour.
D) Monitor the client's temperature every few minutes.
Ans: B
Feedback:
The nurse applies an automatic BP recording machine to the arm to measure the BP every
few minutes. The nurse also keeps emergency equipment and drugs ready in case
complications develop. Monitoring the client's mental and emotional status, blood sugar,
or temperature every few minutes will not reflect the sudden rise in BP of a client with
malignant hypertension.
3. Which of the following diagnostic tests may reveal an enlarged left ventricle?
A) Echocardiography
B) Computed tomographic scan
C) Fluorescein angiography
D) Positron emission tomography (PET) scan
Ans: A
Feedback:
Echocardiography reveals an enlarged left ventricle. Fluorescein angiography reveals
leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood
pressure. A CT scan reveals structural abnormalities.
Page 1
4. A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her
hypertension is not well controlled, and a new blood pressure medicine is prescribed.
What is important for the nurse to teach this client about her blood pressure medicine?
A) Take the medicine on an empty stomach.
B) A possible adverse effect of blood pressure medicine is dizziness when you stand.
C) There are no adverse effects from blood pressure medicine.
D) A severe drop in blood pressure is possible.
Ans: B
Feedback:
A possible adverse effect of all antihypertensive drugs is postural hypotension, which
can lead to falls. Teaching should include tips for managing syncope and dizziness. You
would not teach the client to take the medicine on an empty stomach.
5. You are caring for a client with hypertension who is experiencing complications. What
diagnostic test evaluates the efficiency or inefficiency of the heart to pump blood?
A) Echocardiography
B) Chest radiography
C) Computed tomography scan
D) Multiple gated acquisition (MUGA) scan
Ans: D
Feedback:
The MUGA is a test that detects how efficiently or inefficiently the heart pumps blood.
Echocardiography and chest radiography are used to reveal an enlarged left ventricle.
The computed tomography scan is used to reveal abnormalities in blood pressure.
6. What is blood pressure?
A) The force produced by the volume of blood in arterial walls
B) The force produced by the volume of blood in the venous system
C) The measurement of cardiac output
D) The peripheral resistance of the cardiac output
Ans: A
Feedback:
Blood pressure (BP) is the force produced by the volume of blood in arterial walls. It is
represented by the formula: BP = CO (cardiac output) × PR (peripheral resistance). This
makes options B, C, and D incorrect.
Page 2
7. You are teaching a health class at the local YMCA. What body system would you
explain regulates arterial blood pressure?
A) Cardiovascular system
B) Immune system
C) Lymphatic system
D) Autonomic nervous system
Ans: D
Feedback:
The autonomic nervous system, the kidneys, and various endocrine glands regulate
arterial pressure. The cardiovascular system, immune system, and lymphatic systems do
not regulate arterial blood pressure.
8. The nurse in an oncology clinic notes that the client being treated has hypertension.
What tumor is a predisposing condition for secondary hypertension?
A) Pheochromocytoma
B) Wilms' tumor
C) Astrocytoma
D) Lymphoma
Ans: A
Feedback:
Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the
adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the
adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g.,
weight-control drugs, caffeine), and use of oral contraceptives. Wilms' tumors,
astrocytomas, and lymphomas are not predisposing conditions for secondary
hypertension.
9. You are part of a group of nursing students who are making a presentation on chronic
hypertension. What is one subject you would need to include in your presentation as a
possible consequence of untreated chronic hypertension?
A) Peripheral edema
B) Right-sided heart failure
C) Stroke
D) Pulmonary insufficiency
Ans: C
Feedback:
A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed
in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock.
Options A, B, and D are not usually consequences of untreated chronic hypertension.
Page 3
10. You are caring for a client diagnosed with secondary hypertension. What would be a
predisposing condition for this diagnosis?
A) Use of valium
B) Hypoaldosteronism
C) Pancreatic disease
D) Use of oral contraceptives
Ans: D
Feedback:
Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the
adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the
adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g.,
weight-control drugs, caffeine), and use of oral contraceptives. Secondary hypertension
is not caused by the use of sedatives, hypoaldosteronism, or pancreatic disease.
11. The nurse is creating a community teaching demonstration focusing on the cause of
blood pressure. When completing the visual aid, which body structures represent the
mechanism of blood pressure?
A) Lung and arteries
B) Heart and blood vessels
C) Brain and sympathetic nervous system
D) Kidneys and autonomic nervous system
Ans: B
Feedback:
Blood pressure is the force produced by the volume of the blood in arterial walls. It is
represented by the formula: BP = CO (cardiac output) × PR (peripheral resistance). To
highlight the mechanism of cardiac output, a heart would be on the visual aid and blood
vessels.
12. The nurse is caring for a client who is newly diagnosed with hypertension. The client
states, “I do not understand what is causing my blood pressure to continue to rise.”
Which information does the nurse recognize as the key structure in regulating arterial
blood pressure?
A) Heart
B) Lung
C) Brain
D) Kidney
Ans: D
Feedback:
The body regulates blood pressure throughout the day. The components of the
autonomic nervous system, the kidneys, and endocrine glands regulate arterial pressure.
The heart is the pump sending blood throughout the system. The lungs exchange oxygen
but do not affect blood pressure. The brain recognizes and processes sympathetic
nervous system activity to raise blood pressure.
Page 4
13. The nurse obtains a blood pressure of 136/86 mm Hg on morning assessment of a client
with history of hypertension. Which pressure is of most concern when considering
ventricular relaxation?
A) Central aortic pressure
B) Systolic pressure
C) Diastolic pressure
D) Central venous pressure
Ans: C
Feedback:
Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It
depends on the resistance of the arterioles and the diastolic filing times. Central aortic
pressure is the blood pressure pumped from the left ventricle and measured at the root of
the aorta. Systolic blood pressure is determined by the force and volume of blood that
the left ventricle ejects. Central venous pressure reflects the blood pressure returning to
the heart.
14. The nurse is working on a clinical research study, obtaining data evaluating central
aortic systolic pressure and brachial arm systolic pressure. The client notes difference in
the readings. Which response by the nurse is most accurate?
A) “The difference is due to machine calibration.”
B) “The difference is due to the location of pressure measurement.”
C) “The difference is due to the discomfort caused by the measurement procedure.”
D) “The difference is due to the constrictive force on the arteries when the
measurement is taken.”
Ans: B
Feedback:
Central aortic systolic pressure results, reflecting pressure at the root of the aorta, can be
documented as 30 mm Hg lower than when corresponding results obtained at the
brachial arm. The differences are not due to machine calibration, discomfort, or
constriction of the arteries.
Page 5
15. The nurse is employed in a physician's office and is caring for a client present for an
annual exam. A blood pressure of 124/84 mm Hg is documented. Following revised
guidelines for identifying hypertension, which educational pamphlet is help?
A) Increasing fluids for low blood pressure
B) Stress reduction to lower prehypertensive state
C) Use of beta-blockers for treatment of hypertension
D) Diagnostic testing for determining cardiac functioning
Ans: B
Feedback:
A blood pressure of 124/84 mm Hg is now considered to be in the lower range of
prehypertension. Knowledge of stress reduction may be helpful in lowering the blood
pressure without medication therapy. A blood pressure of 124/84 mm Hg is not
considered a low blood pressure or in need of medication therapy due to hypertension.
Diagnostic testing for cardiac functioning is not typical for a client with
prehypertension.
16. Which of the following client scenarios would be correct for the nurse to identify as a
client with secondary hypertension?
A) A client experiencing depression
B) A client diagnosed with kidney disease
C) A client of advanced age
D) A client with excessive alcohol intake
Ans: B
Feedback:
Secondary hypertension is an elevated blood pressure that results from or is secondary
to some other disorder such as kidney disease, a tumor of the adrenal medulla, or
atherosclerosis. Depression alone is typically not associated with hypertension.
Advanced age and alcohol intake are considered factors for essential hypertension.
17. The nurse is caring for a client with long-standing hypertension. As a client advocate,
which instruction is most helpful in preventing further complications?
A) Maintain a healthy diet of fruits and vegetables.
B) Focus on exercise at least twice a week.
C) Obtain a regular appointment with eye doctor.
D) Avoid use of caffeinated beverages.
Ans: C
Feedback:
When a client has long-standing hypertension, the high blood pressure damages the
arterial vascular system. As a client advocate, the nurse must instruct on not only
prevention but also on early identification of complications. Damages may occur to the
tiny arteries in the eyes compromising vision. The most helpful instruction is to
maintain a regular appointment with an eye doctor. The other options are good
instruction for a healthy lifestyle.
Page 6
18. Which of the following is the nurse most correct to recognize as a direct effect of client
hypertension?
A) Renal dysfunction resulting from atherosclerosis
B) Anemia resulting from bone marrow suppression
C) Hyperglycemia resulting from insulin receptor resistance
D) Emphysema related to poor gas exchange
Ans: A
Feedback:
The nurse is most correct to realize high blood pressure damages the arterial vascular
system and accelerates atherosclerosis. The effect of the atherosclerosis impairs
circulation to the kidney, resulting in renal failure. Neither anemia, hyperglycemia, nor
emphysema occurs as a direct effect of hypertension.
19. The nurse is screening a client at a health fair for hypertension. Which assessment data,
provided by the client, would prompt the nurse to stress physician involvement? Select
all that apply.
A) Fatigue
B) Constipation
C) Headache
D) Insomnia
E) Dysuria
F)
Blurred vision
Ans: A, C, D, F
Feedback:
When assessing the client for symptoms of hypertension, the nurse should recognize
that the client may note fatigue, headache, insomnia, and blurred vision. Other
symptoms include dizziness, nervousness, nosebleeds, angina, and dyspnea.
Constipation and dysuria are not signs of hypertension.
20. The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm
Hg. The client states that lifestyle changes have not been effective in lowering the blood
pressure. Which medication classification does the nurse anticipate first?
A) ACE inhibitors
B) Beta-blocker
C) Thiazide diuretic
D) Calcium channel blocker
Ans: C
Feedback:
Clients with hypertension, unable to be lowered by lifestyle changes, usually are placed
on a thiazide diuretic initially. However, most people with hypertension will need two
or more antihypertensive medications to reduce their blood pressure.
Page 7
21. The nurse is instructing a client who is newly prescribed an antihypertensive
medication. Which nursing instruction is emphasized to maintain client safety?
A) Use a pillbox to store daily medication.
B) Sit on the edge of the chair and rise slowly.
C) Do not operate a motor vehicle.
D) Take the medication at the same time daily.
Ans: B
Feedback:
The nursing instruction emphasized to maintain client safety is to sit on the edge of the
chair before rising slowly. By doing so, the client reduces the possibility of falls related
to postural hypotension. Using a pillbox to store medications and taking the medication
at the same time daily is good medication management instruction. There is no reason
when taking antihypertensive medications to restrict driving.
22. The physician is ordering a test for the hypertensive client that will be able to evaluate
whether the client has experienced heart damage. Which diagnostic test would the nurse
anticipate to determine heart damage?
A) Blood chemistry
B) Multiple gated acquisition scan (MUGA)
C) Chest radiograph
D) Fluorescein angiography
Ans: B
Feedback:
The nurse realizes that undiagnosed (untreated), long-standing hypertension can cause
heart damage. The diagnostic test that best determines heart damage is the multiple gate
acquisition scan (MUGA). This test is used to detect how efficiently the heart pumps. A
blood chemistry determines electrolyte balance. A chest radiograph (chest x-ray) can
provide details of the heart size through shading on the scan. Fluorescein angiography is
an ophthalmologic test revealing leaking retinal blood vessels.
Page 8
23. A nurse is assessing the blood pressure of a large adult client diagnosed with primary
hypertension. To ensure an accurate blood pressure reading, the nurse follows which
standard of care? Select all that apply.
A) Use the large adult blood pressure cuff.
B) Place the cuff midway between the acromion and olecranon process.
C) Vary the blood pressure reading sites every other day.
D) Obtain supine, sitting, and standing readings daily.
E) Document the results immediately after the reading is completed.
Ans: A, B, E
Feedback:
Standards of care require that the nurse use the proper-sized blood pressure cuff placed
at the proper location on the arm at the appropriate time. Using a large adult blood
pressure cuff is the correct size. Placing the cuff between the acromion process and
olecranon process is the correct site. Documenting the blood pressure reading accurately
after obtaining the reading is correct. Varying the blood pressure site and positioning
every 1 or 2 days provides varied readings. Consistency needs to be maintained to draw
accurate conclusions.
24. The nurse is caring for a client with accelerated hypertension. Which body system
would the nurse assess to identify early signs of blood pressure progression?
A) Eyes
B) Kidney
C) Heart
D) Musculoskeletal system
Ans: A
Feedback:
Accelerated hypertension is defined as a markedly elevated blood pressure with
symptoms of hemorrhages and exudates in the eyes. If the hypertension is untreated,
accelerated hypertension progresses to malignant hypertension with symptoms of
papilledema. Long-standing hypertension can produce changes in the kidney, heart, and
musculoskeletal system.
Page 9
25. The nurse is working on a busy cardiac unit caring for four hypertensive clients. Which
client description would the nurse assess first because the client is at an increased risk
for malignant hypertension?
A) A client with anorexia and history of no healthcare insurance
B) A client with liver dysfunction who drinks alcohol daily
C) A schizophrenic residing at an assisted living facility
D) A client with chronic asthma who uses a corticosteroid inhaler
Ans: A
Feedback:
Accelerated and malignant hypertension can occur in individuals who fail to maintain
follow-up or comply with medical therapy. Those individuals who have no healthcare
insurance often are unable to obtain the medical follow-up or afford the cost of
medications to treat the hypertensive state. If the hypertension is untreated, symptoms
and complication can rapidly follow. The other choices need further assessment but are
not the priority.
26. The nurse is caring for a client who is ordered Hyperstat IV to decrease blood pressure.
Which nursing consideration is a priority?
A) Elevate the head of the bed.
B) Use an automatic blood pressure recording machine.
C) Place a Foley catheter to monitor urine output.
D) Assess the client's deep tendon reflex.
Ans: B
Feedback:
A nursing priority is to monitor the client's blood pressure every few minutes. It is
unrealistic to have the nurse manually assess the blood pressures. An automatic blood
pressure machine is programed to assess the blood pressure and record the results for
assessment. The other options may be completed; however, monitoring the blood
pressure is the priority.
Page 10
27. The nurse is volunteering at a community blood pressure screening. A client, never
diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which
assessment questions, asked by the nurse, are appropriate? Select all that apply.
A) “Have you recently drunk a caffeinated beverage?”
B) “Did you have a beer after work?”
C) “Do you smoke?”
D) “Do you have a friend accompanying you?”
E) “Are you married and with children?”
Ans: A, C
Feedback:
At a community blood pressure clinic, the nurse would assess for common factors for a
blood pressure to be elevated. Factors that can affect blood pressures readings include
smoking or drinking coffee within 30 minutes of the reading. One beer after work
should not affect the blood pressure reading, and some individuals may find it relaxing.
Social situations are difficult to assess in a community blood pressure clinic. The client
would be referred to having another blood pressure reading and, if elevated, referred to a
physician.
28. The nurse is evaluating the types of medications prescribed for a client's hypertension.
Which of the following medication classifications establishes an action on
vasoconstrictive hormones in the blood stream?
A) Beta-blocker
B) ACE inhibitor
C) Loop diuretic
D) Calcium channel blocker
Ans: B
Feedback:
The angiotensin-converting enzyme (ACE) inhibitor's primary action is to prevent the
conversion of angiotensin I to angiotensin II, a potent vasoconstricting hormone in the
blood. A beta-blocker blocks the beta-adrenergic receptors decreasing sympathetic
nervous system stimulation. Loop diuretics excrete water from the loop of Henle,
reducing circulating blood volume. Calcium channel blockers dilate coronary and
peripheral arteries.
Page 11
29. The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower
the blood pressure. Which question, asked by the nurse, is most important?
A) “Who eats meals with you?”
B) “How do you prepare your food?”
C) “Do you each three meals per day?”
D) “Do you snack in the evening?”
Ans: B
Feedback:
Asking the client how food is prepared, gives the nurse and dietitian the ability to judge
the sodium content. If the client opens cans of food, typically, there will be elevated
sodium content. If the client uses prepared foods or eats out regularly, there is sodium in
the content. If the client uses fresh ingredients, sodium content is minimal. Asking about
who eats with the client and their eating patterns are not as helpful in determining
sodium content.
30. A client, newly prescribed a low-sodium diet due to hypertension, is asking for help
with meal choices. The client provides four meal choices, which are favorites. Which
selection would be best?
A) Toasted cheese sandwich on whole wheat toast with tomato soup
B) Creamed chipped beef over toast with mashed potatoes
C) Hot dog with ketchup and relish on whole wheat bun
D) Green pepper stuffed with diced tomatoes and chicken
Ans: D
Feedback:
Fresh vegetables are low in sodium with diced tomatoes (fresh) and chicken is a good
low-sodium, high vegetable and protein selection. Cheese and soup (tomato and
creamed) are high in sodium. Processed meats such as a hot dog and condiments such as
ketchup are high in sodium.
31. Which ethnic background would the nurse screen for hypertension at an early age?
A) Asian population
B) Japanese population
C) Mexican population
D) African American population
Ans: D
Feedback:
The African American population is at the highest risk for development of hypertension.
The other ethnic backgrounds have a lower risk.
Page 12
32. The nurse is caring for a client with essential hypertension. The nurse reviews lab work
and assesses kidney function. Which action of the kidney would the nurse evaluate as
the body's attempt to regulate high blood pressure?
A) The kidney retains sodium and water.
B) The kidney excretes sodium and water.
C) The kidney retains sodium and excretes water.
D) The kidney retains water and excretes sodium.
Ans: B
Feedback:
Hypernatremia (elevated serum sodium level) increases blood volume, which raises
blood pressure. The kidney's response to the elevation in blood pressure is to excrete
sodium and excess water. Any retention of sodium and water would increase blood
volume and, thus, blood pressure. Sodium and water move together.
33. Which of the following nursing diagnosis is the nurse most correct to choose when
caring for a client with long-standing hypertension?
A) Impaired Gas Exchange
B) Activity Intolerance
C) Ineffective Tissue Perfusion
D) Risk for Decreased Cardiac Output
Ans: C
Feedback:
The nurse is most correct in choosing ineffective tissue perfusion for the client with
long-standing hypertension. In hypertension, the extra work increases the size of the
heart muscle. Eventually, the heart cannot meet the body's metabolic needs limiting the
perfusion to the tissues. Impaired Gas Exchange, Activity Intolerance, and a Risk for
Decreased Cardiac Output may occur due to the ineffective perfusion.
34. The nurse is caring for a client with hypertension. The nurse is correct to realize that a
24-hour urine is ordered to determine if the cause of hypertension is related to the
dysfunction of which of the following?
A) The thyroid gland
B) The adrenal gland
C) The pituitary gland
D) The thymus
Ans: B
Feedback:
The 24-hour urine collection specimen is ordered to determine dysfunction of the
adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are
not evaluated by a 24-hour urine.
Page 13
1. Chapter 28
The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What
would be an important instruction for the nurse to give a client who is to undergo a
MUGA scan?
A) Avoid any activity at least 2 hours before the test.
B) Drink plenty of fluids during the test.
C) Avoid dairy products a day before and a day after the test.
D) Lie very still at intermittent times during the test.
Ans: D
Feedback:
The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at
intermittent times during the 45-minute test. The client need not to drink plenty of
fluids, avoid activities before or after the test, or avoid dairy products during the test.
2. You are caring for a client with suspected right-sided heart failure. What would you
know that clients with suspected right-sided heart failure may experience?
A) Increased urine output
B) Gradual unexplained weight gain
C) Increased perspiration
D) Sleeping in a chair or recliner
Ans: B
Feedback:
Clients with right-sided heart failure may have a history of gradual, unexplained weight
gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal
dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair
or recliner. Right-sided heart failure does not cause increased perspiration or increased
urine output.
3. A client with left-sided heart failure is in danger of impaired renal perfusion. How
would the nurse assess this client for impaired renal perfusion?
A) Assess for reduced urine output.
B) Assess for reduced blood sodium levels.
C) Assess for elevated blood potassium levels.
D) Assess for elevated blood urea nitrogen levels.
Ans: D
Feedback:
Elevated blood urea nitrogen indicates impaired renal perfusion in a client with
left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or
elevated blood potassium levels do not indicate impaired renal perfusion in a client with
left-sided heart failure.
Page 1
4. The student nurse is caring for a client with heart failure. Diuretics have been ordered.
What method might be used with a debilitated patient to help the nurse evaluate the
client's response to diuretics?
A) Using mechanical ventilation
B) Using a urinary catheter
C) Using a pulmonary artery catheter
D) Using a biventricular pacemaker
Ans: B
Feedback:
To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation
helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate
cardiac output. A biventricular pacemaker is used to sustain life.
5. You are working in a long-term care facility with a group of older adults with cardiac
disorders. Why would it be important for you to closely monitor an older adult receiving
digitalis preparations for cardiac disorders?
A) Older adults are at increased risk for toxicity.
B) Older adults are at increased risk for cardiac arrests.
C) Older adults are at increased risk for hyperthyroidism.
D) Older adults are at increased risk for asthma.
Ans: A
Feedback:
Older adults receiving digitalis preparations are at increased risk for toxicity because of
the decreased ability of the kidneys to excrete the drug due to age-related changes. The
margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using
digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or
asthma.
6. A client diagnosed with heart failure has been admitted to the ICU prior to invasive
treatment. What treatment could be considered curative for this client?
A) Cardiomyoplasty
B) External pacemaker placement
C) Surgical ventricular restoration
D) Ventricular assist device
Ans: C
Feedback:
A procedure known as surgical ventricular restoration (SVR) decreases the size of the
heart to a near normal size and shape by removing dysfunctional heart muscle that does
not contract properly. Once the adynamic (nonfunctioning) area is removed, the
ventricle is repaired with a patch. In the cases that were studied, 91% were free of
congestive heart failure after surgery with an ejection fraction that increased from 30%
to 40%. A cardiomyoplasty, placement of an external pacemaker, or a ventricular assist
device are not considered curative for heart failure.
Page 2
7. A client with pulmonary edema has been admitted to the ICU. What would be the
standard care for this client?
A) Intubation of the airway
B) BP and pulse measurements every 15 to 30 minutes
C) Insertion of a central venous catheter
D) Hourly administration of a fluid bolus
Ans: B
Feedback:
Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP,
and pulse measurements approximately every 15 to 30 minutes.
8. The nurse documents pitting edema in the bilateral lower extremities of the client. What
does this documentation mean?
A) There is excess fluid volume in the interstitial space in areas affected by gravity.
B) There is excess fluid volume in the venous system of the lower extremities.
C) There is excess fluid volume in the arterial system of the lower extremities.
D) There is excess fluid volume in the hepatic system.
Ans: A
Feedback:
Dependent pitting edema (excess fluid volume in the interstitial space in body areas
affected by gravity) in the feet and ankles can be observed. This type of edema may
seem to disappear overnight but really is temporarily redistributed by gravity to other
tissues, such as the sacral area. Options B, C, and D are not descriptive of pitting edema.
9. A client with severe mitral valve insufficiency has been admitted to your unit. The client
has heart failure and has developed pulmonary edema. What would be the best course of
treatment for this client?
A) Cardiac glycosides
B) Beta-blockers
C) Surgery
D) Palliative care
Ans: C
Feedback:
If the cause of heart failure and pulmonary edema can be corrected surgically (e.g., a
mitral valve disorder), the client is supported medically while being prepared for
surgery. Options A, B, and D do not have the potential to reverse or stabilize this client's
disease process, so they would not be the best treatment option.
Page 3
10. What disease processes contribute to chronic heart failure? Select all that apply.
A) Tachydysrhythmias
B) Valvular disease
C) Pancreatic disease
D) Renal failure
E) Pulmonary insufficiency
Ans: A, B, D
Feedback:
Hypertension, tachydysrhythmias, valvular disease, cardiomyopathy, and renal failure
can contribute to chronic heart failure. Pancreatic disease and pulmonary insufficiency
do not contribute to chronic heart failure.
11. The nurse is caring for a client with heart failure. What procedure should the nurse
prepare the client for in order to determine the ejection fraction to measure the
efficiency of the heart as a pump?
A) Echocardiogram
B) A pulmonary arteriography
C) A chest radiograph
D) Electrocardiogram
Ans: A
Feedback:
The heart's ejection fraction is measured using an echocardiogram or multiple gated
acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest
radiograph can reveal the enlargement of the heart. An electrocardiogram is used to
determine the activity of the heart's conduction system.
Page 4
12. A client with chronic heart failure is able to continue with his regular physical activity
and does not have any limitations as to what he can do. According to the New York
Heart Association (NYHA), what classification of chronic heart failure does this client
have?
A) Class I (Mild)
B) Class II (Mild)
C) Class III (Moderate)
D) Class IV (Severe)
Ans: A
Feedback:
Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or
dyspnea. The client does not experience any limitation of activity. Class II (Mild) is
when the client is comfortable at rest, but ordinary physical activity results in fatigue,
heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of
physical activity. The client is comfortable at rest, but less than ordinary activity causes
fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry
out any physical activity without discomfort. Symptoms of cardiac insufficiency occur
at rest. Discomfort is increased if any physical activity is undertaken.
13. The nurse is caring for a client in the hospital with chronic heart failure that has marked
limitations in his physical activity. The client is comfortable when resting in the bed or
chair, but when ambulating in the room or hall, he becomes short of breath and fatigued
easily. What type of heart failure is this considered according to the New York Heart
Association (NYHA)?
A) Class I (Mild)
B) Class II (Mild)
C) Class III (Moderate)
D) Class IV (Severe)
Ans: C
Feedback:
Class III (Moderate) is when there is marked limitation of physical activity. The client is
comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or
dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations,
or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is
when the client is comfortable at rest, but ordinary physical activity results in fatigue,
heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any
physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest.
Discomfort is increased if any physical activity is undertaken.
Page 5
14. A client has a myocardial infarction in the left ventricle and develops crackles
bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy
sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and
symptoms indicate for this client?
A) The development of chronic obstructive pulmonary disease (COPD)
B) The development of left-sided heart failure
C) The development of right-sided heart failure
D) The development of cor pulmonale
Ans: B
Feedback:
When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel
blood into the systemic circulation. Blood subsequently becomes congested in the left
ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided
failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles;
cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary
capillary wedge pressure. COPD develops over many years and does not develop after a
myocardial infarction. The development of right-sided heart failure would generally
occur after a right ventricle myocardial infarction or after the development of left-sided
heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by
lung damage.
15. A client is admitted to the hospital with a diagnosis of heart failure, and the physician
orders a BNP level. What results would indicate to the nurse that the client is in
moderate heart failure?
A) 120 pg/mL
B) 400 pg/mL
C) 780 pg/mL
D) 980 pg/mL
Ans: C
Feedback:
The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL
indicates that the client has heart failure present, 400 pg/mL indicates that the client has
mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure.
Page 6
16. The nurse is caring for a client with right-sided heart failure who has ascites and
hepatomegaly. What interventions can the nurse first provide to ensure the client has
adequate nutritional intake?
A) Offer small, frequent feedings.
B) Give a medication to stimulate the appetite
C) Give the client anything he wants to eat.
D) Offer three larger meals throughout the day.
Ans: A
Feedback:
Preventing stomach distention increases the space in the thoracic cavity for lung
expansion. Medication for appetite stimulation would not be given prior to trying the
small, frequent feedings. The client should not be given foods high in sodium and
should not be given any foods they desire. Three large meals would distend the
abdomen and the client would not increase intrathoracic pressure.
17. A client in the hospital informs the nurse he “feels like his heart is racing and can't catch
his breath.” What does the nurse understand occurs as a result of a tachydysrhythmia?
A) It causes a loss of elasticity in the myocardium.
B) It reduces ventricular ejection volume.
C) It increases afterload.
D) It increases preload.
Ans: B
Feedback:
Reducing ventricular ejection volume because diastole, during which the ventricle fills
with blood (preload), is shortened as a result of a tachydsrhythmia. Causing a loss of
elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not
increased.
18. A client with heart failure is having a decrease in cardiac output. What indication does
the nurse have that this is occurring?
A) Heart rate of 72 beats/minute
B) Respiratory rate of 20 breaths/minute
C) Blood pressure 80/46 mm Hg
D) Oxygen saturation 94%
Ans: C
Feedback:
The body can compensate for changes in heart function that occur over time. When
cardiac output falls, the body uses certain compensatory mechanisms designed to
increase stroke volume and maintain blood pressure. These compensatory mechanisms
can temporarily improve the client's cardiac output but ultimately fail when contractility
is further compromised. A heart rate of 72 beats/minute is within normal range as well
as the blood pressure and oxygen saturation.
Page 7
19. The nurse assists the client to the bathroom, which is approximately 10 feet from the
bed. The client ambulates 3 feet and states, “I cannot catch my breath.” How would the
nurse document this finding?
A) “Can't walk without becoming short of breath.”
B) “Has paroxysmal nocturnal dyspnea when walking.”
C) “Has orthopnea when walking.”
D) Experiences exertional dyspnea when walking 3 feet; states, “I cannot catch my
breath.”
Ans: D
Feedback:
Exertional dyspnea is the effort at breathing when active. Answer A is vague and does
not give a more detailed explanation for documentation purposes. Orthopnea is the
inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being
awakened by breathlessness.
20. The nurse is gathering data from a client recently admitted to the hospital. The nurse
asks the client about experiencing orthopnea. What question would the nurse ask to
obtain this information?
A) “Are you only able to breathe when you are sitting upright?”
B) “How far can you walk without becoming short of breath?”
C) “Are you coughing up blood at night?”
D) “Are you urinating excessively at night?”
Ans: A
Feedback:
To determine if a client is having orthopnea, the nurse needs to ask about the inability to
breathe unless sitting upright. Determining how far the client can walk without
becoming short of breath would indicate exertional dyspnea. Coughing up blood would
indicate hemoptysis. Urinating excessively at night can be indicative of different factors
such as taking a diuretic late in the evening causing the client to urinate often at night.
This question would be vague.
Page 8
21. The nurse is obtaining data on an older adult client. What finding may indicate to the
nurse the early symptom of heart failure?
A) Decreased urinary output
B) Dyspnea on exertion
C) Hypotension
D) Tachycardia
Ans: B
Feedback:
Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of
arterial blood and respiratory symptoms. Many clients notice unusual fatigue with
activity. Some find exertional dyspnea to be the first symptom. An increase in urinary
output may be seen later as fluid accumulates. Hypotension would be a later sign of
decompensating heart failure as well as tachycardia.
22. A client with right-sided heart failure is admitted to the medical-surgical unit. What
information obtained from the client may indicate the presence of edema?
A) The client says that he has been urinating less frequently at night.
B) The client says he has been hungry in the evening.
C) The client says his rings have become tight and are difficult to remove.
D) The client says he is short of breath when ambulating.
Ans: C
Feedback:
Clients may observe that rings, shoes, or clothing have become tight. The client would
most likely be urinating more frequently in the evening. Accumulation of blood in
abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger.
Shortness of breath with ambulation would occur most often in left-sided heart failure.
23. A client is scheduled for a multiple gated acquisition (MUGA) scan the following day.
What medication should the nurse be sure not to administer the morning of the
procedure?
A) Furosemide (Lasix)
B) Acetaminophen (Tylenol)
C) Morphine sulfate
D) Guaifenesin (Mucinex)
Ans: A
Feedback:
Diuretics are contraindicated the morning of a test to avoid any interruptions for
urination. Clients are also medicated to relieve a cough that may cause movement
during the test so administration of Mucinex is not contraindicated. Tylenol and
morphine are not contraindicated the morning of the test.
Page 9
24. The nurse observes a client with an onset of heart failure having rapid, shallow
breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse
anticipate finding initially?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Ans: D
Feedback:
At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid,
shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes
more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors.
25. The nurse is providing discharge instructions to a client with heart failure preparing to
leave the following day. What type of diet should the nurse request the dietitian to
discuss with the client?
A) Low-fat diet
B) Low-potassium diet
C) Low-cholesterol diet
D) Low-sodium diet
Ans: D
Feedback:
Medical management of both left-sided and right-sided heart failure is directed at
reducing the heart's workload and improving cardiac output primarily through dietary
modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and
fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may
become potassium depleted and would need potassium in the diet. A low-cholesterol
and low-fat diet may be ordered but are not specific to the heart failure.
26. The nurse is preparing to administer digoxin to a client with heart failure. The nurse
obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What
is the first action by the nurse?
A) Administer the medication and inform the charge nurse about the rate.
B) Withhold the medication and notify the physician of the heart rate.
C) Administer atropine to speed the heart rate and then administer the digoxin.
D) Administer the medications and then notify the physician.
Ans: B
Feedback:
Digitalis drugs are withheld if the heart rate is less than 60 or more than 120
beats/minute until a physician is consulted. The other choices would have the nurse
administer the drug, which would not be the standard of practice.
Page 10
27. The nurse is preparing to administer furosemide (Lasix) to a client with severe heart
failure. What lab study should be of most concern for this client while taking Lasix?
A) BNP of 100
B) Sodium level of 135
C) Hemoglobin of 12
D) Potassium level of 3.1
Ans: D
Feedback:
Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These
drugs increase sodium and therefore water excretion, but they also increase potassium
excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP
does not demonstrate a severe heart failure. Sodium level of 135 is within normal range,
as is the hemoglobin level.
28. The nurse is administering captopril (Capoten) to a client with a diagnosis of heart
failure. What type of medication does the nurse inform the client is taking?
A) An angiotensin converting enzyme inhibitor (ACE) inhibitor
B) A thiazide diuretic
C) An angiotensin receptor blocker (ARB)
D) A calcium channel blocker
Ans: A
Feedback:
Captopril is an ACE inhibitor. Although the other medications may be used alone or in
conjunction with other medications, the ACE inhibitor is a standard medication used in
heart failure unless not tolerated by the client.
29. A client is awaiting the availability of a heart for transplant. What option may be
available to the client as a bridge to transplant?
A) Implanted cardioverter-defibrillator (ICD)
B) Pacemaker
C) Intra-aortic balloon pump (IABP)
D) Ventricular assist device (VAD)
Ans: D
Feedback:
VADs may be used for one of three purposes: (1) a bridge to recovery, (2) a bridge to
transport, or (2) destination therapy (mechanical circulatory support when there is no
option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is
not a bridge to transplant and will only correct the conduction disturbance and not the
pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump
to supplement the ineffectual contraction of the left ventricle. The IABP is intended for
only a few days.
Page 11
30. A client with heart failure informs the nurse he has not had a bowel movement in 2
days. Why would it be important for the nurse to obtain an order for a stool softener?
A) Straining causes the Valsalva maneuver, which can cause dangerous effects.
B) The client should not develop hemorrhoids.
C) The client can develop a rectal fissure, which will increase pain levels.
D) The client should have a bowel movement every day to avoid development of an
intestinal obstruction.
Ans: A
Feedback:
Avoid activities that engage the Valsalva maneuver, such as straining with bowel
elimination or using the arms to pull and reposition oneself. The Valsalva maneuver
increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and
increases blood pressure. The client's discomfort would be increased if hemorrhoids or a
rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary
for the client to have a bowel movement on a daily basis.
31. A client is brought to the emergency department via rescue squad with suspicion of
cardiogenic pulmonary edema. What complication should the nurse monitor for? Select
all that apply.
A) Nausea and vomiting
B) Pulmonary embolism
C) Cardiac dysrhythmias
D) Respiratory arrest
E) Cardiac arrest
Ans: C, D, E
Feedback:
Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange
in the alveoli. It represents an acute emergency and is a frequent complication of
left-sided heart failure. Cardiac dysrhythmias and cardiac or respiratory arrest are
associated complications. Nausea and vomiting are not complications but are symptoms
of many disorders. The client is not at increased risk for the development of pulmonary
embolism with pulmonary edema.
Page 12
32. A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen
saturation of 84%. What method of oxygen delivery would best meet the needs of this
client?
A) Intubation and mechanical ventilation
B) Face mask with nonrebreather
C) Oxygen cannula at 6 L/minute
D) Venturi mask at 35%
Ans: A
Feedback:
The client's respiratory status is severely compromised and has developed signs of
respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is
administered under continuous positive airway pressure or with mechanical ventilation
with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not
deliver the concentration or ventilatory support that an endotracheal tube with
mechanical ventilation will provide.
33. A client develops cardiogenic pulmonary edema and is extremely apprehensive. What
medication can the nurse administer with physician orders that will relieve anxiety and
slow respiratory rate?
A) Furosemide (Lasix)
B) Nitroglycerin
C) Dopamine (Intropin)
D) Morphine sulfate
Ans: D
Feedback:
Morphine seems to help relieve respiratory symptoms by depressing higher cerebral
centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes
muscle relaxation and reduces the work of breathing. Lasix is a loop diuretic and will
decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote
smooth muscle relaxation in the vessel walls and will relieve pain but not reduce
anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction
but will not alleviate anxiety.
34. A client is taking furosemide (Lasix) for the treatment of heart failure. What food
should the nurse suggest that is rich in potassium?
A) Pasta
B) Peanut butter
C) Coffee
D) Angel food cake
Ans: B
Feedback:
Peanut butter is rich in potassium and low potassium items are pasta, coffee, and angel
food cake.
Page 13
35. The nurse instructs the client with heart failure to weight themselves at the same time
each day using the same scale. When should the client contact the physician?
A) If the weight gain is more than 3 lb in 1 week.
B) If the weight gain is more than 4 lb in 1 month.
C) If the weight gain is more than 2 lb in 24 hours.
D) If the weight gain is more than 1 lb in 48 hours.
Ans: C
Feedback:
Check weight at the same time each day using the same scale: consult a physician if you
gain more than 2 pounds in 24 hours. The other distractors are not correct since there is
a variance with weight on a daily basis.
Page 14
1. Chapter 29
The nursing instructor is giving a class on assessing cardiac clients after thoracic
surgery. What assessment is most important for the nurse to perform when caring for
this client?
A) Pulmonary artery pressure
B) Temperature
C) Skin and mentation
D) Blood pressure
Ans: D
Feedback:
The nurse assesses the blood pressure (BP) and pulse rate in both arms after thoracic
surgery. Although it is necessary for the nurse to also assess pulmonary artery pressure,
temperature, skin, and mentation after thoracic surgery, blood pressure and pulse rate
are the most essential assessments.
2. When discussing the nursing process, the instructor stresses that for clients undergoing
cardiac surgery, it is important for the nurse to demonstrate competence. What is the
rationale for this statement?
A) To acknowledge the client's emotion
B) To encourage verbal conversation
C) To relieve the client's insecurity and anxiety
D) To encourage the client to communicate
Ans: C
Feedback:
When the nurse is knowledgeable and competent, it relieves the client's insecurity and
anxiety regarding the surgery.
3. A nurse caring for a client who has had cardiac or vascular surgery knows to do hourly
assessments on which of the following?
A) Blood sugar level
B) Fluid intake and urine output
C) Mentation
D) Blood pressure and pulse rate in both arms
Ans: B
Feedback:
While accessing a client undergoing cardiac or vascular surgery, the nurse assesses the
client's fluid intake and urine output on hourly basis. The nurse may assess the blood
sugar level during the initial assessment process but not hourly. For a client undergoing
a cardiac or vascular surgery, the nurse does not assess for mentation. The nurse
assesses the client's blood pressure and pulse rate in both arms after thoracic surgery.
Page 1
4. The pathophysiology instructor is discussing heart disease with a class of prenursing
students. One of the students asks what indications there are for coronary artery bypass
surgery with cardiopulmonary bypass. What would be the instructor's answer? Select all
that apply.
A) Atheromas are calcified and noncompressible.
B) The heart cannot be repaired without compromising oxygenation of the body.
C) The client has multiple coronary artery occlusions.
D) Transluminal coronary angioplasty is necessary.
E) The anatomic location of the occlusion(s) interferes with the safe insertion of a
coronary artery catheter.
Ans: A, B, E
Feedback:
A coronary artery bypass is performed when (1) the client has multiple coronary artery
occlusions, (2) the atheromas are calcified and noncompressible, or (3) the anatomic
location of the occlusion(s) interferes with the safe insertion of a coronary artery
catheter. This makes options B and D incorrect.
5. One of the nursing students asks the nursing instructor why someone would need
cardiac surgery. What would be an appropriate response by the nursing instructor?
A) A ventricular aneurysm
B) Mitral valve sufficiency
C) An atrial aneurysm
D) Endocarditis
Ans: A
Feedback:
A ventricular aneurysm is the most lethal complication among clients who survive the
acute stage of a myocardial infarction (MI). Because the motion of the myocardium may
rupture the aneurysm, an emergency procedure may be performed to suture the
weakened area. If waiting is possible, the stretched tissue is excised 4 to 8 weeks after
the MI when scar tissue has formed. If surgery is performed too early, it is difficult to
differentiate healthy from necrotic tissue, and sutures placed in necrotic tissue usually
are not retained. Mitral valve insufficiency produces a “backup” of blood within the left
atrium but is not necessarily a cause for surgery. Atrial aneurysm is rare. Endocarditis is
an infection and does not require surgery.
Page 2
6. While teaching a pathophysiology class, you are asked what vessels are used for
alternative grafts if the saphenous vein is not used. What would be your answer? Select
all that apply.
A) The popliteal vein
B) The internal mammary artery
C) The gastroepiploic artery
D) The basilic and cephalic veins in the arm
Ans: B, C, D
Feedback:
Alternative graft vessels include the following: the internal mammary and internal
thoracic arteries in the chest; the basilic and cephalic veins in the arm; the radial artery
in the arm; and the gastroepiploic artery from the stomach, in some cases. This makes
option A incorrect.
7. You are caring for an 81-year-old client who is deciding whether to have cardiovascular
surgery. The client asks you why the risks are greater for them than for a younger
person, what would be your answer?
A) Many older adults have other things wrong with them besides their cardiac
problems.
B) Older adults have the same risk factors as younger adults.
C) Older adults have hypersensitive renal systems, and younger adults don't.
D) Older adults have different thought processes than younger adults do.
Ans: A
Feedback:
Many older adults have comorbidities such as diabetes, heart failure, cardiac
dysrhythmias, hypertension, and poor renal function, necessitating careful consideration
regarding the potential risks and benefits of cardiovascular surgery. These clients
require close observation during the postoperative period. Options B, C, and D are
incorrect.
8. A client has been admitted for a commissurotomy. You know that a commissurotomy
repairs which of the following?
A) A ventricle
B) A valve
C) Part of the myocardium
D) An artery
Ans: B
Feedback:
Heart valves need surgical repair or replacement if they become narrowed (stenosed) or
stretched (incompetent). One method of repair is commissurotomy (opening adhesions
in the valve cusps), which is done without direct visualization of the valve.
Page 3
9. Bruising and bleeding of the heart may be caused by blunt trauma. What may stop the
bleeding?
A) Embolectomy
B) Pericarditis
C) Thoracentesis
D) Inactivity and pressure from blood in the pericardium
Ans: D
Feedback:
The inactivity and increased pressure from blood in the pericardium may stop the
bleeding. The client may need to have the blood aspirated from the pericardial sac, in
which case pericardiocentesis is performed. One aspiration is sufficient in most cases,
but if bleeding continues, open thoracotomy is indicated to control blood loss.
Procedures to stop the bleeding caused by heart trauma do not include embolectomy or
thoracentesis. Pericarditis is an inflammation of the pericardium.
10. A nurse caring for a client who has had cardiac surgery must understand how pulmonary
artery pressure is monitored. What is important about pulmonary artery pressure?
A) Aids in early treatment of right-sided congestive heart failure
B) Aids in the early treatment of fluid imbalances
C) Assesses right-sided heart pressures
D) Assesses left atrial heart pressures
Ans: B
Feedback:
Pulmonary artery pressure monitoring aids in the early treatment of fluid imbalances,
prevents left-sided congestive heart failure or promotes its early correction, and helps
monitor the client's response to treatment. Options C and D are incorrect. The
measurement of pulmonary artery pressure does not assess right-sided heart pressures or
left atrial pressure.
11. A client will be placed on cardiopulmonary bypass for a mitral valve replacement. What
type of medication will be required for this client?
A) An anticoagulant
B) A calcium channel blocker
C) An antipyretic
D) A beta-adrenergic blocker
Ans: A
Feedback:
One of the disadvantages of cardiopulmonary bypass is the need for anticoagulation. A
calcium channel blocker, antipyretic, and beta-adrenergic blocker are not required for a
client on cardiopulmonary bypass.
Page 4
12. A client has experienced a myocardial infarction (MI). After the acute stage of the MI,
what is the most lethal complication the nurse should be aware can occur?
A) Thrombophlebitis
B) Ventricular aneurysm
C) Mitral valve prolapse
D) Septic shock
Ans: B
Feedback:
A ventricular aneurysm is the most lethal complication among clients who survive the
acute stage of a myocardial infarction (MI). Thrombophlebitis is a complication of
immobility. Mitral valve prolapse is an acquired disorder that is not a complication from
having an MI. Cardiogenic shock, not septic shock, is a complication after sustaining an
MI.
13. A client recently had a myocardial infarction (MI) and asks the nurse if he will require a
heart transplant. Based on the nurse's knowledge of indications for heart transplant,
what is the best response?
A) “No. Heart transplant is indicated for cardiomyopathy, end-stage coronary artery
disease, and end-stage heart failure.”
B) “No. Heart transplant is only indicated for congenital heart defects.”
C) “Yes. You may require a heart transplant if you have another heart attack.”
D) “Yes. Your heart will not function as well as it did before the heart attack, and a
new heart will give you the best chance for survival.”
Ans: A
Feedback:
In adults, heart transplantation is indicated for cardiomyopathy, end-stage coronary
artery disease, and end-stage heart failure. In newborns and infants, heart transplantation
is indicated for a severe congenital cardiac defect. It is performed only when other
treatment modalities fail or are unavailable. It is not used to treat clients after an MI
unless they meet any of the given criteria.
Page 5
14. A client had a cardiac transplant 6 weeks previously. The client calls the clinic and
informs the nurse he has a fever of 101° F, chest tenderness, and flulike symptoms.
What does the nurse suspect the client is experiencing?
A) Hyperacute rejection
B) Acute rejection
C) Chronic rejection
D) Subacute rejection
Ans: B
Feedback:
Acute rejection occurs from 1 week to 3 months after the transplant; almost all
transplant recipients experience acute rejection to some degree. Hyperacute rejection is
rare and occurs within a few minutes of the transplant when the donor organ and
recipient are extremely mismatched. Chronic rejection may occur at any time over the
remaining lifetime of a recipient, causing varying degrees of damage to the donor heart.
Subacute rejection is not a classification of rejection.
15. The nurse is preparing the client for discharge after cardiac transplant. The client has a
prescription for tacrolimus (Prograf). What should the nurse include in the instructions?
A) Do not take the medication with grapefruit juice.
B) The medication may be crushed and put in chocolate milk.
C) If a dose is skipped, you may double the next dose.
D) Do not take any over-the-counter medications.
Ans: A
Feedback:
Tacrolimus (Prograf) should not be taken with grapefruit juice. Omit the morning dose
when and until blood work is completed. The medication should not be crushed. A
double dose should not be taken unless approved by the physician. There are some
medications that may be taken but prior approval should be had by the physician.
16. A client will be taking mycophenolate (CellCept) to reduce the risk of rejection after a
cardiac transplant. What should the nurse be sure to inform the client to report?
A) Increase in appetite
B) Swelling of the fingers
C) A cough
D) Unusual bleeding or bruising
Ans: D
Feedback:
CellCept may lower the platelet count. The client should be instructed to report any
unusual bleeding or bruising. Cough, swelling of the fingers, or increase in appetite are
not indicators of a low platelet count.
Page 6
17. The nurse is obtaining vital signs for a client in the clinic who has had a cardiac
transplant. The nurse obtains an apical heart rate of 110 beats/minute. What is a priority
action by the nurse?
A) Obtain an electrocardiogram.
B) Notify the physician.
C) No action is required because the transplanted heart beats faster than the natural
heart.
D) Administer a calcium channel blocker to decrease the heart rate.
Ans: C
Feedback:
The transplanted heart beats faster than the client's natural heart, averaging about 100 to
110 beats/minute, because nerves that affect heart rate have been severed. The new heart
also takes longer to increase the heart rate in response to exercise. If the client is
asymptomatic, there is no reason to obtain an ECG or notify the physician. The nurse
would not administer the calcium channel blocker without a physician's order.
18. A client is diagnosed with obstructive atherosclerotic plaque of the left carotid artery.
What procedure does the nurse anticipate preparing the client for?
A) Endarterectomy
B) Thrombectomy
C) Embolectomy
D) Coronary artery bypass graft
Ans: A
Feedback:
Endarterectomy is the resection and removal of the lining of an artery. This type of
surgery is performed to remove obstructive atherosclerotic plaques from the aorta,
carotid, femoral, or popliteal arteries. A thrombectomy is used to remove a thrombus for
a vessel. An embolectomy is the removal of an embolus. Coronary artery bypass
grafting is not indicated for the removal of an atherosclerotic plaque.
Page 7
19. A client is in the intensive care unit with a diagnosis of severe uncontrolled
hypertension. What method of monitoring would best meet the needs of this client?
A) Central venous pressure monitoring
B) Direct blood pressure monitoring
C) Pulmonary artery pressure monitoring
D) Manual blood pressure readings with a sphygmomanometer
Ans: B
Feedback:
Direct blood pressure monitoring continuously displays the waveform and indicates the
client's systolic, diastolic, and mean arterial pressures. This type of equipment
eliminates the need to auscultate the BP. Direct BP monitoring may be used in clients
with severe and sustained hypertension or hypotension and during and after cardiac
surgery. Central venous pressure monitoring would be used to detect an excess or deficit
in venous blood volume and would not be indicated for this client. Pulmonary artery
pressure monitoring aids in the early treatment of fluid imbalances prevents left-sided
heart failure or promotes its early correction and helps monitor the client's response to
treatment and would not be indicated for this client. A manual reading is dependent on
who takes the BP and can vary in its readings. It is not as accurate as the direct blood
pressure monitoring.
20. The nurse is measuring central venous pressure readings for a client receiving fluid
resuscitation. Prior to obtaining the reading, what priority nursing action is required?
A) Have the head of the bed at 90°.
B) Ensure the level of the transducer is at the level of the right atrium.
C) Ensure the transducer is above the level of the heart.
D) Ensure the transducer is 2 inches below the level of the heart.
Ans: B
Feedback:
When measuring CVP, the nurse makes sure that the transducer is at the level of the
client's right atrium; otherwise, an incorrect reading is obtained. The client is position
supine or with the head slightly elevated but in exactly the same position as during
previous measurements. Between CVP measurements, the head of the bed can be raised
or lowered.
Page 8
21. A client has a pulmonary artery catheter for monitoring and to ensure fluid balance.
When measuring pulmonary capillary wedge pressure, the nurse forgets to deflate the
balloon and leaves it inflated. What outcome can be the result of this action by the
nurse?
A) Pulmonary embolism
B) Pulmonary edema
C) A myocardial infarction
D) Pulmonary infarction
Ans: D
Feedback:
When measuring pulmonary capillary wedge pressure, the balloon must be deflated
immediately after the pressure is measured to avoid pulmonary infarction from
prolonged blockage of capillary blood flow. Pulmonary embolism, pulmonary edema,
and myocardial infarction would not be the result of not deflating the balloon initially.
22. A client has had cardiothoracic surgery, and the nurse is palpating the peripheral pulses.
The nurse cannot palpate the left lower extremity pulse. What is the first action by the
nurse?
A) Call the physician.
B) Call the charge nurse.
C) Apply a vasodilator such as nitroglycerin cream on the skin surface and then
palpate.
D) Use a Doppler ultrasound device.
Ans: D
Feedback:
Palpate the peripheral pulses or use a Doppler ultrasound device if the pulses are not
palpable. Prior to calling the physician or notifying the charge nurse, attempt to use the
Doppler, and then, if no pulse is heard, you may notify either. Administration of
medications without a physician's order is contraindicated.
Page 9
23. The nurse is answering questions that the client and family have about the upcoming
cardiovascular surgery the client is having. What expected outcome would be best for a
nursing diagnosis of Deficient Knowledge related to unfamiliarity with diagnostic tests,
preoperative preparations, and postoperative care?
A) Client and family will understand the purpose, preparation, and aftercare of tests
and surgery.
B) Provide verbal and written information concerning the surgical procedure and
aftercare.
C) Ask the client or family member to explain the surgical procedure before signing
the consent form.
D) Clarify misconceptions concerning surgery.
Ans: A
Feedback:
Client and family will understand the purpose, preparation, and aftercare of tests and
surgery is an outcome statement that would be appropriate for the diagnostic statement.
The other statements are all interventions that are associated with the diagnostic
statement and outcome standard.
24. The client is being prepared for cardiothoracic surgery and is very apprehensive. What
medication can be administered with a physician's order to decrease the amount of
anesthetic that the client will receive in surgery?
A) An antipsychotic drug
B) An anxiolytic drug
C) An anticholinergic drug
D) An analgesic
Ans: B
Feedback:
Anxiolytics may be used before surgery to lessen anxiety and sedate the client. Clients
who are relaxed and sedated when anesthesia is given require a smaller dose of
anesthetic. An antipsychotic would not be indicated for this client. An anticholinergic
medication may be given to decrease the amount of secretions the client will have
during surgery but will not decrease anxiety. An analgesic is normally given
postoperatively for pain control.
Page 10
25. A client is 2 days postoperative from mitral valve replacement and is in pain at an 8 on a
0 to 10 scale. What interventions can the nurse provide to control the pain before getting
to this level? Select all that apply.
A) Suggest the client be placed on a patient-controlled analgesia (PCA) pump.
B) Administer a non-narcotic analgesic between prescribed doses of narcotic
analgesics.
C) Administer the pain medication prior to the pain becoming severe.
D) Wait until the client asks for the pain medication.
E) Administer the narcotic analgesic more frequently.
Ans: A, B, C
Feedback:
Small, frequent self-administration of an opioid drug controls acute pain within
consistently tolerable levels. Administer non-narcotic analgesics between prescribed
doses of narcotic analgesics. Non-narcotics have a different mechanism of action and
are not likely to cause respiratory depression or depressed level of consciousness if
given concurrently with narcotics. Pain is more easily controlled by giving analgesic
medication before the pain becomes severe, so you would not wait until the client to ask
for the pain medication. The nurse cannot administer more of the narcotic than the
physician orders.
26. The nurse is caring for a client postoperatively after undergoing a coronary artery
bypass graft. What intervention can the nurse provide to reduce the risk of the
development of wound dehiscence?
A) Encourage oral fluids.
B) Assess lung sounds every 8 hours.
C) Suction the client every 2 hours.
D) Assist the client to splint with a pillow when coughing and deep breathing.
Ans: D
Feedback:
Instruct the client to press a pillow against the chest when deep breathing, coughing, and
performing active exercise. Splinting promotes comfort and decreases the potential for
dehiscence. Encouraging oral fluids will not prevent dehiscence. Lungs should be
assessed every 4 hours or more frequently according to the client's condition. Suction
should only be provided as needed.
Page 11
27. The nurse listens to the lung sounds of a postoperative client and determines that the
client is not able to clear the secretions from the lungs. What intervention should the
nurse provide prior to suctioning?
A) Hyperoxygenate the client with 100% oxygen.
B) Place the client in the supine position.
C) Plan to suction for at least 20 seconds to remove secretions.
D) Administer a sedative prior to suctioning.
Ans: A
Feedback:
Hyperoxygenate with 100% oxygen before suctioning; do not suction for more than 10
to 15 seconds. Suctioning removes oxygen and can cause hypoxemia, myocardial
ischemia, and dysrhythmias. Hyperoxygenation saturates the blood and hemoglobin to
compensate for temporary removal during suctioning. Elevate the head of the bed, not
place the client in the supine position. Administering a sedative may cause respiratory
depression and should be avoided prior to suctioning so the cough reflex will not be
depressed.
28. The nurse is caring for a client who is having a mitral valve replacement with a
mechanical valve. What instructions should the nurse be sure the client understands
prior to being discharged?
A) The valve should last for 10 to 15 years.
B) The client will require anticoagulation.
C) There is a low potential for thrombi formations so anticoagulation is not
necessary.
D) The valve is prone to calcification.
Ans: B
Feedback:
A mechanical valve should last at least 20 years. The disadvantages are the risk for
thrombi and emboli, so anticoagulation are necessary. There is a risk of bleeding, and
there can be a sudden malfunction in the valve. An allograft will last 10 to 15 years. A
bioprosthetic valve does not require anticoagulation but is prone to deterioration and
calcification.
Page 12
29. A client is at the clinic for follow-up after cardiothoracic surgery and tells the nurse, “I
don't know what is wrong with me. I don't want to eat, and I feel depressed.” What is the
best response by the nurse to this statement?
A) “I think we need to get you in to see a psychiatrist.”
B) “There should be no reason for you to be depressed. You came through the
surgery fine.”
C) “It may take several weeks for your appetite to return, and the depression is
normal and temporary.”
D) “You need to tell the physician because this could be serious.”
Ans: C
Feedback:
Discharge instruction should be given prior to the client leaving the hospital about it
taking several weeks for a normal appetite to return and that depression is normal and
temporary. The client does not need psychiatric help at this point but may benefit from a
support group with other clients that have had cardiothoracic surgery. Informing a client
that he has no reason for being depressed is nontherapeutic and demeans the client's
feelings. Informing the physician because the depression could be serious could cause
alarm.
30. A client had cardiothoracic surgery and informed the nurse that he has a 6-month-old
grandchild. The client states, “I can't wait to hold my grandchild!” What is the best
response by the nurse?
A) “I bet your grandchild is wonderful, and I know you are glad you made it through
the surgery.”
B) “I am sure you are excited to see your grandchild but you must refrain from
lifting, pushing, or pulling anything over 10 lb for at least 6 to 12 weeks.”
C) “You will not be able to lift that grandchild for at least 6 months, but you can sit
with him and play.”
D) “You have done so well after your surgery, and there are no restrictions for your
activities.”
Ans: B
Feedback:
The client must refrain from lifting, pushing, or pulling anything that weighs more than
10 lb until the physician relieves the restriction in approximately 6 to 12 weeks.
Informing the client that he is glad he made it through the surgery is nontherapeutic. Six
months for lifting is an excessive time frame for activity to resume. There are several
restrictions that the client should be made aware of during the postoperative time period.
Page 13
31. After being discharged from the hospital after undergoing cardiothoracic surgery, the
client asks the nurse when he can resume sexual activity. What is the best response by
the nurse?
A) “I can't believe you are worried about that so soon after your surgery.”
B) “You won't be able to resume sexual activity until your 6-month checkup with the
surgeon.”
C) “In about 2 to 4 weeks if you are able to climb stairs without difficulty breathing
or chest pain.”
D) “You may have a difficult time resuming sexual activities after this surgery.”
Ans: C
Feedback:
Sexual relations usually can be resumed in 2 to 4 weeks depending on your comfort
level and tolerance for activity; climbing two flights of stairs without dyspnea or chest
pain is a common guideline. Option A and D are nontherapeutic responses to the client's
concern. Six months is an excessively long time period to wait if the client has been able
to resume activities without shortness of breath or chest pain.
32. A client has been discharged from the hospital following coronary artery bypass grafting
(CABG). The client asks the nurse about the chest pain he experienced prior to coming
to the hospital during the heart attack. What instructions should the nurse include in the
instructions?
A) “If chest pain occurs, rest. If it doesn't go away, take nitroglycerin and report the
even to the physician even if the pain is relieved.”
B) “If chest pain occurs, take a nitroglycerin. If unrelieved, take another one 5
minutes later. If relieved, no further action is required.”
C) “If chest pain occurs, it may be related to gastritis. Take an antacid and lie down
for 30 minutes.”
D) “You should not have chest pain because you had the CABG, and it fixed the
problem with your heart.”
Ans: A
Feedback:
If chest pain occurs after the client has had a CABG, the client should take a
nitroglycerin, and even if relieved, the client need to report the incidence to the
physician. Reocclusion of a vessel may occur, or a new myocardial infarction may occur
from another vessel occlusion. If the pain is relieved, the client may have had a coronary
vasospasm. The client should notify the physician for any chest pain even if it is
relieved. The client should not attribute the pain to a gastrointestinal symptom and
notify the physician. Chest pain may still occur as well as a myocardial infarction even
after a CABG.
Page 14
33. The nurse is preparing a client for coronary artery bypass surgery. What vessel does the
nurse know is most commonly used for grafting?
A) Saphenous vein
B) Basilic vein
C) Radial artery
D) Gastroepiploic artery
Ans: A
Feedback:
The saphenous vein in the leg is the vessel most often used for grafting in coronary
artery bypass. The basilic vein in the arm, radial artery in the arm, and gastroepiploic
artery from the stomach are alternative graft vessels.
34. The client will be having a surgical procedure that does not use cardiopulmonary
bypass, and the surgeon keeps the heart at a rate of 40 beats/minute. What surgical
procedure does the nurse anticipate preparing the client for?
A) Port access coronary artery bypass (PACAB)
B) Heart transplant
C) Coronary artery bypass grafting
D) Off-pump coronary artery bypass (OPCAB)
Ans: D
Feedback:
OPCAB is very similar to conventional CABG except that it does not involve the use of
a cardiopulmonary bypass machine. Instead, the surgeon keeps the heart beating at a
slow rate (about 40 beats/minute) with drugs such as adenosine (Adenocard) and
esmolol (Brevibloc). The other answers require cardiopulmonary bypass.
35. A client was driving a car without wearing a seat belt and slid off of the road and hit a
tree. The client's chest was crushed against a steering wheel. What type of lethal injury
does the nurse anticipate the client may have suffered?
A) Cardiac tamponade
B) A pleural effusion
C) Bladder trauma
D) Fractured pelvis
Ans: A
Feedback:
A nonpenetrating injury of the chest, such as being crushed against a steering wheel,
may cause bruising and bleeding of the heart. Because the pericardium encloses the
heart, blood accumulates in the pericardial space, resulting in cardiac tamponade.
Although a fractured pelvis and bladder trauma may be sustained, they are generally not
lethal. A pleural effusion would not result from this traumatic injury.
Page 15
36. A client has been waiting for a donor heart for several months. When he receives the
call that a heart has become available, the client states, “How long do I have to get to the
hospital?” What is the best response by the transplant nurse?
A) “You can take your time. We have to get your heart so it could be 24 hours.”
B) “You must be at the hospital within the next 15 minutes, or your heart will go the
next person on the list.”
C) “The heart has to be transplanted within 6 hours, so it is advisable that you go to
the hospital to be prepared now.”
D) “We can put the heart on ice and wait for you for 2 days.”
Ans: C
Feedback:
When a donor heart becomes available, it must be removed from the donor and
transplanted within 6 hours of being harvested. Answers A and D are too long of a time
frame for the donor heart to be transplanted. It is unreasonable to expect a client to be in
the hospital within 15 minutes and would be an incorrect time frame.
Page 16
1. Chapter 30
You are caring for three clients who have the following blood count values: Client A has
24,500/mm3 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C
has a 250,000/mm3 platelet count. Which statement correctly describes the condition of
each client?
A) Client A has a normal WBC count, client B has a higher hemoglobin count than
normal, and client C has a normal platelet count.
B) Client A has a higher WBC count than normal, client B has a normal hemoglobin
count, and client C has a normal platelet count.
C) Client A has a higher WBC count than normal, client B has a normal hemoglobin
count, and client C has a higher platelet count than normal.
D) Client A has a normal WBC count than normal, client B has a normal hemoglobin
Ans: B
count, and client C has a normal platelet count.
Feedback:
The normal leukocyte count is between 5000 and 10,000/mm3. Client A has an
increased number of leukocytes greater than 10,000/mm3 and hence has leukocytosis. In
adults, the normal amount of hemoglobin is 12.0 to 17.4 g/dL; therefore, client B has a
normal hemoglobin count. A normal circulating platelet count is 150,000 to
350,000/mm3 platelets; therefore, client C has a normal platelet count.
2. A client is admitted to the emergency department with significant blood loss. The
physician orders 2 units of packed red blood cells to be transfused immediately. Which
blood groups would be compatible with his O Rh-positive blood group?
A) O Rh-positive or O Rh-negative
B) Only O Rh-positive
C) Only O Rh-negative
D) AB Rh-positive or Rh-negative
Ans: A
Feedback:
People with Rh-positive blood can receive Rh-positive or Rh-negative blood because a
negative Rh indicates a missing Rh factor. Antibodies, immunoglobulins in plasma that
inactivate any substance that is nonself, react with incompatible red blood cell antigens.
Therefore, people with type O blood are universal donors because they do not have
antigens on the red cell membrane. Therefore, the client can be transfused with either O
Rh-positive or O Rh-negative blood.
Page 1
3. You are caring for a client who is undergoing bone marrow aspiration to determine the
blood cell formation status. What nursing intervention should you provide to your client
during the test?
A) Administer oral radioactive vitamin B12 to the client.
B) Administer a nonradioactive B12 injection.
C) Collect urine for 24 to 48 hours after the client receives the nonradioactive B12.
D) Support the client and monitor the status.
Ans: D
Feedback:
When a client undergoes a bone marrow aspiration, the nurse assists the physician,
supports the client during the procedure, and monitors his or her condition afterward.
The client needs to be administered oral radioactive vitamin B12 or a nonradioactive B12
injection in case of the Schilling test, which helps in determining pernicious anemia and
macrocytic anemia. Collecting urine for 24 to 48 hours after administering
nonradioactive B12 is also applicable to the Schilling test.
4. A nurse is providing care to a cancer patient. Which protein in plasma functions
primarily as immunologic agents?
A) Gamma globulins
B) Albumin
C) Fibrinogen
D) Beta globulins
Ans: A
Feedback:
Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins
are also called immunoglobulins. Globulins function primarily as immunologic agents;
they prevent or modify some types of infectious diseases. Therefore options B, C, and D
are incorrect.
5. A patient's family member asks what hematopoiesis is. What should the nurse tell the
family member?
A) The manufacture and development of blood cells
B) The production of lymphatic fluid in the body
C) The making of red blood cells and lymph
D) The development of lymph in the bone marrow
Ans: A
Feedback:
Hematopoiesis is the manufacture and development of blood cells. It also considers the
lymphatic system, which includes the thymus gland and spleen; this system assists in the
maturation of certain lymphocytes. Hematopoiesis is not the production of lymphatic
fluid or the development of lymph in the bone marrow.
Page 2
6. The nursing instructor is teaching her clinical group about laboratory blood tests. What
is the major function of erythrocytes?
A) Act as mediators for the immune system
B) Destroy invading organisms
C) Transportation of O2 to the tissues and removal of CO2 from the tissues
D) Oxygenation of the brain
Ans: C
Feedback:
Erythrocytes (or RBCs) are flexible, anuclear (lacking a nucleus), biconcave disks
covered by a thin membrane through which oxygen (O2) and carbon dioxide (CO2) pass
freely. The flexibility of erythrocytes allows them to change shape as they travel
through capillaries. Their major function is to transport O2 to and remove CO2 from the
tissues. The RBCs are not involved in immunological functions, so choices A and B are
not correct. Oxygenation of the brain is important but that is not a major function of
RBCs.
7. A student nurse is having difficulty understanding the function of globulins. What
information can you provide to the student?
A) Immunologic agents
B) Destruction of invading organisms
C) Precursors to clot formation
D) Transport of oxygen to the tissues
Ans: A
Feedback:
Globulins function primarily as immunologic agents; they prevent or modify some types
of infectious diseases. Globulins do not destroy invading organisms, participate in clot
formation, or transport oxygen to the tissues.
8. Undifferentiated cells that migrate to the thymus gland develop into which of the
following?
A) A lymphocytes
B) D lymphocytes
C) T lymphocytes
D) S lymphocytes
Ans: C
Feedback:
The thymus gland is lymphatic tissue in the upper chest that contains undifferentiated
stem cells released from bone marrow. Once the undifferentiated cells migrate to the
thymus gland, they develop into T lymphocytes because they are thymus derived.
Options A, B, and D are distractors for this question.
Page 3
9. Macrophages attack and destroy foreign substances to the body. Where does this action
occur?
A) At the site of trauma
B) In the lymph node
C) In the vascular system
D) In the thymus
Ans: B
Feedback:
As lymph passes through the node, macrophages attack and engulf foreign substances
such as bacteria and viruses, abnormal body cells, and other debris. Options A, C, and D
are incorrect.
10. Albumin is a protein in the plasma portion of the blood. Under normal conditions,
albumin cannot pass through the wall of a capillary. What significance is this for the
vascular compartment?
A) Helps push oxygen into the tissues of the body
B) Retains leukocytes in the vascular compartment
C) Helps retain fluid in the vascular compartment
D) Absorbs carbon dioxide from the tissues for transport to the lungs
Ans: C
Feedback:
Under normal conditions, albumin cannot pass through a capillary wall. Consequently,
albumin helps maintain the osmotic pressure that retains fluid in the vascular
compartment. Albumin does not push oxygen into the tissues of the body or absorb
carbon dioxide for transport to the lungs. Albumin also does not retain leukocytes in the
vascular compartment.
11. A client is seeing the physician at the clinic and tells the nurse he is fatigued and short
of breath with minimal exertion. What lab study may reflect a decrease in transport of
oxygen?
A) Erythrocyte count
B) Leukocyte count
C) Platelet count
D) Albumin level
Ans: A
Feedback:
Erythrocytes function is to transport oxygen. Leukocytes protect against infection.
Platelets participate in clotting blood, and albumin affects intravascular osmotic
pressure.
Page 4
12. A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion.
He has been typed and crossmatched for 2 units of packed red blood cells and found to
have type O blood. What type of blood will the nurse administer to this client?
A) Type A
B) Type B
C) Type AB
D) Type O
Ans: D
Feedback:
Those with type O blood can only receive type O blood. Clients with all other blood
types can receive type O blood provided the Rh factor is compatible.
13. A client with end-stage renal disease has a decreased red blood cell production. What
medication can the nurse administer with physician's order that will increase the
production of erythrocytes?
A) Filgrastim (Neupogen)
B) Pegfilgrastim (Neulasta)
C) Epoetin alfa (Epogen)
D) Interleukin 2
Ans: C
Feedback:
The drug epoetin alfa (Epogen, Procrit) can be used to stimulate the production of
RBCs. Filgrastim (Neupogen) and pegfilgrastim (Neulasta) promote proliferation of
neutrophils. Interleukin 2 stimulates cytokine production by lymphocytes.
14. The nurse is discussing vitamin replacement with a client in the clinic. Which vitamin
should the nurse discuss with the client in order to increase the absorption of folic acid
and iron?
A) Vitamin B12
B) Vitamin C
C) Vitamin B6
D) Vitamin E
Ans: B
Feedback:
Vitamin C enhances the absorption of folic acid and iron. Vitamin B12 and folic acid are
essential for the maturation of red blood cells. Vitamin B6 serves as a coenzyme in
hemoglobin formation. Vitamin E protects blood cells from vitamin E–deficient
hemolytic anemia.
Page 5
15. A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does
the nurse understand is the basic nutritional component of heme in hemoglobin that the
client may be deficient in?
A) Folic acid
B) Copper
C) Protein
D) Iron
Ans: D
Feedback:
Iron is the basic nutritional component of heme in hemoglobin. Folic acid is essential
for the maturation of red blood cells. Copper (minute amount) is involved in the transfer
of iron from storage to plasma.
16. A client is brought to the emergency department with suspected bleeding esophageal
varices. Which hemoglobin level should the nurse immediately report to the physician?
A) 13.0 g/dL
B) 10.2 g/dL
C) 5.0 g/dL
D) 11.4 g/dL
Ans: C
Feedback:
The nurse should immediately report a 5.0 g/dL, which is a critical low level and should
be followed by a blood transfusion. A 13.0 g/dL is a normal level, 11.4 is slightly low,
and 10.2 is low.
17. A client informs the nurse that he is having a difficult time coping with seasonal
allergies and have taken some over-the-counter medications to assist with control of
symptoms. What results would indicate to the nurse that the client does have allergies?
A) Elevated eosinophils
B) Elevated basophils
C) Elevated monocytes
D) Elevated neutrophils
Ans: A
Feedback:
Eosinophils phagocytize foreign material. Their numbers increase in allergies, some
dermatologic disorders, and parasitic infections. Basophils are also capable of
phagocytosis; they are active in allergic contact dermatitis and some delayed
hypersensitivity reactions. Monocytes engulf microbial invaders and display the
antigenic surface to T lymphocytes. Neutrophils are a major component of the
inflammatory response and defense against bacterial infection.
Page 6
18. The nurse is inspecting the tonsils of a client that complaints of a sore throat for size and
appearance. What is the appropriate documentation for an observation of tonsils that
touch the uvula?
A) 1
B) 2
C) 3
D) 4
Ans: C
Feedback:
A scale of 3 is when the tonsils touch the uvula. A 1 is when the tonsils are visible, a 2
is when the tonsils extend medially toward the uvula, and a 4 is when the tonsils touch
each other.
19. The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse
observes purulent exudate on the surface of the tonsils. What does this finding indicate
to the nurse?
A) Filariasis
B) Thrush
C) An abscess
D) Tonsillitis
Ans: D
Feedback:
Purulent exudate on the surface of the tonsils suggests tonsillitis. Filariasis is also
known as elephantiasis and is a consequence of a roundworm infection in which the
lymphatic vessels become occluded. An abscess would not have purulent drainage on
the surface unless ruptured.
20. A client is scheduled for a Schilling test in the morning. What diagnostic results would
be indicated if the test is positive? Select all that apply.
A) Iron-deficiency anemia
B) Pernicious anemia
C) Macrocytic anemia
D) Malabsorption syndromes
E) A gastric ulcer
Ans: B, C, D
Feedback:
A Schilling test is used to diagnose pernicious anemia, macrocytic anemia, and
malabsorption syndromes. A blood test to determine iron-deficiency anemia would be
diagnostic. A gastric ulcer can be determined with a gastroesophagoscopy.
Page 7
21. The nurse is assisting the physician with obtaining a sample to determine the status of
blood cell formation. What type of procedure will the nurse have prepared the client
for?
A) A bone marrow aspiration
B) A Schilling test
C) A thoracentesis
D) A urine sample
Ans: A
Feedback:
A bone marrow aspiration is performed to determine the status of blood cell formation.
In this procedure, the physician applies local anesthesia and removes bone marrow from
the posterior iliac crest or the sternum. The marrow is examined for the types and
percentage of immature and maturing blood cells.
22. A client will be having a bone marrow aspiration to determine the status of blood cell
formation. What role does the nurse have during the test?
A) Inject the anesthetic so the client will have no sensation of pain.
B) The nurse explains the procedure to the patient and obtains the informed consent.
C) The nurse sets up the equipment for the physician and then must leave the room to
allow for privacy.
D) The nurse assists the physician and supports the client during the procedure.
Ans: D
Feedback:
The nurse assists the physician, supports the client during the procedure, and monitors
the client's status afterward. Injecting anesthetic agents is beyond the scope of practice
for the nurse. The physician obtains informed consent for the procedure, and the nurse
witnesses the signature. The nurse should not leave the room because the client requires
monitoring during and after the procedure.
Page 8
23. A client is scheduled for a bone marrow aspiration and is extremely apprehensive about
having the procedure done. The nurse explains that there may be a feeling of pressure or
discomfort when puncturing the bone. What intervention can the nurse provide to assist
with this concern?
A) Inform the client that he will not be able to move and will have to tolerate the
discomfort for 20 minutes.
B) Inform the client that if he is concerned that he will move when the bone is
punctured, soft wrist restraints can be used if the client approves.
C) Assist the client with focused imagery to avoid focusing on the procedure and any
discomfort associated with it.
D) Suggest chewing gum or eating candy in order to focus on something other than
the discomfort.
Ans: C
Feedback:
Suggest distraction techniques to avoid focusing on the pressure or discomfort
associated with puncturing the bone that may take approximately 20 minutes. Restraints
should not be applied during the procedure because the client may not be able to
determine if they are too tight. The client has a right to pain relief and should not have
to “tolerate” pain for 20 minutes. Chewing gum or eating candy may increase the
client's risk for aspiration during the procedure.
24. The nurse will be assisting the physician with a bone marrow aspiration. Where should
the nurse cleanse, clip hair, and drape the skin prior to the procedure?
A) Over the posterior superior iliac crest
B) Over the anterior tibia
C) Over the radius
D) Over the metatarsal area
Ans: A
Feedback:
The posterior superior iliac crest is the preferred site because no vital organs or blood
vessels are nearby. The anterior tibia, radius, or metatarsal area are not used for bone
marrow aspirations.
Page 9
25. The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest.
What would be the best position for the nurse to place the client in for the test?
A) Head of the bed in a 90° semi-Fowler's position
B) Prone position
C) On the side opposite the aspiration site
D) Lithotomy position
Ans: C
Feedback:
The client should be positioned on his or her back or side to facilitate access to the
aspiration site. The 90° semi-Fowler's and prone position would not allow adequate
access to the bone marrow aspiration site. The lithotomy position is used for
genitourinary and gynecological testing and procedures.
26. The nurse is assisting the physician to control the bleeding for a client who has had an
insertion of a vascular access. What can the nurse obtain for the physician to use to
control the bleeding?
A) A fibrin sponge
B) Injection of alpha globulins
C) Albumin
D) Injection of beta globulins
Ans: A
Feedback:
Fibrinogen plays a key role in forming blood clots. It can be transformed from a liquid
to fibrin, a solid that controls bleeding. Alpha and beta globulins function primarily as
immunologic agents; they prevent or modify some types of infectious diseases. The help
maintain osmotic pressure in the vascular compartment. Albumin is formed in the liver
and is the most abundant protein in plasma but does not stop vessel bleeding.
27. A client is volunteering to donate blood for the second time and was mailed a letter
telling him that he has type AB blood. If the client requires a blood transfusion in the
future, what type of blood must he receive?
A) They can receive blood from persons with any type of blood if the RH factor is
compatible.
B) They can only receive blood from persons with type A blood.
C) They can only receive blood from persons with type B blood.
D) They can only receive blood from persons with type O blood if the RH factor is
positive.
Ans: A
Feedback:
People with type AB blood are considered universal recipients because both A and B
antigens are present on the red cell membrane. Clients with type AB blood can receive
blood from persons with any type of blood, but the Rh factor must be compatible. The
other distractors are incorrect because the client can receive blood from any type.
Page 10
28. A client has been involved in an automobile accident and is assessed to have an
enlarged spleen. What does the nurse understand is the significance of attempting to
prevent unnecessary removal of the spleen for this client?
A) The spleen is a large lymph node and takes waste debris away.
B) The spleen is a lymphatic structure and assists with phagocytosis.
C) The spleen is lymphoid tissue in the upper chest that contains stem cells.
D) The spleen assists with blood clotting.
Ans: B
Feedback:
The spleen is the largest lymphatic structure, is a reservoir of blood, and contains
phagocytes that engulf damaged erythrocytes and foreign substances. Lymph fluid takes
waste debris away. The thymus is lymphoid tissue that is in the upper chest and contains
stem cells. The spleen does not assist with blood clotting.
29. Why would it be important for the nurse to obtain information regarding dietary history
of a client with a possible abnormality of the hematopoietic or lymphatic system?
A) It could determine if the illness is self-induced by nutritional starvation.
B) If the client has impaired protein intake, it will cause diseases of the
hematopoietic system.
C) Altered nutrition is the cause of abnormalities of the hematopoietic and lymphatic
system.
D) Compromised nutrition interferes with production of blood cells and hemoglobin.
Ans: D
Feedback:
The nurse obtains a dietary history because compromised nutrition interferes with the
production of blood cells and hemoglobin. The history cannot determine if the illness is
self- induced by starvation. Nutritional deficiencies do not cause diseases of the
hematopoietic system and lymphatic system.
30. A client is taking a medication that has the side effect of depressing the hematopoietic
system. What signs of leukopenia should the nurse monitor for while the client is taking
this drug?
A) Fever, sore throat, and chills
B) Nausea and vomiting
C) Diarrhea, diaphoresis, and fever
D) Intolerance to heat and rash
Ans: A
Feedback:
Closely monitor clients taking medications that depress the hematopoietic system,
particularly thrombocytes and leukocytes. Signs of leukopenia include fever, sore throat,
and chills. Nausea and vomiting, diarrhea, diaphoresis, heat intolerance, and rash are not
indicative of leukocytosis.
Page 11
31. The nurse is observing the skin of a client who is taking medications that depress the
hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding
for a prolonged period after an IV was started; and reports of black, tarry stool. What
does the nurse understand may be a side effect of this medication that the client
displays?
A) Leukocytosis
B) Leukopenia
C) Thrombocytopenia
D) Neutropenia
Ans: C
Feedback:
Signs of thrombocytopenia include unusual or easy bleeding; oozing from injection
sites; bleeding gums; and dark, tarry stools. Leukocytosis would cause fever as well as
other signs and symptoms of infection. Leukopenia symptoms are fever, sore throat, and
chills. Neutropenia reduces the client's ability to fight infection and makes susceptible to
microorganisms.
32. When obtaining vital signs from a client who has reduced erythrocyte production and a
hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?
A) Heart rate of 120 beats/minute
B) Respiratory rate of 16 breaths/minute
C) Blood pressure of 140/90 mm Hg
D) Oxygen saturation of 95%
Ans: A
Feedback:
A rapid pulse rate can indicate reduced erythrocytes or inadequate hemoglobin levels.
The respiratory rate for this client is within normal range. Hypertension is not indicative
of a low hemoglobin level, and what is usually seen would be hypotension. The oxygen
saturation level is within normal range.
33. The nurse observes that a client who had an arterial blood gas performed 30 minutes ago
is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes
after the puncture and another 5 minutes when the site was still oozing. What factor
does the nurse know will participate in the ability for the blood to clot?
A) Platelets
B) Leukocytes
C) Erythrocytes
D) Albumin
Ans: A
Feedback:
Platelets participate in clotting blood. Leukocytes protect against infection. Erythrocytes
transport oxygen, and albumin affects intravascular osmotic pressure.
Page 12
34. A client has laboratory studies that determine he is deficient in copper. What does the
nurse understand is the importance of copper in the body?
A) Essential for the maturation of red blood cells
B) Basic nutritional component of heme in hemoglobin
C) Involved in the transfer of iron from storage to plasma
D) Serves as a coenzyme in hemoglobin formation
Ans: C
Feedback:
Copper is involved in the transfer of iron from storage to plasma. Folic acid and B12 are
essential for the maturation of red blood cells. Iron is the basic nutritional component of
heme in hemoglobin. Vitamin B6 serves as a coenzyme in hemoglobin formation.
Page 13
1. Chapter 31
Your client was admitted to the emergency department after an accident with a chain
saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from
severe blood loss. What signs and symptoms would you assess for?
A) Malabsorption disorders
B) Postural hypotension
C) Fatigue
D) Reduced urine output
Ans: D
Feedback:
Acute hypovolemic anemia from severe blood loss is evidenced by the signs and
symptoms of hypovolemic shock, which include reduced urine output. The symptoms of
chronic hypovolemic anemia include fatigue and postural hypotension. Clients with
malabsorption disorders are at great risk of iron-deficiency anemia.
2. A client with a diagnosis of pernicious anemia comes to the clinic complaining of
numbness and tingling in his arms and legs. What do these symptoms indicate?
A) Loss of vibratory and position senses
B) Neurologic involvement
C) Severity of the disease
D) Insufficient intake of dietary nutrients
Ans: B
Feedback:
In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia
are the most common signs of neurologic involvement. Some affected clients lose
vibratory and position senses. Jaundice, irritability, confusion, and depression are
present when the disease is severe. Insufficient intake of dietary nutrients is not indicated
by these symptoms.
Page 1
3. The nurse caring for an older adult with a diagnosis of leukemia would encourage the
client to use an electric razor. Why?
A) Trauma and microabrasions may contribute to anemia.
B) Fragile tissues and altered clotting mechanisms may result in hemorrhage.
C) The client is at risk for spontaneous and uncontrolled bleeding.
D) The client is at risk for infection from microorganisms.
Ans: A
Feedback:
In a client with leukemia who is at risk for hemorrhage, the nurse handles the client
gently when assisting and encourages the client to use electric razors. Trauma and
microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and
altered clotting mechanisms may result in hemorrhage even after minor trauma.
Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports
melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and
uncontrolled bleeding or infection from microorganisms are not addressed by the use of
electric razors.
4. You are caring for an 87-year-old female who has been admitted to your unit with
anemia. What would you suspect?
A) Excessive consumption of coffee or tea
B) Elimination of iron by the body
C) Decrease in the total body iron stores with age
D) Blood loss from the gastrointestinal or genitourinary tract
Ans: D
Feedback:
If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is
suspected. This is because iron-deficiency anemia is unusual in older adults as the body
does not eliminate excessive iron, causing total body iron stores to increase with age.
Excessive consumption of coffee or tea is not a causative factor for anemia in older
adults.
Page 2
5. A client diagnosed with polycythemia vera has come into the clinic because he has
developed a nighttime cough, fatigue, and shortness of breath. What complication would
you suspect in this client?
A) Stroke
B) Tissue infarction
C) Congestive heart failure
D) Pulmonary embolus
Ans: C
Feedback:
The symptoms exhibited by this client are indicative of congestive heart failure.
Complications include hypertension, congestive heart failure, stroke, tissue and organ
infarction, and hemorrhage. Stroke would present with headache, aphasia, and/or
numbness in extremities. Tissue infarction would involve extremity discoloration or an
organ failure. Pulmonary embolism would be associated with chest pain.
6. You are caring for a client with multiple myeloma. Why would it be important to assess
this client for fractures?
A) Osteopathic tumors destroy bone causing fractures.
B) Osteoclasts break down bone cells so pathologic fractures occur.
C) Osteolytic activating factor weakens bones producing fractures.
D) Osteosarcomas form producing pathologic fractures.
Ans: B
Feedback:
The abnormal plasma cells proliferate in the bone marrow, where they release
osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells,
resulting in increased blood calcium and pathologic fractures. The plasma cells also
form single or multiple osteolytic (bone-destroying) tumors that produce a
“punched-out” or “honeycombed” appearance in bones such as the spine, ribs, skull,
pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the
spine accompanied by significant pain. Options A, C, and D are distractors for this
question.
Page 3
7. The nursing instructor is talking with her clinical group about coagulopathies. How
should the instructor define coagulopathies?
A) Coagulopathies are bleeding disorders that are characterized by abnormalities in
the numbers and types of red blood cells in the body.
B) Coagulopathies are bleeding disorders that involve platelets or clotting factors.
C) Coagulopathies are bleeding disorders that are characterized by a deficiency of
globulins in the plasma.
D) Coagulopathies are bleeding disorders that involve the destruction of stem cells in
the bone marrow.
Ans: B
Feedback:
Coagulopathies are bleeding disorders that involve platelets or clotting factors.
Coagulopathies do not involve the numbers and types of red blood cells. They are not
characterized by a deficiency of globulins in the plasma, and they do not involve the
destruction of stem cells in the bone marrow.
8. A client comes to the walk-in clinic complaining of weakness and fatigue. While
assessing this client, you find evidence of petechiae and ecchymoses. You note that the
spleen appears enlarged. What would you suspect is wrong with this client?
A) Aplastic anemia
B) Pernicious anemia
C) Iron-deficiency anemia
D) Agranulocytosis
Ans: A
Feedback:
Clients with aplastic anemia experience all the typical characteristics of anemia
(weakness and fatigue). In addition, they have frequent opportunistic infections plus
coagulation abnormalities that are manifested by unusual bleeding, small skin
hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged
with an accumulation of the client's blood cells destroyed by lymphocytes that failed to
recognize them as normal cells, or with an accumulation of dead transfused blood cells.
The blood cell count shows insufficient numbers of blood cells. A bone marrow
aspiration confirms that the production of stem cells is suppressed. This scenario does
not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.
Page 4
9. You are assisting your client with multiple myeloma to ambulate. What is the most
important nursing diagnosis to help prevent fractures in this client?
A) Increased mobility
B) Adequate hydration
C) Safety
D) Adequate nutrition
Ans: C
Feedback:
Safety is paramount because any injury, no matter how slight, can result in a fracture.
10. The nursing instructor is discussing disorders of the hematopoietic system with the
pre-nursing pathophysiology class. What disease would the instructor list with a primary
characteristic of erythrocytosis?
A) Polycythemia vera
B) Sickle cell disease
C) Aplastic anemia
D) Pernicious anemia
Ans: A
Feedback:
Polycythemia vera is associated with a rapid proliferation of blood cells produced by the
bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under
hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Options B, C, and
D do not have the characteristics of erythrocytosis.
11. A client is found to have a low hemoglobin and hematocrit when laboratory work was
performed. What does the nurse understand the anemia may have resulted from? Select
all that apply.
A) Infection
B) Blood loss
C) Abnormal erythrocyte production
D) Destruction of normally formed red blood cells
E) Inadequate formed white blood cells
Ans: B, C, D
Feedback:
Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte
production, or (3) destruction of normally formed red blood cells. The most common
types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic
acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form
of anemia has unique manifestations, all share a common core of symptoms. Anemia
does not result from infection or inadequate formed white blood cells.
Page 5
12. A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results.
What symptoms does the nurse expect to find for this client when collecting objective
data?
A) Postural hypotension
B) Urinary output of 10 mL/hr
C) Altered consciousness
D) Extreme pallor
Ans: A
Feedback:
Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural
hypotension, and rapid heart rate and respiratory rates. The symptom of decreased
urinary output, altered consciousness, and extreme pallor are all signs of acute
hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.
13. A client is being treated in the hospital for hypovolemia related to a bleeding peptic
ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112
beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the
nurse?
A) Administer blood.
B) Notify the physician.
C) Insert two large-bore intravenous catheters.
D) Administer a colloid solution.
Ans: B
Feedback:
A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute
should be reported immediately. Administering blood, inserting two large-bore IV
catheters, and administration of a colloid solution should be performed only with a
physician's order and may not be required at this time.
Page 6
14. The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic
shock. What indication does the nurse have that the client is having inadequate renal
perfusion?
A) Hematuria
B) Blood pressure of 90/60 mm Hg
C) Jaundice of the sclera
D) Urine output of 15 mL/hour
Ans: D
Feedback:
Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The
kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes
sufficiently. Hematuria is an indicatory of other problems such as hemorrhagic cystitis,
trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of
90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor
does jaundice. Jaundice is present when the liver starts to fail.
15. The nurse is caring for a client who is developing hypovolemic shock from a duodenal
ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow
to the brain?
A) Prepare the client for an endoscopy.
B) Administer a crystalloid solution.
C) Place the client in a modified Trendelenburg position.
D) Test the client for blood in the stool.
Ans: C
Feedback:
The first action by the nurse would be to place the client in a modified Trendelenburg
position to facilitate blood flow to the brain. Administering a crystalloid solution and
testing the client for blood in the stool may be later action but is not relevant in
facilitating blood flow to the brain. Preparing the client for an endoscopy would be
important after the physician obtains the informed consent but would not facilitate blood
flow to the brain.
Page 7
16. The LPN is following a plan of care for a client who is being treated for hypovolemic
anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2
saturation and observes the saturation at 89% for 3 minutes. What should the first action
by the nurse be?
A) Notify the charge nurse.
B) Prepare to assist with intubation.
C) Give oxygen per nasal cannula
D) Place the client in the supine position.
Ans: C
Feedback:
An expected outcome for the client with hypovolemic anemia is to monitor to detect
hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation
should be monitored to measure the percentage of oxygen bound to hemoglobin. The
nurse should report a sustained oxygen saturation value below 90%. Give oxygen per
nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is
important to administer the oxygen first and then contact the charge nurse to alert them.
It is not necessary at this time if the client is not in respiratory distress to intubate the
client. Placing the client in the supine position would decrease the oxygen saturation
level further.
17. The registered nurse (RN) and licensed practical nurse (LPN) are preparing an
educational program for clients who may be at risk for the development of
iron-deficiency anemia. Which clients would receive the greatest benefit from this
program? Select all that apply.
A) A young female client with bulimia nervosa
B) An older adult client on a fixed income
C) A client with Crohn's disease
D) A client who lives in a nursing home
E) A client who is a vegetarian
Ans: A, B, C
Feedback:
Those who consume a healthy diet absorb less than 10% of the iron in food. Clients
whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a
healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at
great risk for iron-deficiency anemia. A young female client with bulimia nervosa has
an unhealthy diet. An older adult client on a fixed income may not have the funds to eat
a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client
who resides in a nursing home has prepared meals as well as available supplements if
required. A client who is a vegetarian is still able to receive ample iron supplementation
in the vegetables being eaten.
Page 8
18. The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a
hematocrit of 34%. To determine where the blood loss is coming from, what
intervention can the nurse provide?
A) Observe stools for blood.
B) Observe the gums for bleeding after the client brushes teeth.
C) Observe the sputum for signs of blood.
D) Observe client for facial droop.
Ans: A
Feedback:
Iron-deficiency anemia is unusual in older adults. Normally, the body does not eliminate
excessive iron, causing total body iron stores to increase with age and necessitating
maintenance of hydration. If an older adult is anemic, blood loss from the
gastrointestinal or genitourinary tracts is suspected. Observing the stool for blood will
help detect blood from GI loss. Bleeding gums may indicate periodontal disease, or
anticoagulation from medication is not related to age. Blood in sputum can be an
indicator of various lung disorders that may affect all age groups. Facial droop may
indicate an impending stroke or Bell's palsy and would not be a reason for blood loss.
19. The nurse is collecting data for a patient who has been diagnosed with iron-deficiency
anemia. What subjective findings does the nurse recognize as symptoms related to this
type of anemia?
A) “I feel hot all of the time.”
B) “I have a difficult time falling asleep at night.”
C) “I have an increase in my appetite.”
D) “I have difficulty breathing when walking 30 feet.”
Ans: D
Feedback:
Most clients with iron-deficiency anemia have reduced energy, feel cold all the time,
and experience fatigue and dyspnea with minor physical exertion. The heart rate usually
is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are
decreased. The client would feel cold and not hot. The client is fatigue and able to sleep
often with a decrease in appetite, not an increase.
Page 9
20. The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling
cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding
would be an indicator of iron-deficiency anemia?
A) Erythrocytes that are microcytic and hypochromic
B) Erythrocytes that are macrocytic and hyperchromic
C) Clustering of platelets with sickled red blood cells
D) An increased number of erythrocytes
Ans: A
Feedback:
A blood smear reveals erythrocytes that are microcytic (smaller than normal) and
hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than
normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood
cells would indicate sickle cell anemia. An increase in the number of erythrocytes would
indicate polycythemia vera.
21. The nurse is instructing a client about taking a liquid iron preparation for the treatment
of iron-deficiency anemia. What should the nurse include in the instructions?
A) Do not take medication with orange juice because it will delay absorption of the
iron.
B) Iron may cause indigestion and should be taken with an antacid such as Mylanta.
C) Dilute the liquid preparation with another liquid such as juice and drink with a
straw.
D) Discontinue the use of iron if your stool turns black.
Ans: C
Feedback:
Dilute liquid preparations of iron with another liquid such as juice and drink with a
straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid,
which interferes with iron absorption. Drink orange juice or take other forms of vitamin
C with iron to promote its absorption. Expect iron to color stool dark green or black.
22. The nurse is caring for four clients on the medical-surgical unit of the hospital. What
client is mostly likely to be receiving treatment for sickle cell crisis?
A) A 29-year-old Caucasian female
B) A 19-year-old African American male
C) A 24-year-old Native American female
D) A 36-year-old Eastern European female
Ans: B
Feedback:
Sickle cell disease is a common genetic disorder found primarily in African Americans
but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a
Caucasian female, Native American female, or eastern European female will be affected
by this disease.
Page 10
23. A client is seen in the emergency department with severe pain related to a sickle cell
crisis. What does the nurse understand is occurring with this client?
A) The client has a decreased tolerance of pain related to the chronic nature of the
illness.
B) Bone marrow decreases the erythrocyte production causing decrease in hypoxia.
C) Overhydration enlarges the red blood cells.
D) Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
Ans: D
Feedback:
The person with sickle cell disease repeatedly suffers from two major problems: (1)
episodes of sickle cell crisis from vascular occlusion, which develops rapidly under
hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the
sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and
oxygen to the affected tissue. The vascular occlusion induces severe pain in the
ischemic tissue. The client may have increased tolerance for pain due to the chronic
nature of the illness. Bone marrow increases the erythrocyte production. Underhydration
increases the client's risk of developing a vaso-occlusive crisis.
24. A client with sickle cell disease informs the nurse that he is having chest pain. The nurse
hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect
is occurring with this client?
A) Vaso-occlusive crisis
B) Pneumocystis pneumonia
C) Acute chest syndrome
D) Acute muscular strain
Ans: C
Feedback:
One of the unique manifestations of sickle cell disease is “acute chest syndrome,” a type
of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs. Acute
chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing,
tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion and
predisposes the client to pneumonia but is not the present problem with this client.
Pneumocystis pneumonia is present in the client with HIV/AIDS or other
immunocompromised clients. The client's symptoms do not correlate with a diagnosis of
acute muscular strain.
Page 11
25. Parents arrive to the clinic with their 5-year-old child and inform the nurse the child has
just been diagnosed with sickle cell disease. The parents ask the nurse how this could
have happened and which one of them is the carrier. What is the best response by the
nurse?
A) “Most likely, the father is the carrier of the gene.”
B) “The trait is passed down through the mother.”
C) “The child must inherit two defective genes, one from each parent.”
D) “It is an acquired, not a hereditary disorder.”
Ans: C
Feedback:
Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must
inherit two defective genes, one from each parent, in which case all the hemoglobin is
inherently abnormal. If the person inherits only one gene, he or she carries sickle cell
trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The
other distractors are incorrect due to these factors.
26. The nurse is instructing the client with sickle cell disease about the use of an inhaled
vasodilator that may reduce sickling. What medication is the nurse instructing the client
about?
A) Nitrous oxide
B) Nitric oxide
C) Betamethasone
D) Terbutaline (Brethine)
Ans: B
Feedback:
Inhaled nitric oxide—not nitrous oxide (laughing gas), a vasodilating agent—is believed
to reduce sickling by promoting the binding of oxygen to hemoglobin. It is being used in
the form of handheld inhalers to abort or relieve pain experienced during sickle cell
crises. Betamethasone is a corticosteroid, and terbutaline is not used as an inhaler.
27. The nurse is caring for a client who is having a sickle cell crisis. Which order for
analgesia should the nurse consult with the physician?
A) Meperedine (Demerol)
B) Morphine sulfate
C) Sublimaze (Fentanyl)
D) Buprenorphine (Buprenex)
Ans: A
Feedback:
Consult the physician if meperidine (Demerol) is prescribed for treating pain in clients
with sickle cell crisis. The liver converts meperidine to normeperidine, which is toxic.
Grand mal seizures can result. The other medications are acceptable alternatives to
Demerol.
Page 12
28. The nurse is caring for an older adult client with hemolytic anemia. What does the nurse
understand about the reason this client is most susceptible to this disorder?
A) The client is older and is probably noncompliant with medications.
B) Older adult clients often take more medications than younger people.
C) Older adult clients have more incidences of coagulation disorders.
D) The older adult client does not follow up with physician appointments.
Ans: B
Feedback:
Older adults are particularly susceptible to drug-induced hemolytic anemia because they
often take more drugs than younger people. Discontinuing the offending drug usually
corrects the anemia. The assumption that because a client is older and probably
noncompliant is incorrect. Older clients are more susceptible to gastrointestinal and
genitourinary bleeding but not coagulation disorders. The older adult client does not
lack follow-up with physicians more than other populations.
29. The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin
of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's
skin?
A) Bronzing of the skin
B) Jaundice of the skin and mucous membranes
C) Ruddy complexion
D) Pale skin and mucous membranes
Ans: A
Feedback:
Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of
severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The
client is not jaundice, ruddy, or pale with this disorder.
30. The nurse is assigned to care for a client with polycythemia vera. When the nurse
encourages the client to drink 3 L of fluid per day, the client states, “Why do I have to
drink so much?” What is the best response by the nurse?
A) “We don't want you to get dehydrated.”
B) “It helps adequately hydrate you and ensures a sufficient urine production.”
C) “It will help your heart beat regularly and effectively.”
D) “It will help restrict blood circulation.”
Ans: B
Feedback:
The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration
promotes venous return and ensures sufficient urine production. Informing the client
that the healthcare team does not want them to get dehydrated does not address the
rationale that the client requires. Fluid hydration will not help the heart beat regularly or
more effectively and it will not help to restrict blood circulation.
Page 13
31. The nurse is instructing the client with polycythemia vera how to perform isometric
exercises such as contracting and relaxing the quadriceps and gluteal muscle during
periods of inactivity. What does the nurse understand is the rationale for this type of
exercise?
A) Isometric exercise programs are inclusive of all muscle groups and have an
aerobic effect to increase the heart rate.
B) Isometric exercise decreases the workload of the heart and restores oxygenated
blood flow.
C) This type of exercise increases arterial circulation as it returns to the heart.
D) Contraction of skeletal muscle compresses the walls of veins and increases the
circulation of venous blood as it returns to the heart.
Ans: D
Feedback:
Isometric exercise induce contraction of skeletal muscle so that it compresses the walls
of veins and increases the circulation of venous blood as it returns to the heart. Isometric
exercises do not have an aerobic effect and should not increase the heart rate; although,
it may increase blood pressure. Isometric exercise does not decrease the workload of the
heart. Arterial flow moves blood flow away from the heart after being oxygenated.
32. A client is suspected of having leukemia and is having a series of laboratory and
diagnostic studies performed. What does the nurse recognize as the hallmark signs of
leukemia? Select all that apply.
A) Diarrhea
B) Nausea and vomiting
C) Frequent infections
D) Fatigue from anemia
E) Easy bruising
Ans: C, D, E
Feedback:
Infections, fatigue from anemia, and easy bruising are hallmarks of leukemia. At the
onset of leukemia, particularly in acute lymphocytic leukemia (ALL), a fever is present,
the spleen and lymph nodes enlarge, and internal or external bleeding develops.
Diarrhea and nausea and vomiting are not the hallmark signs of leukemia and can be
indicators in many illnesses and gastrointestinal disorders.
Page 14
33. A client was admitted to the hospital with a pathologic pelvic fracture. The client
informs the nurse that he has been having a strange pain in the pelvic area for a couple
of weeks that was getting worse with activity prior to the fracture. What does the nurse
suspect may be occurring based on these symptoms?
A) Hemolytic anemia
B) Polycythemia vera
C) Leukemia
D) Multiple myeloma
Ans: D
Feedback:
The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease
progresses, the pain becomes more severe and localized. The pain intensifies with
activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures
develop. Hemolytic anemia does not result in pathologic fractures nor does
polycythemia vera or leukemia.
34. A client with multiple myeloma is complaining of severe pain when the nurse comes in
to give a bath and change position. What is the priority intervention by the nurse?
A) Inform the client that the position must be changed, and then you will give her
pain medication and omit the bath.
B) Inform the client that she will feel better after receiving a bath and clean sheets.
C) Obtain the pain medication and delay the bath and position change until the
medication reaches its peak.
D) Inform the client that the bath and positioning is an important part of client care
and will be done right after pain medication administration.
Ans: C
Feedback:
When pain is severe, the nurse delays position changes and bathing until an
administered analgesic has reached its peak concentration level and the client is
experiencing maximum pain relief. Pain medication should never be delayed to assist in
the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only
analgesics at this point in the client's illness.
Page 15
35. A 15-year-old client with hemophilia sustains a leg laceration after falling off of his
skateboard and is brought to the emergency department. The laceration is bleeding
profusely even with direct pressure to the site. What does the nurse anticipate will be
ordered for administration to control bleeding?
A) Fresh frozen plasma
B) A colloid solution such as hetastarch (Hespan)
C) A crystalloid solution such as lactated Ringer's
D) Albumin
Ans: A
Feedback:
Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate,
and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for
hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to
the bleeding area. Other measures used to help control bleeding are the administration of
fresh frozen plasma, aminocaproic acid (Amicar) that helps to hold a clot in place once
it has formed, direct pressure over the bleeding site, and cold compresses or ice packs.
Hespan, lactated Ringer's, or albumin will not control the bleeding related to
hemophilia.
Page 16
1. Chapter 32
The family nurse practitioner is performing a physical assessment on a client with a
suspected lymphatic disorder. What would be the nurse practitioner's primary
assessment for all clients with lymphatic disorders?
A) Fever and sore throat
B) Painful joints
C) Signs of leukopenia and thrombocytopenia
D) Enlargement of the lymph glands
Ans: D
Feedback:
Most of the disorders related to the lymph glands cause an inflammation of the lymph
nodes. As a result, the nurse should assess the extent of enlargement of the lymph glands
in a client suspected of a lymphatic disorder. Fever and sore throat are the secondary
signs and symptoms in such disorders. These clients do not complain of painful joints or
exhibit signs of leukopenia and thrombocytopenia.
2. A client has just been admitted to your unit with a diagnosis of Hodgkin's disease. When
doing the initial assessment, what pertinent questions should the nurse ask the client to
help determine the correct nursing diagnosis?
A) Are you experiencing fever, chills, or night sweats?
B) Do you use artificial respirators?
C) Have you ever had a blood transfusion?
D) Have you ever experienced fractures?
Ans: A
Feedback:
In a client with Hodgkin's disease, the nurse should ask how long the client has noticed
the enlarged lymph nodes. The nurse checks for the presence and the extent of
tenderness in the area of the lymph node enlargement. The nurse should also ask the
client about fever, chills, or night sweats. It is not pertinent to ask the client about any
previous history of fractures, the use of artificial respirators, or any blood transfusions.
Page 1
3. Your client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client
experiences nausea. What measures should the nurse suggest to help the client reduce
the feeling of nausea?
A) Administer immunosuppressive drugs.
B) Apply ice to the skin for brief periods.
C) Offer clear liquids such as carbonated beverages, water, and ice pops.
D) Advise bed rest as much as possible.
Ans: C
Feedback:
To help reduce the feeling of nausea in a client who underwent chemotherapy, the nurse
should offer clear liquids such as carbonated beverages, water, ice pops, and gelatin
until the nausea subsides. Immunosuppressive drugs are known to cause non-Hodgkin's
lymphoma when administered to prevent a transplant rejection. These drugs do not help
in reducing the feeling of nausea. The nurse may need to apply ice to the skin to prevent
it from itching and thereby promote the skin integrity. Bed rest, analgesic and
antipyretic therapy, and increased fluid intake are recommended to clients with
infectious mononucleosis.
4. A 55-year-old female client has developed lymphedema postmastectomy. What is the
common method used to promote lymphatic drainage and prevent edema in all clients
with lymphedema?
A) Reduce the intake of fluids.
B) Avoid exercising the affected part.
C) Decrease the intake of sodium and calcium.
D) Elevate the affected part of the body.
Ans: D
Feedback:
Treatment usually is symptomatic. In the early stages, the client elevates the affected
part to promote lymphatic drainage. Exercising the affected part in the client helps in
promoting the lymphatic circulation and maintaining the functional use of the limb.
Reducing the sodium and calcium intake or fluids does not promote lymphatic drainage
or prevent edema.
Page 2
5. A client with lymphadenitis has developed persistent swelling of the affected area. What
would be important information for you to teach this client?
A) How to apply an elastic sleeve or stocking
B) How to apply ice to the affected area
C) How to do exercises to increase blood flow in the area
D) How to dependently do activities of daily living
Ans: A
Feedback:
The nurse inspects the area two to three times daily and notes the client's response to
antibiotic therapy. He or she gives assistance if the discomfort interferes with activities
of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances
circulation. The nurse notifies the physician if the affected area appears to enlarge,
additional lymph nodes become involved, or body temperature remains elevated. In
severe cases with persistent swelling, the nurse teaches the client how to apply an elastic
sleeve or stocking. Ice does not reduce the swelling. Exercise does not reduce the
swelling.
6. The nurse is caring for a client diagnosed with infectious mononucleosis who is having
trouble eating. What would the nurse advise this client to improve his oral intake?
A) Eat warm food and drink warm liquids.
B) Eat soft, bland foods and drink cool liquids.
C) Avoid spicy foods and drink warm liquids.
D) Eat soft, bland foods and drink warm liquids.
Ans: B
Feedback:
The nurse inspects the client's throat for the extent of inflammation or edema. He or she
gently palpates the lymph nodes to detect swelling and encourages fluids. Soft, bland
foods and cool liquids are best for clients with ulcerations of the oral mucosa. Warm
food and liquids and spicy food are not recommended.
7. The nurse is caring for a client with Hodgkin's disease who has developed anemia. What
would you expect would be ordered for this client?
A) Lower doses of radiation
B) Transfusions
C) A break in chemotherapy
D) Increased rest and fluid
Ans: B
Feedback:
Transfusions are prescribed to control anemia. If resistance to treatment develops,
autologous bone marrow or peripheral stem cells are harvested, followed by high doses
of chemotherapy that destroy the bone marrow. A transplant is performed after
separating the normal stem cells from the malignant cells in the harvested specimen.
Options A, C, and D are not considered part of the treatment regimen for anemia.
Page 3
8. A young client has just been diagnosed with lymphoma. The client asks you what a
lymphoma is. What would be your best answer?
A) It is a group of cancers that affect the body.
B) It is a group of cancers connected to the hematopoietic system.
C) It is a group of cancers that affect the lymphatic system.
D) It is a group of cancers connected to the cardiovascular system.
Ans: C
Feedback:
The term lymphoma applies to a group of cancers that affect the lymphatic system.
Option A is correct in part, but choice C is more specific. Lymphomas are not related to
the hematopoietic or cardiovascular systems.
9. A 16-year-old male client is in the burn unit following a motor vehicle accident. The
nurse notes nonpitting edema in the client's left calf. What would the nurse document
about this finding?
A) 3+ edema of the left calf
B) Secondary edema of the left calf
C) Nonpitting primary edema of the left calf
D) Primary edema of the left calf
Ans: B
Feedback:
Secondary lymphedema develops (1) as a complication of other disorders, such as
repeated bouts of phlebitis and streptococcal infection, burns, or insect bites; or (2) as a
consequence of treatment, such as the removal of multiple lymph nodes at the time of a
mastectomy. Lymphedema following a burn injury is not primary lymphedema as in
choice C or D, and it is not pitting edema as in choice A.
Page 4
10. You are caring for a client newly admitted to the unit with a diagnosis of lymphangitis.
What interventions would you institute to help promote the resolution of the
lymphangitis? Select all that apply.
A) Apply ice to the area.
B) Note the response to antibiotic therapy.
C) Encourage independent activities of daily living.
D) Elevate the area.
E) Apply warm soaks/compresses to the area.
Ans: B, C, D, E
Feedback:
The nurse inspects the area two to three times daily and notes the client's response to
antibiotic therapy. He or she gives assistance if the discomfort interferes with activities
of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances
circulation. The nurse notifies the physician if the affected area appears to enlarge,
additional lymph nodes become involved, or body temperature remains elevated. In
severe cases with persistent swelling, the nurse teaches the client how to apply an elastic
sleeve or stocking.
11. A client had a left radical mastectomy with an axillary node dissection 6 months ago
and is having a large amount of edema in the left arm down to the fingers. What should
the nurse inform the client is the reason for the edema?
A) An accumulation of lymphatic fluid that results from impaired lymph circulation.
B) It is congenitally acquired and is not related to the mastectomy.
C) They are most likely ingesting too much sodium and should be advised to
decrease the amount.
D) There is inadequate blood flow from circulatory impairment.
Ans: A
Feedback:
Lymphedema is an accumulation of lymphatic fluid that results from impaired lymph
circulation. It is a complication resulting from the removal of multiple lymph nodes at
the time of mastectomy or radiation for cancer. It may be congenitally acquired, but in
this situation, it is secondary and related to the mastectomy. Sodium intake would not be
related to the accumulation of lymph fluid and would be generalized. There is not
circulatory impairment from decreased blood flow but impaired lymphatic flow.
Page 5
12. A client, age 22 years, comes to the clinic and informs the nurse that he began having
swelling in his right arm. There has been no injury or precipitating occurrence that
caused the swelling. The nurse observes nonpitting edema from the upper arm to the
fingertips. What action should the nurse initially perform?
A) Instruct the client to elevate the extremity.
B) Inspect and measure the arm.
C) Apply a compression stocking.
D) Administer a diuretic.
Ans: B
Feedback:
The nurse inspects and measures the affected area to assess the extent of enlargement
and the condition of the skin initially. After collected the data, the nurse may instruct the
client to elevate the arm and obtain the correct size for a compression stocking. Diuretic
use is not an appropriate intervention at this time and would not be administered without
a physician's order.
13. The nurse is on a mission trip to a third world country to provide nursing care to a large
group of clients. A client asks the nurse to look at his leg that is grossly edematous
compared to the other extremity. What does the nurse understand is the most common
cause of this disorder known as elephantiasis?
A) Reaction to an antibiotic
B) Smallpox vaccination
C) Lack of healthcare
D) A parasitic worm
Ans: D
Feedback:
Worldwide, the most common cause of lymphedema is a parasitic worm; mosquitoes
transmit the parasite, resulting in a condition known as elephantiasis.
Page 6
14. The nurse is caring for a client with lymphedema of the left arm in the clinic. The nurse
measures a circumference of the affected extremity 4 cm larger in circumference than
the opposite limb, and the client complains of feeling a heaviness and pain. There is
limited movement of the left arm. What would the nurse grade and document this
lymphedema as?
A) Grade I (Mild)
B) Grade II (Moderate)
C) Grade III (Severe)
D) Grade IV (Grossly edematous)
Ans: B
Feedback:
Grade II (Moderate), the circumference of affected limb is 4 cm, but not more than 8 cm
larger than the unaffected limb; client experiences symptoms such as heaviness in the
limb, pain, and limited movement. In Grade I (Mild), the circumference of the affected
limb is 2 cm, but not more than 4 cm larger than the unaffected limb; the client is
asymptomatic. In Grade III (Severe), the circumference of the affected limb is 8 cm
greater than the unaffected limb, involves the entire limb, or is accompanied by
infection or cellulitis.
15. A client with lymphedema in the left arm has weeping from the skin and has a small
2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be
prepared for?
A) X-ray of the left arm
B) Ultrasound of the left arm
C) CT scan
D) Lymphangiography
Ans: D
Feedback:
Lymphangiography is a special examination in which an intravenous dye and
radiography are used to detect lymph node involvement that reveals the degree and
extend of blockage in the lymph system. An x-ray of the arm, ultrasound, or CT scan
will not reveal the extent of blockage.
Page 7
16. The nurse is sending a client to be fitted for a compression garment for the treatment of
lymphedema after having a mastectomy and node dissection. What does the nurse
inform the client that will do to decrease the edema? Select all that apply.
A) Increases local tissue pressure
B) If worn for 30 days continuously, will permanently reduce the edema
C) Decreases the stretching of the skin
D) Helps muscles to propel lymphatic drainage
E) Prevents tissue refilling with an excess volume of lymph
Ans: A, C, D, E
Feedback:
A compression garment, which consists of multiple layers of elastic material with
proximal to distal compression gradation, increases local tissue pressure, decreases
stretching of the skin, assists muscles to propel lymphatic drainage, and prevents tissue
refilling with an excess volume of lymph. Because the lymph nodes have been removed,
the condition will not be able to be permanently reduced by using the garment.
17. A client with lymphedema of the left leg has a nursing diagnosis of Disturbed Body
Image related to lymphedema of the left leg as evidenced by the statement, “I look
terrible and am embarrassed to go out.” What intervention can the nurse provide to help
this client?
A) Inform the client it is acceptable to stay away from social activities.
B) Encourage the client to go out and socialize even if he doesn't want to.
C) Suggest certain styles of clothing that conceal the enlargement of the leg.
D) Refer the client to a psychiatrist.
Ans: C
Feedback:
Extensive emotional support is necessary when the edema is severe. The client's
self-esteem often is decreased, which can lead to social withdrawal. The nurse supports
the client's self-image by suggesting certain styles of clothing that conceal abnormal
enlargement of an arm or leg. Informing the client to stay away from social activities
can create a depressed mood and loneliness. The client should not be encouraged to go
out and socialize if he is not ready nor referred to a psychiatrist at this point.
Page 8
18. A client has developed an infection that resulted in lymphangitis. What does the nurse
suspect the causative organism is that caused the infection?
A) A streptococcal microorganism
B) A Staphylococcus microorganism
C) Escherichia coli
D) Candida albicans
Ans: A
Feedback:
An infectious agent, commonly a streptococcal microorganism, usually causes both
lymphangitis and lymphadenitis. It is not commonly caused by staph, E. coli, or C.
albicans (a fungal infection).
19. The nurse is obtaining objective data from a client with lymphangitis of the left arm.
What does the nurse expect to find when collecting this data from the client?
A) Pulsatile mass in the axilla
B) Weeping and oozing of fluid from the arm
C) Cold, clammy arm
D) Red streaks following the course of the lymph channels
Ans: D
Feedback:
Red streaks follow the course of the lymph channels and extend up the arm or leg. Fever
also may be present. When lymphadenitis is present, the lymph nodes along the
lymphatic channels are enlarged and tender on palpation. Diagnosis is made by visual
inspection and palpation. The nurse does not expect to find a pulsatile mass. Weeping
and oozing would indicate lymphedema. The arm would be warm or hot, not cold and
clammy.
20. The nurse is caring for a client with lymphangitis of the right leg who is receiving
treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the
right leg is larger than it was 2 hours ago and the client feels hot. What is the first action
by the nurse?
A) Place the leg below the level of the heart.
B) Notify the physician.
C) Place cool compresses on the extremity.
D) Begin performing passive range of motion exercises.
Ans: B
Feedback:
The nurse notifies the physician if the affected area appears to enlarge, additional lymph
nodes become involved, or body temperature remains elevated. In severe cases with
persistent swelling, the nurse teaches the client how to apply an elastic sleeve or
stocking. The leg should be elevated to reduce the edema. A warm compress may be
applied to promote comfort and enhance circulation. Passive range of motion would be
contraindicated at this time.
Page 9
21. An adolescent client diagnosed with infectious mononucleosis asks the nurse if he will
keep getting the disease. What is the best response by the nurse?
A) “After having the disease, the virus dissipates and is gone forever.”
B) “Once you get the virus, it will infect you when your immune system is
compromised.”
C) “One episode produces immunity, but the virus remains for a lifetime.”
D) “Once you have the symptoms of the virus, it will go away within a week and
there will be no further episodes.”
Ans: C
Feedback:
One episode of infectious mononucleosis produces subsequent immunity; however, the
virus remains in the body for the person's lifetime. The virus does not dissipate and go
away. If you have an incidence of infection, you are immune from further infections of
Epstein-Barr virus. The symptoms do not generally go away for 2 to 6 weeks.
22. The nurse is caring for a group of clients. Which client does the nurse suspect is most
likely to have mononucleosis?
A) A 46-year-old male who is complaining of chest pain and weakness
B) A 19-year-old college student with cervical node enlargement and fever
C) A 28-year-old female with lower abdominal discomfort and vaginal discharge
D) A 30-year-old male client with a cough, chest discomfort, and fever
Ans: B
Feedback:
The virus most commonly affects young adults, especially those in close living quarters,
such as armed services housing and college dormitories. Fatigue, fever, sore throat,
headache, and cervical lymph node enlargement typically occur. The tonsils ooze white
or greenish-gray exudates. Pharyngeal swelling can compromise swallowing and
breathing. Some clients develop a faint red rash on their hands or abdomen. The liver
and spleen become enlarged. The other clients with presenting symptoms do not
correlate with the symptoms of mononucleosis.
Page 10
23. A 15-year-old client arrives at the clinic and informs the nurse that he attended 2 weeks
of summer camp last month and now is not feeling well with complaints of sore throat,
fever, and very tired. The nurse observes white exudate on the tonsils. What test does
the nurse anticipate the physician will order for this client?
A) Monospot test
B) AST and ALT
C) Glucose level
D) T3, T4, and TSH
Ans: A
Feedback:
A positive slide agglutination test (Monospot, Monotest, Monosticon) is presumptive
evidence that the Epstein-Barr virus is causing the symptoms. A rise in the Epstein-Barr
virus antibody titer and a heterophil agglutination test result of 1:224 or greater is
conclusive for infectious mononucleosis. The AST and ALT would indicate possible
liver disorders. A glucose level would not be indicative of Epstein-Barr virus. T3, T4,
and TSH would be indicative of thyroid dysfunction, which the client's age and
symptoms do not correlate with.
24. The nurse is caring for the client with infectious mononucleosis that has inflammation
of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?
A) A hot cup of milk
B) Vanilla pudding and iced tea
C) Tomato soup and hot herbal tea
D) Beef and broccoli stir fry and a soft drink
Ans: B
Feedback:
Vanilla pudding and ice tea would be appropriate food for the nurse to offer. Soft, bland
foods; cool liquids; and gargling with warm salt water are best for clients with
inflammation of the oral and pharyngeal mucosa. Hot milk, tomato soup, hot tea, and
beef and broccoli stir fry would not help with the inflammation of the pharynx.
25. A client calls the clinic and informs the nurse that her boyfriend was diagnosed with
infectious mononucleosis and wonders how long it would be before she got it. What
does the nurse inform the client that the incubation period is for infectious
mononucleosis?
A) 3 days
B) 7 to 10 days
C) 30 to 50 days
D) 50 to 70 days
Ans: C
Feedback:
The incubation period for infectious mononucleosis is 30 to 50 days. The other answers
are incorrect.
Page 11
26. The nurse is caring for a client with a diagnosis of Hodgkin's disease and is aware that
there is enlargement of the retroperitoneal nodes when reviewing the review of systems
on the physician's history and physical. What symptoms are the nurse aware may be
indicative of enlargement of the retroperitoneal nodes?
A) Complaints of a sense of fullness in the stomach and epigastric pain
B) Sore throat, white discharge on the tonsils
C) Nausea and vomiting
D) Respiratory rate of 14 and shallow
Ans: A
Feedback:
As retroperitoneal nodes enlarge, there is a sense of fullness in the stomach and
epigastric pain in clients with Hodgkin's disease. A sore throat and white discharge on
the tonsils may be indicative of a throat infection or infectious mononucleosis. Nausea
and vomiting are vague symptoms that are related to many disorders and diseases.
Respiratory symptoms do not indicate Hodgkin's disorders related to retroperitoneal
node enlargement.
27. A client is having a lymph node biopsy for suspicion of Hodgkin's disease. What type of
cells would be identifiable in the lymph node biopsy that may indicate this disease
process?
A) Reed-Sternberg cells
B) Sickled cells
C) Epstein-Barr virus
D) Red blood cells
Ans: A
Feedback:
The Reed-Sternberg cells, characterized as giant multinucleated B lymphocytes, are
microscopically identifiable in lymph node biopsies. Sickled red blood cells would
indicate sickle cell disease but would be identifiable in a blood test, not a lymph node
biopsy. The Epstein-Barr virus is linked to the development of Hodgkin's disease, but
the virus is not identified in the lymph node biopsy. Red blood cells would be seen
normally on blood tests.
Page 12
28. A client with Hodgkin's disease has a weight loss of 10% of body weight 6 months prior
to the diagnosis, fever of 101° F, and drenching night sweats. What subclassification of
Hodgkin's disease does this client fit into?
A) A
B) B
C) C
D) E
Ans: B
Feedback:
Stages I, II, III, and IV of adult Hodgkin's disease are subclassified into A and B
categories: B for those with defined general symptoms and A for those without B
symptoms. The B designation is given to client with any of the following symptoms:
unexplained loss of more than 10% of body weight in 6 months before diagnosis,
unexplained fever with temperatures over 100.4° F, and drenching night sweats. There
is no subclassification of C or D.
29. A client with Hodgkin's disease has bilateral lymph nodes that are affected with
extension through the spleen as well as affecting the bone marrow. What stage of the
disease does the nurse recognize the client is in?
A) I
B) II
C) III
D) IV
Ans: D
Feedback:
Stage IV involves bilateral lymph nodes affected and extension includes spleen plus one
or more of the following: bones, bone marrow, lungs, liver, skin, gastrointestinal
structures, or other sites. Stage I is single lymph node region. Stage II is two or more
lymph node regions on one side of the diaphragm. Stage III is lymph node regions on
both sides of the diaphragm, but extension is limited to the spleen.
Page 13
30. The nurse is caring for a client in the hospital who is being treated for Hodgkin's disease
and is taking a chemotherapeutic regimen in the hospital's oncology unit. When
reviewing the client's medication history, what regimen does the nurse recognize as the
drugs in the treatment of Hodgkin's disease?
A) Rocephin, Lasix, rifampin
B) Cisplatin, cytarabine, prednisone
C) Infliximab (Remicade)
D) Enalapril (Lisinopril), Lopressor (Atenolol)
Ans: B
Feedback:
Cisplatin, cytarabine, prednisone are known as ICE for the chemotherapeutic treatment
of Hodgkin's disease. There are several different regimens that may be used but the
medications in options A, C, and D are not used for the treatment of Hodgkin's disease.
31. The nurse is providing instruction on the use of compression garments for the client
with lymphedema. What should be included in the instructions? Select all that apply.
A) Purchase two compression garments.
B) Change the garment in the morning and in the evening.
C) Limit the time the garment is not worn to 30 to 60 minutes.
D) Replace a compression garment every month.
E) Place the garment in the dryer after washing.
Ans: A, B, C
Feedback:
When instructing the client on use of the compression garment, purchase two
compression garments so that one can be worn while the other is washed and dried.
Change the garment in the morning and again in the evening because the garment
becomes stretched after 12 hours of being worn. Limit the time that the garment is not
worn to no more than 30 to 60 minutes to prevent reaccumulation of tissue fluid and
stretched skin. The garment should be replaced every 4 to 6 months, not every month.
The garment should be air dried, not placed in the dryer.
Page 14
32. A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The
client is complaining of nausea during treatment. To maintain fluid intake, what type of
food or fluid could the nurse offer the client?
A) Milk
B) Pudding
C) Popsicle
D) Chicken
Ans: C
Feedback:
Offer clear liquids such as carbonated beverages and water, ice pops, and flavored
gelatin until nausea subsides. Thereafter, small, frequent, low-fat meals help prevent
nausea, improve nutritional intake, and reduce weight loss. Milk, pudding, and chicken
are too heavy when clients are experiencing nausea and may be given after the nausea
subsides.
33. A client has been diagnosed with non-Hodgkin's lymphoma but has no symptoms at this
time. The client has received radiation and chemotherapy with responsiveness to this
treatment. How would this disease be classified according to the lack of symptoms and
responsiveness to treatment?
A) Indolent
B) Aggressive
C) Cured
D) Immunosuppressed
Ans: A
Feedback:
Non-Hodgkin's lymphoma is classified as either indolent, meaning that the client is
relatively asymptomatic at diagnosis, and the disorder is relatively responsive to
radiation and chemotherapy; or aggressive, because the condition has a shorter onset
with acute symptoms. There is no classification considered cured or immunosuppressed.
Page 15
34. The nurse is collecting objective data from the client with lymphedema of the left leg.
The nurse observes that the affected leg is 10 cm greater in measurement than the
unaffected leg. The affected leg is hot to the touch and red. What classification of
lymphedema does the nurse recognize this client has?
A) Grade I (Mild)
B) Grade II (Moderate)
C) Grade III (Severe)
D) Grade IV (Extreme)
Ans: C
Feedback:
In severe, the circumference of the affected limb is 8 cm greater than the unaffected
limb, involves the entire limb, or is accompanied by infection or cellulitis (inflammation
of connective tissue in or close to the skin). Mild is the circumference of the limb is 2
cm, but not more than 4 cm larger than the unaffected limb; client is asymptomatic.
Moderate lymphedema is the circumference of the affected limb is 4 cm, but not more
than 8 cm larger than the unaffected limb; client experiences symptoms such as
heaviness in the limb, pain, and limited movement. There is no classification considered
extreme.
35. Which client does the nurse recognize as most likely to be diagnosed with
non-Hodgkin's lymphoma rather than Hodgkin's lymphoma?
A) A 55-year-old client with AIDS
B) A 35-year-old client with type 2 diabetes mellitus
C) A 20-year-old client with infectious mononucleosis
D) A 40-year-old client with Reed-Sternberg cells in an axillary lymph node
Ans: A
Feedback:
Non-Hodgkin's lymphoma peak onset is after 50 years and is common among clients
with immunosuppression. There is no correlation with client that has diabetes and
non-Hodgkin's lymphoma. Forty percent of affected clients test positive for
Epstein-Barr virus that causes infectious mononucleosis and that test positive for
Reed-Sternberg cells in the lymph nodes that are correlated with Hodgkin's lymphoma.
Page 16
1. Chapter 33
The anatomy and physiology instructor is explaining a cell-mediated response to the prenursing students. What actions would the instructor explain occur in a cell-mediated
response?
A) Toxins of invading antigens are neutralized.
B) The invading antigens link together (agglutination).
C) The invading antigens precipitate.
D) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Ans: D
Feedback:
During a cell-mediated response, T-cell lymphocytes survey proteins in the body,
actively analyze the surface features, and respond to those that differ from the host by
directly attacking the invading antigen. For example, a cell-mediated response occurs
when an organ is transplanted. Immunoglobulins hinder the antigens physically by
neutralizing their toxins through agglutination or by causing them to precipitate.
2. You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are
preparing to draw blood for a confirmatory diagnostic test on this client. What is the
most important action that the nurse should perform before testing a client for HIV?
A) Advise the client to avoid excess fluid intake.
B) Advise the client to abstain from having intercourse.
C) Advise the client to take off any ornaments and metallic objects.
D) Obtain a written consent from the client.
Ans: D
Feedback:
It is important that the nurse obtain written consent from the client before performing an
HIV test and keep the results of HIV test confidential. The nurse may not ask the client
to avoid excess fluid intake or abstain from intercourse before the tests. The client also
need not take off ornaments and metallic objects worn unless they are likely to interfere
with the test results.
Page 1
3. A child is brought to the clinic with a rash. The child is diagnosed with measles. The
mother tells the nurse that she had the measles when she was a little girl. What
immunity to measles develops after the initial infection?
A) Naturally acquired active immunity
B) Artificially acquired active immunity
C) Naturally acquired passive immunity
D) Artificially acquired passive immunity
Ans: A
Feedback:
Immunity to measles that develops after the initial infection is an example of naturally
acquired active immunity. Artificially acquired active immunity results from the
administration of a killed or weakened microorganism or toxoid (attenuated toxin),
whereas passive immunity develops when ready-made antibodies are given to a
susceptible client.
4. You are caring for a client on tube feedings. The physician has ordered Osmolite HN as
the feeding formula for the client. The family asks why the physician has ordered
Osmolite HN instead of another formula to feed their family member. What is an
important reason that tube-feeding formulas, such as Impact, Osmolite HN, or Perative,
be recommended to clients?
A) To suppress immune system function
B) To block tumor necrosis factor
C) To enhance the production of lymphocytes and NK cells
D) To stimulate the immune system to attack tumor cells
Ans: C
Feedback:
Immune-enhancing tube-feeding formulas enhance the production of lymphocytes and
NK cells, resulting in increased cell-mediated immunity. Drugs such as azathioprine,
cyclosporine, and muromonab-CD3 suppress immune system function, whereas
infliximab and etanercept minimize inflammation by blocking tumor necrosis factor.
Aldesleukin is used as biologic therapy for clients who do not respond to conventional
cancer treatment. Aldesleukin stimulates the immune system's ability to attack tumor
cells.
Page 2
5. A 64-year-old male client, who leads a sedentary lifestyle, and a 31-year-old female
client, who has a very stressful and active lifestyle, require a vaccine against a particular
viral disorder. As the nurse, you would know that in one of these clients, the vaccine
will be less effective. In which client is the vaccine more likely to be less effective and
why?
A) The male client because of his age
B) The male client because of his lifestyle
C) The female client because of her age
D) The female client because of her lifestyle
Ans: A
Feedback:
Vaccines are less effective in an older adult than in a younger adult because the activity
of the immune system declines with the aging process. The lifestyle or gender of the
client does not have great implications on the effectiveness of a vaccine.
6. The nursing students are learning about the immune system in their anatomy and
physiology class. What would these students learn is a component of the immune
system?
A) Stem cells
B) Cytokines
C) Lymphoid tissues
D) Red blood cells
Ans: C
Feedback:
The immune system actually is a collection of specialized white blood cells and
lymphoid tissues that cooperate to protect a person from external invaders and the
body's own altered cells. The function of these structures is assisted and supported by
the activities of natural killer cells, antibodies, and nonantibody proteins such as
cytokines and the complement system. Red blood cells and stem cells are not part of the
immune system.
Page 3
7. What is the function of the thymus gland?
A) Produces stem cells
B) Programs B lymphocytes to become regulator or effector B cells
C) Develops the lymphatic system
D) Programs T lymphocytes to become regulator or effector T cells
Ans: D
Feedback:
The thymus gland is located in the neck below the thyroid gland. It extends into the
thorax behind the top of the sternum. The thymus gland produces lymphocytes during
fetal development. It may be the embryonic origin of other lymphoid structures such as
the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to
become regulator or effector T cells. The thymus gland becomes smaller during
adolescence but retains some activity throughout the life cycle. Options A, B, and C are
incorrect.
8. You are caring for a client with a suspected immune system disorder. What test would
be ordered if a deficiency or excess of immunoglobulins was suspected?
A) Protein electrophoresis
B) Enzyme-linked immunosorbent assay
C) T-cell and B-cell assays
D) Plasmapheresis
Ans: A
Feedback:
When an immune system disorder is suspected, protein electrophoresis screens for
diseases associated with a deficiency or excess of immunoglobulins may be ordered.
Options B, C, and D are incorrect tests to diagnose a deficiency or excess of
immunoglobulins.
Page 4
9. When an attenuated toxin is administered to a client, the B lymphocytes create memory
cells that recognize the antigen if it invades the body at a future time. What kind of
immunity is this?
A) Artificially acquired active immunity
B) Passive immunity
C) Natural immunity
D) Naturally acquired active immunity
Ans: A
Feedback:
Artificially acquired active immunity results from the administration of a killed or
weakened microorganism or toxoid (attenuated toxin). The memory cells manufactured
by the B lymphocytes “remember” the killed or weakened antigen and recognize it if a
future invasion occurs. Passive immunity develops when ready-made antibodies are
given to a susceptible person. Natural immunity is not one of the types of immunity.
Naturally acquired active immunity occurs as a direct result of infection by a specific
microorganism.
10. A 15-year-old client has been brought to the clinic by his mother and is suspected of
having an immune system disorder. What tests would you expect to be ordered for this
young client?
A) Cerebral spinal fluids aspiration
B) Sedimentary rate
C) Complete blood count with differential
D) Complete chemistry panel
Ans: C
Feedback:
Laboratory tests are used to identify immune system disorders. They usually include a
complete blood count with differential. Protein electrophoresis screens for diseases
associated with a deficiency or excess of immunoglobulins. T-cell and B-cell assays (or
counts) and the enzyme-linked immunosorbent assay may be performed. Options A, B,
and D are not diagnostic of immune disorders.
Page 5
11. A client's immune system has the ability to protect itself from external invaders. What
type of immune function is present when this occurs?
A) Immunosuppression
B) Immunocompetence
C) An immune response
D) Immune incompatibility
Ans: B
Feedback:
The immune system is a collection of specialized white blood cells and lymphoid tissues
that maintain immunocompetence, the ability to cooperatively protect a person from
external invaders and the body's own altered cells. Immunosuppression is the opposite
and the white blood cells and lymphoid tissue are not able to protect a person from
external invaders. An immune response, primarily involves the lymphocytes that are
located in blood and lymphoid tissue. Immune incompatibility is not relevant in this
situation.
12. A client is informed that his white blood cell count is low and that he is at risk for the
development of infections. The client asks, “Where do I make new white blood cells?”
What is the best response by the nurse?
A) “White blood cells are produced in the plasma.”
B) “White blood cells are produced in the thymus gland.”
C) “White blood cells are produced in the lymphatic tissue.”
D) “White blood cells are produced in the bone marrow.”
Ans: D
Feedback:
White blood cells (leukocytes) are produced in the bone marrow. They are not produced
in the plasma, thymus gland, or the lymphatic tissue.
Page 6
13. A client is cutting vegetable for dinner and accidently cuts his finger. What response is
desirable to destroy foreign agents such as microorganisms to prevent infection from
developing in the finger?
A) A cell-mediated response
B) The release of antibodies
C) The release of memory cells
D) Passive immunity
Ans: B
Feedback:
Antibodies are chemical substances that destroy foreign agents such as microorganisms,
which decrease the risk of infection at the site. A cell-mediated response occurs when T
cells survey proteins in the body, actively analyze the surface features, and respond to
those that differ from the host by directly attacking the invading antigen such as an
organ transplant. Memory cells convert to plasma cells on reexposure to a specific
antigen. When activated, B cells accumulate in lymphoid tissues and result in swollen
lymph nodes. Passive immunity develops when ready-made antibodies are given to a
susceptible person. They provide immediate but short- lived protection from an invading
antigen.
14. A client has had a kidney transplant performed for end-stage kidney disease. What type
of immune response that T-cell lymphocytes perform is related to this type of surgery?
A) Activation of the complement system
B) Stimulation of colony-stimulating factors
C) A cell-mediated response
D) Naturally acquired active immunity
Ans: C
Feedback:
A cell-mediated response occurs when T cells survey proteins in the body, actively
analyze the surface features, and respond to those that differ from the host by directly
attacking the invading antigen. An example of a cell-mediated response is one that
occurs when an organ is transplanted. The complement system cooperates with
antibodies to attract phagocytes and coat antigens to make them more recognizable for
phagocytosis and stimulate inflammation and is not related to the surgery.
Colony-stimulating factors prompt the bone marrow to produce, mature, and promote
the functions of blood cells. Naturally acquired active immunity is a direct result of
infection by a specific microorganism.
Page 7
15. A client has dilated cardiomyopathy and has just found out he will be receiving a heart.
What medication does the client understand that he will have to take for the duration of
his life to help suppress the immune system to prevent rejection of the new heart?
A) Infliximab (Remicade)
B) Etanercept (Enbrel)
C) Adalimumab (Humira)
D) Cyclosporine (Sandimmune)
Ans: D
Feedback:
After organ transplantation, the client's immune system may attack the new organ's cells
because it recognizes them as nonself. Cyclosporine is used to intentionally suppress the
immune system. The medications in A, B, and C are all used to suppress inflammation.
16. A parent of a child who has been having frequent bouts of tonsillitis brings the child
back to the clinic for another sore throat. The parent asks the nurse, “What are tonsils
good for anyway?” What is the best response by the nurse?
A) “They really do not have a function and should be removed.”
B) “These tissues filter bacteria from tissue fluid.”
C) “The tissue acts as an emergency reservoir of blood.”
D) “The tissue removes blood and bacteria.”
Ans: B
Feedback:
Tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to
pathogens in the oral cavity, they can become infected and locally inflamed. The spleen
acts as an emergency reservoir of blood and removes blood and bacteria, not the tonsils.
17. A client who is being treated for complications related to acquired immunodeficiency
disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy.
Why does the nurse understand this route is being used?
A) The taste of the medication is not palatable.
B) The medication will work more rapidly parenterally.
C) The medication, given orally, will cause diarrhea.
D) Digestive enzymes destroy its protein structure.
Ans: D
Feedback:
Interferon is administered parenterally because digestive enzymes destroy its protein
structure. The medicine does not have an oral preparation.
Page 8
18. A client will be taking the tumor necrosis factor inhibitor, infliximab (Remicade), for
the treatment of rheumatoid arthritis. Prior to beginning this therapeutic regimen, what
screening should the client have?
A) Screening for tuberculosis
B) Screening for peptic ulcer disease
C) Screening for syphilis
D) Screening for rubella
Ans: A
Feedback:
Before prescribing a TNF inhibitor, clients should be screened for tuberculosis because
there is a risk for activating latent tuberculosis. It is not necessary to screen for peptic
ulcer disease, syphilis, or rubella prior to beginning TNF inhibitor therapy.
19. A client will be starting treatment with the tumor necrosis factor inhibitor, adalimumab
(Humira). To begin a new job, the client must receive a tetanus shot because he hasn't
received one in 10 years. What should the nurse advise the client?
A) The tetanus shot may be taken at any time without regard to TNF inhibitor drug
therapy.
B) The client should receive the tetanus shot prior to beginning TNF inhibitor drug
therapy.
C) The client should receive the tetanus shot after beginning TNF inhibitor drug
therapy to decrease the complications related to the tetanus.
D) The client should get a note from the physician stating the tetanus shot is not able
to be taken by the client.
Ans: B
Feedback:
TNF inhibitors decrease the efficacy of vaccines that are T-cell dependent such as those
for hepatitis B, viral influenza A and B, human papillomavirus, and tetanus. It is best for
clients to receive these types of vaccines before beginning TNF inhibitor drug therapy.
Options A, C, and D would be incorrect instructions to give the client.
Page 9
20. A client with chronic renal failure has begun treatment with a colony-stimulating factor.
What medication does the nurse anticipate administering to the client that will promote
the production of blood cells?
A) Etanercept (Enbrel)
B) infliximab (Remicade)
C) Epoetin alfa (Epogen)
D) Adalimumab (Humira)
Ans: C
Feedback:
Colony-stimulating factors are cytokines that prompt the bone marrow to produce,
mature, and promote the functions of blood cells. CSFs enable stem cells in bone
marrow to differentiate into specific types of cells such as leukocytes, erythrocytes, and
platelets. Pharmacologic preparation of CSFs, such as epoetin alfa (Epogen), is used to
promote the natural production of blood cells in people whose own hematopoietic
functions have become compromised. The other medications in A, B, and D are tumor
necrosis factor inhibitors.
21. A client has had mumps when he was 9 years old. He had a titer prior to entering
nursing school and shows immunity. What type of immunity does this reflect?
A) Artificially acquired active immunity
B) Naturally acquired active immunity
C) Passive immunity
D) Natural passive immunity
Ans: B
Feedback:
Naturally acquired active immunity occurs as a direct result of infection by a specific
microorganism. An example is the immunity to measles that develops after the initial
infection. Not all invading microorganisms produce a response that gives lifelong
immunity. Artificially acquired immunity is obtained by receiving a killed or weakened
microorganism or toxoid. Passive immunity is acquired when ready-made antibodies are
given to a susceptible person.
Page 10
22. A laboring mother asks the nurse if the baby will have immunity to some illnesses when
born. What type of immunity does the nurse understand that the newborn will have?
A) Naturally acquired active immunity
B) Artificially acquired active immunity
C) Passive immunity transferred by the mother
D) There is no immunity passed down from mother to child.
Ans: C
Feedback:
Passive immunity develops when ready-made antibodies are given to a susceptible
person. The antibodies provide immediate but short-lived protection from the invading
antigen. Newborns receive passive immunity to some diseases for which their mothers
have manufactured antibodies. Naturally acquired active immunity occurs as a direct
result of infection by a specific microorganism. An example is the immunity to measles
that develops after the initial infection. Not all invading microorganisms produce a
response that gives lifelong immunity. Artificially acquired immunity is obtained by
receiving a killed or weakened microorganism or toxoid.
23. A client will be receiving a hepatitis B vaccination series prior to employment in a
dialysis center. What type of immunity will this provide?
A) Forced immunity
B) Naturally acquired active immunity
C) Passive immunity
D) Artificially acquired active immunity
Ans: D
Feedback:
Artificially acquired immunity is obtained by receiving a killed or weakened
microorganism or toxoid. Passive immunity develops when ready-made antibodies are
given to a susceptible person. The antibodies provide immediate but short-lived
protection from the invading antigen. Newborns receive passive immunity to some
diseases for which their mothers have manufactured antibodies. Naturally acquired
active immunity occurs as a direct result of infection by a specific microorganism. An
example is the immunity to measles that develops after the initial infection. Not all
invading microorganisms produce a response that gives lifelong immunity. There is not
a type of immunity called forced immunity.
Page 11
24. The nurse is beginning the physical examination of a client with a complaint of fatigue.
What documentation will the nurse provide to describe this general appraisal of the
client's health?
A) The client appears mildly ill, listless, and disheveled.
B) The client has a blood pressure of 120/72 mm Hg.
C) The client is alert and oriented to all spheres.
D) The client has palpable peripheral pulses in the upper extremities.
Ans: A
Feedback:
The beginning of the physical examination is a general appraisal of the client's health.
The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished,
extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then
performs a more comprehensive examination.
25. The nurse is obtaining information from a client with Crohn's disease about his
medication history. What medication would the nurse include when asking about what
medications the client has taken for suppression of the inflammatory and immune
response?
A) Ibuprofen (Advil)
B) Angiotensin-converting enzyme inhibitors (ACE-I)
C) Diuretics
D) Corticosteroids
Ans: D
Feedback:
The nurse obtains a history of immunizations, recent and past infectious diseases, and
recent exposure to infectious diseases. He or she reviews the client's drug history
because certain drugs, such as corticosteroids, suppress the inflammatory and immune
responses. Advil is a nonsteroidal anti-inflammatory medication and does not suppress
the inflammatory and immune responses. An ACE-I prevents the conversion of
angiotensin I to angiotensin II and does not suppress the inflammatory or immune
response. Diuretics also do not suppress the immune response but help reduce excess
fluid from the kidneys.
Page 12
26. Why would it be important for the nurse to question the client about sexual practices,
history of substance abuse, and his lifestyle during the interview process?
A) To find out if the client will be compliant with therapeutic treatments
B) To determine if the client has practices that put him at risk for acquired
immunodeficiency syndrome (AIDS)
C) To determine if the client needs a referral to counseling services
D) To determine what type of personality the client has
Ans: B
Feedback:
The nurse investigates the client's allergy history and questions the client about practices
that put him or her at risk for AIDS. The interview will not determine the client's ability
to be compliant. The physician would make the determination if a counseling referral
should be made. It is irrelevant to determine the personality traits in the initial interview.
27. A client asks the nurse about the importance of taking supplements to maximize
immune function. The client is healthy and does not have any medical problems. What
is the best information to give to the client?
A) Instead of taking supplements, eat a lot of fruits and vegetables, and this will help
maximize immune function
B) Adopt a vegetarian diet and omit all meats, and you will maximize immune
function.
C) You should take a variety of vitamin and mineral supplements to maximize
immune function.
D) Eating a moderate diet that is balanced and varied will maximize immune
function.
Ans: D
Feedback:
Until more is known about nutrient interactions, the best dietary advice to maximize
immune function in healthy people is to eat a moderate diet that is balanced and varied.
Eating fruits and vegetables and a vegetarian lifestyle may be healthy choices but do not
maximize immune function as a balanced diet will. Because little is known about
nutrient interactions, dietary balance is optimum.
Page 13
28. The nurse is administering a skin test for detection of exposure to tuberculosis. How
would the nurse determine if the client was exposed to tuberculosis?
A) The client will have a productive cough.
B) The injection area swells if the client has developed antibodies against the
antigen.
C) The injection area will become painful with induration if the client has antibodies
against the antigen.
D) The injection area will break out in a fine macular rash.
Ans: B
Feedback:
The injection area swells if the client has developed antibodies against the antigen. The
client is not necessarily actively infectious if the test results are positive. Although a
productive cough is one of the symptoms of active tuberculosis, it may also indicate
other diseases and disorders. The area should not be painful, and the client should not
break out with a rash.
29. A client is admitted to the hospital with a diagnosis of pneumonia. The client informs
the nurse that he has several drug allergies. The physician has ordered an antibiotic as
well as several other medications for cough and fever. What should the nurse do prior to
administering the medications?
A) Administer the medications that the physician ordered.
B) Call the pharmacy and let them know the client has several drug allergies.
C) Consult drug references to make sure the medicines do not contain substances
which the client is hypersensitive.
D) Give the client one medicine at a time and observe for allergic reactions.
Ans: C
Feedback:
Clear identification of any substances to which the client is allergic is essential. The
nurse must consult drug references to verify that prescribed medications do not contain
substances to which the client is hypersensitive. Administering the medications or
giving one at a time may cause the client to have an allergic reaction. The nurse may
call the pharmacy but still maintains responsibility for the medications administered.
Page 14
30. A client is treated in the clinic for a sexually transmitted infection, and the nurse
suspects that the client is at risk for HIV. The physician determines that the client should
be tested for the virus. What responsibility does the nurse have?
A) The nurse ensures a written consent is obtained prior to testing.
B) The nurse should send the client to have the blood drawn without informing him
about the specific screening test.
C) The nurse will call the client with the results of the test.
D) The nurse will inform the client that the results will have to be reported to the
Centers for Disease Control and Prevention (CDC).
Ans: A
Feedback:
The nurse ensures that a written consent is obtained before testing for human
immunodeficiency virus (HIV) and keeps the results of HIV testing confidential. The
client should never be tested without his knowledge. The physician will review the
results when the client comes in for a follow-up visit. It is not necessary for the nurse to
report results to the CDC.
31. What type of immunoglobulin does the nurse recognize that promotes the release of
vasoactive chemicals such as histamine when a client is having an allergic reaction?
A) IgG
B) IgA
C) IgM
D) IgE
Ans: D
Feedback:
IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in
allergic, hypersensitivity, and inflammatory reaction. IgG neutralizes bacterial toxins
and accelerates phagocytosis. IgA interferes with the entry of pathogens through
exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
32. The nurse understands that which cells circulate throughout the body looking for
virus-infected cells and cancer cells?
A) Natural killer cells
B) Cytokines
C) Interleukins
D) Interferons
Ans: A
Feedback:
Natural killer cells are lymphocyte-like cells that circulate throughout the body looking
for virus-infected cells and cancer cells. Cytokines are chemical messengers released by
lymphocytes, monocytes, and macrophages. Interleukins carry messages between
leukocytes and tissues that form blood cells. Interferons are chemicals that primarily
protect cells from viral infections.
Page 15
33. A client has not responded to chemotherapy and radiation therapy. What option may be
available for treatment for this client?
A) If chemotherapy and radiation do not work, there is no other treatment.
B) Aldesleukin
C) Tumor necrosis factor inhibitors
D) Colony-stimulating factor
Ans: B
Feedback:
Aldesleukin is a genetically engineered from of human interleukin-2. It is being used as
biologic therapy for clients who have not responded to conventional cancer treatments
to stimulate the immune system's ability to target cancer cells. Tumor necrosis factor
inhibitors were originally going to be used for shrinking tumors but were found
ineffective. Colony-stimulating factors help with manufacturing blood cells.
34. The nurse is instructing client's about the importance of taking the shingles vaccine.
Which client would benefit from this vaccine?
A) A 24-year-old client who is pregnant
B) A 17-year-old client who will be attending college and living in a dormitory
C) A 32-year-old client who has never had chickenpox
D) A 65-year-old client who had chicken pox when he was 12 years old
Ans: D
Feedback:
Half of individuals living to age 65 years have had or will develop shingles and may not
understand the potential seriousness and risk for complications. Nurses as client
advocates should determine and provide health information regarding the shingles
vaccine. The other clients are not candidates for the vaccine.
35. What type of cytokine will attract neutrophils and monocytes to remove debris?
A) Lymphokines
B) Cytotoxic T cells
C) Suppressor T cells
D) Regulator T cells
Ans: A
Feedback:
Lymphokines, a type of cytokine, attract cells when they detect antigens and direct
B-cell lymphocytes to multiply and mature. Cytotoxic T cells bind to invading cells,
destroy the targeted invader by altering their cellular membrane and intracellular
environment, and stimulate the release of chemicals called lymphokines. Suppressor T
cells limit or turn off the immune response in the absence of continued antigenic
stimulation. Regulator T cells are made of up of helper and suppressor cells.
Page 16
1. Chapter 34
Your client is about to have a skin test for an allergic disorder. What critical instruction
should the nurse give this client?
A) Avoid red meat for 48 to 72 hours before the test.
B) Avoid strenuous physical activity for 24 hours before the test.
C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
D) Avoid sunlight for 48 to 72 hours before the test.
Ans: C
Feedback:
The nurse should instruct the client to avoid taking prescribed or over-the-counter
antihistamine or cold preparations for at least 48 to 72 hours before a skin test because
this reduces the potential for false-negative test results. The nurse should not ask the
client to avoid red meat, strenuous physical activity, or sunlight because these do not
affect the test results.
2. The clinic nurse is caring for a client with an allergic disorder who has received the first
sensitizing dose of a new drug. What nursing action is most important at this point?
A) Assess the client for reduced urine output.
B) Monitor the client for reactions.
C) Assess the client for reduced appetite.
D) Monitor the client for increased heart rate.
Ans: B
Feedback:
Monitoring the client for 30 minutes after desensitization injection is necessary to assess
for allergic symptoms. Although it is important to ensure the client's comfort, it is not
essential to assess the client for changes in urine output, appetite, or heart rate.
3. You are caring for a client with an autoimmune disease. What is a characteristic of
autoimmune disorders?
A) Progressive tissue damage without any verifiable etiology
B) Absence of a triggering event
C) Profound fatigue with no identifiable cause
D) Affects only older adults and infants less than 3 months
Ans: A
Feedback:
Diseases are considered autoimmune disorders and are characterized by unrelenting,
progressive tissue damage without any verifiable etiology. In many autoimmune
disorders, there tends to be a triggering event, such as an infection, trauma, or
introduction of a drug that integrates itself into the membranes of the host's cells.
Although older adults face a greater risk of developing autoimmune disorders, persons
belonging to any age-group can be affected. Chronic fatigue syndrome is primarily
characterized by profound fatigue with no identifiable cause, and this is not a
characteristic of autoimmune disorders.
Page 1
4. You are caring for a client with chronic fatigue syndrome. What is a realistic nursing
intervention when taking care of a client with this diagnosis?
A) Educate the client about the disease process.
B) Advise the client to avoid moderate exertion.
C) Instruct the client to reduce the intake of potassium-rich foods.
D) Advise the client to avoid being in crowds.
Ans: A
Feedback:
The nurse should educate the client about the disease process and the limitations that it
requires because nothing, as yet, holds promise for a complete cure. The client need not
be advised to avoid moderate exertion because the physician may prescribe a modest
exercise program to treat chronic fatigue syndrome. A client who experiences
hypotension may be advised to increase salt and water intake but need not reduce the
intake of potassium-rich foods or avoid being in crowds.
5. A client presents at the clinic with an allergic disorder. The client asks the nurse what an
“allergic disorder” means. What would be the nurse's best response?
A) “It means you are very sensitive to something inside of yourself.”
B) “It is a hyperimmune response to something in the environment that is usually
harmless.”
C) “It is a muted response to something in the environment.”
D) “It is a harmless reaction to something in the environment.”
Ans: B
Feedback:
An allergic disorder is characterized by a hyperimmune response to weak antigens that
usually are harmless. The antigens that can cause an allergic response are called
allergens.
Page 2
6. The nursing instructor is discussing allergic reactions with her clinical group. What
allergic reactions would the nursing instructor talk about? Select all that apply.
A) Atypical
B) Unmediated
C) Cytotoxic
D) Atopic
E) Immune complex
Ans: C, D, E
Feedback:
Once sensitization occurs, one of four types of hypersensitivity responses can occur.
These may be immediate or delayed depending on the time it takes for the immune
system to mount a response. An immediate hypersensitivity response is due to
antibodies interacting with allergens and occurs rapidly. There are three types of
immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated
by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by
immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which
is mediated by IgG antibodies. The first two types of responses occur within minutes;
type III responses reach a peak within 6 hours after exposure to an allergen. Atypical
and unmediated hypersensitivity responses are distractors for this question.
7. A client has been hospitalized for diagnostic testing. The client has just been diagnosed
with multiple sclerosis, which the physician explains is an autoimmune disorder. How
would the nurse explain an autoimmune disease to the client?
A) A disorder where the body has too many immunoglobulins.
B) A disorder where histocompatible cells attack the immunoglobulins.
C) A disorder where killer T cells and autoantibodies attack or destroy natural
cells—those cells that are “self.”
D) A disorder where the body does not have enough immunoglobulins.
Ans: C
Feedback:
Autoimmune disorders are those in which killer T cells and autoantibodies attack or
destroy natural cells—those cells that are “self.” Autoantibodies, antibodies against
self-antigens, are immunoglobulins. They target histocompatible cells, cells whose
antigens match the person's own genetic code. Autoimmune disorders are not caused by
too many or too few immunoglobulins, and histocompatible cells do not attack
immunoglobulins in an autoimmune disorder.
Page 3
8. A client with lupus has had antineoplastic drugs prescribed. Why would the physician
prescribe antineoplastic drugs for an autoimmune disorder?
A) To decrease the body's risk of infection
B) Because an autoimmune disease is a neoplastic disease
C) So the client has strong drug therapy
D) For their immunosuppressant effects
Ans: D
Feedback:
Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay
for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their
immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of
infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just
so the client has strong drug therapy.
9. A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease
the symptoms of his disease. What would be the best response by the nurse?
A) “The doctor could prescribe anti-inflammatory drugs.”
B) “The doctor could prescribe antipyretic drugs.”
C) “The doctor could prescribe antineoplastic drugs.”
D) “The doctor could prescribe antihypertensive drugs.”
Ans: A
Feedback:
Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay
for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for
autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder
until it is in its late stages and uncontrolled by the first-line drugs.
10. A client with an allergic disorder is in treatment for his disorder. What might the
treatment be?
A) Autoimmune therapy
B) Hypersensitive therapy
C) Desensitization therapy
D) Drug therapy for symptoms
Ans: D
Feedback:
Besides avoiding the allergen if possible, many clients experience symptomatic relief
with drug therapy. Options A, B, and C are distractors for this question.
Page 4
11. A client comes to the clinic and states he has “broken out in hives and itching since
eating strawberries this morning.” The client states he has never had problems with
strawberries before. What is the best response by the nurse?
A) “It is probably not the strawberries that you are having an allergy to if you have
eaten them before.”
B) “It is possible to develop an allergic reaction to something you have had prior
exposure to previously.”
C) “Are you sure that you haven't had an allergic reaction before; this doesn't seem
possible.”
D) “We will probably be admitting you to the hospital; this could cause respiratory
arrest.”
Ans: B
Feedback:
Allergies can occur at any age, and the pattern of allergic response can vary in the same
person during his or her life. For example, a person may suddenly develop an allergic
reaction to a substance such as latex, even though he or she has had multiple prior
contacts with latex and no past problems. Although an allergic reaction may cause
laryngeal swelling, this client does not exhibit any of the signs and symptoms of
respiratory distress that would lead to respiratory arrest.
12. A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug
for complaints of abdominal pain. Ten minutes after receiving the medication, the
client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority
measure should the nurse prepare to do?
A) Intubate the client.
B) Perform an electrocardiogram (ECG).
C) Assess the client's vital signs.
D) Administer epinephrine.
Ans: D
Feedback:
Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release
of histamine causes vasodilation; increased capillary permeability; angioneurotic edema
(acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs);
hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine
subcutaneously to a client experiencing a severe allergic reaction. It is outside of the
nurse's practice to intubate a patient. Performing an ECG and assessing the vital signs
delays the treatment of the client and can have negative outcomes.
Page 5
13. A client received 2 units of packed red blood cells while in the hospital with rectal
bleeding. Three days after discharge, the client experienced an allergic response and
began to itch and break out with hives. What type of reaction does the nurse understand
could be occurring?
A) Delayed hypersensitivity response
B) Anaphylactic reaction
C) Sensitization
D) An immediate hypersensitivity response
Ans: A
Feedback:
A delayed hypersensitivity response may develop over several hours or days, or it may
reach maximum severity after repeated exposure. Examples of a delayed
hypersensitivity response include a blood transfusion reaction that occurs days to weeks
after blood administration, rejection of transplanted tissues, and reaction to a tuberculin
skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response.
Sensitization is the process by which cellular and chemical events occur after a second
or subsequent exposure to an allergen. An immediate hypersensitivity response is due to
antibodies interacting with allergens and occurs rapidly.
14. A client comes to the clinic to see the physician with the complaint of “I think I ate
something that I am allergic to.” What symptoms would be appropriate for the nurse to
ask the questions about?
A) Nasal congestion and coughing
B) Hives and itching
C) Sneezing and runny nose
D) Diarrhea and abdominal cramping
Ans: D
Feedback:
Clinical manifestations generally correlate with the manner in which the allergen enters
the body. Inhaled allergens usually cause respiratory symptoms, including nasal
congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Contactants cause
skin reactions such as hives, which appear as vesicles filled with clear fluid surrounded
by a margin of redness, rash, and localized itching. Cramping, vomiting, and diarrhea
are associated with ingested food allergens. Allergic skin responses may also occur with
allergies to foods.
Page 6
15. The nurse is talking with a client who was stung by a bee and began having difficulty
breathing. What serious complication from injected venom should the nurse discuss
with the client?
A) Hives
B) Itching
C) Airway obstruction
D) Diarrhea
Ans: C
Feedback:
Injectants, such as bee venom, and some other allergens can produce systemic and
potentially fatal effects, including shock and airway obstruction caused by laryngeal
swelling. Although all other answers can occur with an allergen, they are not the most
serious complication.
16. A client comes to the clinic and informs the nurse that he feels as though he has
allergies. What laboratory test results will be a positive indicator for an allergic
disorder?
A) Radioallergosorbent blood test (RAST) of 3
B) WBC of 7000/mm3
C) Neutrophils 60%
D) Eosinophils 6%
Ans: A
Feedback:
When the RAST, which measures IgE on a scale of 0 to 5, indicates a score of 2 or
greater, it is a significant indication for an allergic disorder. The RAST does not identify
those, if any, substances to which a person is allergic. It only validates that the person is
potentially hypersensitive to antigenic substances. The other test results are all within
normal range and are not indicative of a definite allergic disorder.
Page 7
17. A client is scheduled to have a prick test to determine what specific allergens are
creating problems for the client. What should the nurse inform the client is involved
with the testing?
A) A concentrated form of the substance is applied to the skin and covered with an
occlusive dressing for 48 hours and then examined.
B) A dilute solution of an antigen is injected intradermal and observed for a wheal.
C) The skin will be scratched, and applying a small amount of the liquid test antigen
to the scratch, usually on the back.
D) The client will taste several different possible antigens and observe for wheals.
Ans: C
Feedback:
The scratch or prick test involves scratching the skin and applying a small amount of the
liquid test antigen to the scratch. The tester applies one allergen per scratch over the
client's forearm, upper arm, or back. The back is more sensitive than the arm. Results of
the test are identifiable in as little as 20 minutes. If a raised wheal with localized
erythema appears, the tester measures its length and width and width in millimeters.
Distractor A is the patch test, and B is the intradermal injection test. The client does not
taste in any of the skin tests.
18. A client informs the nurse that he is very allergic to poison ivy but loves to go camping
and has several camping trips planned for the summer months. What suggestions can be
made to protect against poison ivy?
A) Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet
B) Bentoquatam 5% (Ivy Block) applied 15 minutes prior to exposure and every 4
hours
C) Vinegar and water applied to the skin every 2 hours
D) Take diphenhydramine (Benadryl) 50 mg prior to the camping trip.
Ans: B
Feedback:
To protect against poison ivy, clients can apply bentoquatam 5% (Ivy Block) to the skin
15 minutes prior to exposure and at least every 4 hours as long as risk of exposure
continues. The cream forms a protective layer on top of the skin. Calamine lotion can be
used for the itching related to poison ivy exposure. Vinegar and water is not an effective
way to manage the prevention of poison ivy. Benadryl will not protect against poison
ivy.
Page 8
19. The nurse is interviewing a client being admitted to the hospital and inquires about any
allergies the client has. The client states he is allergic to aspirin and penicillin. What
intervention should the nurse provide immediately to prevent complications related to
allergies?
A) Apply an allergy bracelet and flag the chart.
B) Tape an Epipen to the head of the bed.
C) Inform the client not to take any medications with those substances in them.
D) Call the physician.
Ans: A
Feedback:
The nurse asks each client about the existence of any allergies. If any are reported, the
nurse flags the medical record and applies a wristband with the appropriate information.
Throughout the client's care, the nurse observes for signs of an allergic reaction,
especially when administering medication, applying substances such as tape or adhesive
patches to the skin. Medication should never be left in the client's room. The
responsibility for medications with the identified allergens lies with the healthcare
personnel in the acute care facility. The physician does not need to be called if the chart
is flagged.
20. A client has an allergic reaction to seafood with generalized edema and informs the
nurse that he is unable to get his wedding ring off and it is too tight. The client was
unable to remove it with soap and water. What action by the nurse can facilitate removal
of the ring without damaging it?
A) Administer a diuretic and wait for the swelling to go down.
B) There is not another option other than to use a ring cutter to remove the ring.
C) Use twine to wrap the finger and, when the tissue is compressed, pull the free end
of the twine and remove the ring.
D) Use a tongue blade to remove the ring.
Ans: C
Feedback:
If applying soap or oil to the finger proves unsuccessful, the nurse may wrap the finger
with twine. Once the tissue is compressed, the ring can be removed by pulling on the
free end of the twine. This technique is preferable to damaging the ring with a metal
cutter. If nothing else facilitates ring removal, however, cutting the ring is a better
option than allowing damage from ischemia to develop. The nurse cannot administer a
diuretic without a physician's order, and allowing the swelling to go down may cause
tissue ischemia from the constricted ring. There are options other than cutting the ring,
but if they fail, there is no other choice. A tongue blade will not remove a ring that is too
tight.
Page 9
21. A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be
sure to instruct the client prior to the scheduled appointment?
A) Do not take prescribed or over-the-counter antihistamines or cold preparations for
at least 72 hours before testing.
B) Do not take antihypertensive medications the morning of the scheduled skin
testing.
C) Do not take nonsteroidal anti-inflammatory (NSAID) medications for 1 week
prior to the scheduled skin testing.
D) Prior to having the skin test, have the client take an over-the-counter histamine
prophylactically for any possible reaction that could cause anaphylaxis.
Ans: A
Feedback:
The nurse instructs clients who are scheduled for diagnostic skin testing to avoid taking
prescribed or over-the-counter antihistamines or cold preparations for at least 48 to 72
hours before testing. Doing so reduces the potential for false-negative results. Clients
must temporarily discontinue some medications for even longer. Antihypertensive
medication should not be omitted the day of the procedure. It is not necessary to omit
the use of NSAIDs.
22. A client has been having joint pain and swelling in the left foot and is diagnosed with
rheumatoid arthritis. The symptoms began suddenly without any identifiable cause, and
the client has significant joint destruction. What type of disease is this considered?
A) An exacerbation of a previous disorder
B) Autoimmune
C) An alloimmunity disorder
D) A cause-and-effect relationship
Ans: B
Feedback:
Diseases are considered autoimmune disorders when they are characterized by
unrelenting, progressive tissue damage without any verifiable etiology. The client did
not have a previous disorder that has caused an exacerbation. An alloimmunity
describes an immune response that is waged against transplanted organs and tissues that
carry nonself antigens. Because there is no identifiable cause, there can be no effect.
Page 10
23. A client injured the left eye while playing basketball when another player hit him in the
eye with his elbow. The client complained that although the right eye was not affected,
he is having difficulty now with the vision in that eye too. What does the nurse
understand this phenomenon is known as?
A) Cataracts
B) Psychosomatic blindness
C) Glaucoma
D) Sympathetic uveitis
Ans: D
Feedback:
When a person experiences trauma followed by inflammation to the iris, ciliary body,
and choroid layer of one eye, the vision in the untraumatized eye also becomes affected.
The term for this phenomenon is sympathetic uveitis. Cataracts do not occur from
trauma, they develop over time. Psychosomatic blindness does not relate to the clients
visual disturbance because the client is not blind at this time. Glaucoma is an eye
disorder that occurs over time and is not related to trauma to the eye.
24. A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not
had any symptoms of the disease in 8 months. What does the nurse understand this
asymptomatic period is referred to?
A) An exacerbation
B) Remission
C) A cure
D) An acute inflammatory response
Ans: B
Feedback:
Periods of remission refer to times when the client has no symptoms. The duration of
these periods is completely unpredictable. An exacerbation is periods of acute flare-ups
when the client often experiences a low-grade fever, malaise, or fatigue. He may also
lose weight. Other symptoms such as pain and diarrhea can be associated with a flare-up
of Crohn's disease. The client is not having an acute inflammatory response that would
be considered an exacerbation.
Page 11
25. The nurse is collecting data from a client with the autoimmune disorder, endocarditis.
What does the nurse recognize as symptom of an acute exacerbation?
A) Temperature of 100.9° F
B) Respiratory rate of 20 breaths/minute
C) Constipation
D) Nausea
Ans: A
Feedback:
Periods of acute flare-ups (known as exacerbations) are completely unpredictable.
During acute exacerbations, clients often experience a low-grade fever, malaise, or
fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within
normal range. Constipation and nausea are not characteristic of a flare-up of
endocarditis.
26. A client with rheumatoid arthritis informs the nurse that since he has been in remission
and not having any symptoms, he doesn't need to take his medication any longer. What
is the best response by the nurse?
A) “If you don't take your medication, you will become very ill.”
B) “Be sure to let the physician know after you stop your medications.”
C) “It is important that you continue to take your medication to avoid an acute
exacerbation.”
D) “As long as you are not having symptoms, you can take a medication vacation.”
Ans: C
Feedback:
Even with remission, most people must continue taking prescribed medications to avoid
another acute exacerbation. The client should be encouraged to maintain the therapeutic
regimen in order to avoid an exacerbation and prolong the period of remission as long as
possible. If the client is considering the discontinuation of the medication, he should
notify the physician prior. The nurse is not at liberty to allow the client to discontinue
medication use. Informing the client he will become ill if he discontinues the medication
does not inform them of the rationale.
Page 12
27. A client is taking a corticosteroid for the treatment of systemic lupus erythematosus.
When the nurse is providing instructions about the medication to the client, what
priority information should be included?
A) If the client experiences nausea, omit the dose.
B) The client should be alert for joint aches.
C) This medication is commonly used for many inflammatory reactions and is
relatively safe.
D) Be alert for signs and symptoms of infection and report them immediately to the
physician.
Ans: D
Feedback:
Instruct the client about signs and symptoms of and the increased risk for infection.
Instruct the client to report signs and symptoms of infection immediately to the
physician. Early treatment promotes a shorter duration of illness and reduced
complication. Tell the client to avoid high-risk activities, such as being in crowds,
during periods of immunosuppression. The client should not omit a dose if nausea is
experienced; he may take the medication with food. There are many side effects and
required laboratory work to detect the side effects from immunosuppressive therapy.
Joint aches are vague symptoms and are not a priority for reporting purposes.
28. The nurse has four clients who are scheduled to see the physician for “fatigue” and other
general symptom complaints. Which client does the nurse determine is at most risk for
having chronic fatigue syndrome?
A) Hispanic male, age 28 years
B) Caucasian female, age 47 years
C) African American female, age 42 years
D) Chinese American female, age 18 years
Ans: B
Feedback:
Estimates are that as many as 4 million people in the United States have symptoms
corresponding with chronic fatigue syndrome, but fewer than 80% have been diagnosed
by a medical provider. Most clients who seek treatment for their symptoms are white
women 40 to 59 years of age. CFS also occurs at lower rates among children,
adolescents, and men.
Page 13
29. A client comes to the clinic and informs the nurse that he had a mild case of the flu a
couple of months ago and “hasn't felt well since.” The client tells the nurse that he is
fatigued and it gets worse after any physical activity and a recurrent sore throat and joint
pain. What does the nurse recognize these symptoms may indicate?
A) Chronic fatigue syndrome
B) Rheumatoid arthritis
C) Ulcerative colitis
D) Recurrent flu
Ans: A
Feedback:
Many clients with CFS report having had a recent illness with flulike symptoms or an
upper respiratory infection. Despite having been uncomfortable, most clients do not
describe their initial symptoms as being extraordinarily severe. Severe, ongoing fatigue
lasts for at least 6 months without any explanation. Even though the fatigue is constant,
it worsens after physical activity. The fatigue is so debilitating that it usually interferes
with a person's ability to work in or outside the home. Rheumatoid arthritis and
ulcerative colitis are autoimmune disorders with symptoms that are more specific than
CFS and can be diagnosed with diagnostic testing and laboratory studies. The symptoms
that the client is having are not characteristic of the flu.
30. The client is scheduled for a tilt-table test to assist in the diagnosis of chronic fatigue
syndrome (CFS). What is the nurse's responsibility while the client is having the test?
A) Diagnose the client's chronic fatigue syndrome.
B) Position the client while monitoring the oxygen saturation.
C) Perform venipuncture for glucose levels during testing.
D) Position the client while monitoring blood pressure and pulse.
Ans: D
Feedback:
A tilt-table test, one in which the client lies horizontally on a table whose incline is
elevated to approximately 79° for 45 minutes, may be done. During the test, the blood
pressure and pulse are monitored. The test tends to provoke hypotension in 97% of
those eventually diagnosed with CFS. The diagnosis is made by the physician, not the
nurse. It is not necessary to monitor the oxygen saturation or glucose levels for testing
purposes.
Page 14
31. The nurse is instructing a client with chronic fatigue syndrome about what type of
dietary sources are the best to eat to supply eicosapentaenoic acid (EPA). What
statement by the client demonstrates the instruction is understood?
A) “I will eat shrimp at least twice a week.”
B) “I love crab cakes and will be sure to make them once a week.”
C) “Fresh salmon is one of my favorites, and I will eat it twice a week.”
D) “Lobster is expensive, but I will eat it once a week.”
Ans: C
Feedback:
Fish oils provide the only dietary source of EPA. Fatty fish, such as mackerel, sardines,
herring, salmon, and tuna, are the best sources. Shell fish, such as shrimp, crab, and
lobsters do not offer the dietary source of EPA that is required.
32. A client presents to the clinic with complaints that he began to itch and break out in
hives after taking an aspirin this morning. What medication does the nurse anticipate
administering that blocks histamine receptors?
A) Diphenhydramine (Benadryl)
B) Flunisolide (Nasalide)
C) Beclomethasone dipropionate (Beconase)
D) Pseudoephedrine hydrochloride (Sudafed)
Ans: A
Feedback:
Diphenhydramine (Benadryl) is an antihistamine which blocks histamine receptors and
is used for allergic reactions. Flunisolide (Nasalide) is a nasal decongestant agent and is
used locally to the nasal mucosa. Beclomethasone dipropionate (Beconase) is a nasal
steroid spray and inhalant. Pseudoephedrine hydrochloride (Sudafed) only constricts
nasal membranes.
33. A client calls the clinic and asks the nurse if using Afrin nasal spray would be alright to
relieve the nasal congestion he is experiencing due to seasonal allergies. What
instructions should the nurse provide to the client to avoid complications?
A) Report white patches in the mouth because Afrin can cause a fungal infection.
B) Do not use Afrin for longer than 3 to 5 days in a row or rebound congestion can
occur.
C) Taper the dose when discontinuing the medication.
D) Do not operate machinery or drive while using Afrin nasal spray.
Ans: B
Feedback:
Using Afrin nasal spray for more than 3 to 5 days can cause rebound congestion so the
client should be sure that he is discontinuing use after that time. Afrin does not cause
fungal infection. Corticosteroids should be tapered, but it is not necessary to taper the
Afrin. Afrin does not cause sleepiness so the client can operate machinery or drive.
Page 15
34. A client is taking oral corticosteroids after having an exacerbation of asthma. What
should the nurse be sure to include when instructing the client how to take the
medication?
A) The medication will cause weight loss.
B) The medication will cause drowsiness so do not drive.
C) Take the medication on an empty stomach to increase absorption.
D) Take the medication in the morning with food.
Ans: D
Feedback:
Taking the oral corticosteroids in the morning with food will help reduce the
gastrointestinal upset that may be experienced. The medication causes weight gain not
weight loss, does not cause drowsiness, and should not be taken on an empty stomach.
35. A client is taking the immunosuppressant medication, azathioprine (Imuran), for the
treatment of Crohn's disease. What statement made by the client demonstrates an
understanding of the side effects of this medication?
A) “I will notify the doctor if I have a fever or any other signs of infection.”
B) “I will drink at least 3 L of fluid per day.”
C) “I will notify the doctor if I am not having a bowel movement daily.”
D) “I will stop taking my medication if I notice any side effects and then notify the
doctor.”
Ans: A
Feedback:
The client should be instructed to be sure to report any signs of infection since this drug
suppresses the immune system and make the client susceptible to infections. It is
important for a client to drink 3 L of fluid if he is taking the immunosuppressant drug,
cyclosporine, to prevent hemorrhagic cystitis. It is not necessary to inform the physician
if the client is not having a bowel movement daily. The client should not stop taking the
medication for any reason unless discussed with the physician.
Page 16
1. Chapter 35
A client visits the nurse complaining of diarrhea every time he eats. The client has AIDS
and wants to know what he can do to stop having diarrhea. What should the nurse
advise?
A) Avoid fibrous foods, lactose, fat, and caffeine.
B) Encourage large, high-fat meals.
C) Reduce food intake.
D) Increase the intake of iron and zinc.
Ans: A
Feedback:
Diarrhea may subside when the client avoids residue, lactose, fat, and caffeine. Although
eating may seem to cause diarrhea, the client must understand that limiting the intake of
food to control diarrhea only exacerbates wasting. The client will tolerate a low-fat, highcarbohydrate, and soft or liquid diet better than large, high-fat meals. The client should
be advised to avoid large doses of iron and zinc because they can impair the functioning
of the immune system.
2. A woman infected with HIV comes into the clinic. What symptoms may be the focus of
a medical complaint in women infected with HIV?
A) Rashes on the face, trunk, palms, and soles
B) Muscle and joint pain
C) Gynecologic problems
D) Weight loss
Ans: C
Feedback:
In women with HIV, gynecologic problems, such as abnormal results of Papanicolaou
tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may be the
focus of a majority of complaints. Acute retroviral syndrome (viremia) may be the chief
complaint in one third to more than one half of those infected, not necessarily women. Its
manifestations include rashes, muscle and joint pain, and weight loss.
Page 1
3. A healthcare worker has been exposed to the blood of an HIV-positive client and is
awaiting the results of an HIV test. In the meantime, what precautions must the
healthcare worker take to prevent the spread of infection?
A) Limit interactions with people who are not HIV infected.
B) Limit interactions with people who are already HIV infected.
C) Follow the same sexual precautions as someone who has been diagnosed with
AIDS.
D) Quit his job and admit himself to a hospital or a cancer treatment center.
Ans: C
Feedback:
The healthcare worker will be tested for HIV at regular intervals and treated with
antiretrovirals depending on the results of the tests or the potential for infection. While
awaiting the results, the healthcare worker should follow the same sexual precautions as
someone who has been diagnosed with AIDS. The healthcare worker should not limit
interactions with either non–HIV-infected or HIV-infected people. In addition, the
healthcare worker should not quit and admit himself to a hospital for treatment.
Treatment, if required, can begin if the result of the test is positive.
4. A client who is HIV positive is taking zidovudine. Which adverse effects should the
nurse closely monitor for in this client?
A) Anemia and granulocytopenia
B) Numbness in the extremities
C) Alterations in the renal function
D) Pancreatitis
Ans: A
Feedback:
The most common adverse effects associated with the administration of zidovudine are
anemia and granulocytopenia. The drug does not cause numbness in the extremities,
alterations in the renal function, or pancreatitis.
Page 2
5. A client who is HIV/AIDS positive has orders for laboratory tests to be performed.
What precautions should the nurse observe whenever there is a risk of exposure to the
blood and body fluids of an infected client?
A) Avoid any physical contact with the client.
B) Avoid cleaning up spilled urine and feces.
C) Wear barrier garments for as long as possible after leaving a client's room.
D) Transport the specimens of body fluids in leak-proof containers.
Ans: D
Feedback:
Whenever there is a risk of exposure to the blood and body fluids of an infected client,
the nurse should transport these specimens in leak-proof containers. The nurse need not
avoid physical contact with the client or cleaning the client's urine or stools. On the
other hand, the nurse can use utility gloves and barrier garments, such as face shields
and glasses. These objects should be removed, cleaned, and disinfected soon after
leaving a client's room.
6. A client with AIDS is brought to the clinic by his family. The family tells the nurse the
client has become forgetful, with a limited attention span, decreased ability to
concentrate, and delusional thinking. What condition is represented by these symptoms?
A) Distal sensory polyneuropathy (DSP)
B) Candidiasis
C) AIDS dementia complex (ADC)
D) Cytomegalovirus (CMV)
Ans: C
Feedback:
ADC, a neurologic condition, causes the degeneration of the brain, especially in areas
that affect mood, cognition, and motor functions. Such clients exhibit forgetfulness,
limited attention span, decreased ability to concentrate, and delusional thinking. DSP is
characterized by abnormal sensations, such as burning and numbness in the feet and
later in the hands. Candidiasis is a yeast infection that may develop in the oral,
pharyngeal, esophageal, or vaginal cavities or in the folds of the skin. CMV infects the
choroid and retinal layers of the eye, leading to blindness, and can also cause ulcers in
the esophagus, colitis, diarrhea, pneumonia, and encephalitis.
Page 3
7. A public health nurse is giving an informational presentation on HIV/AIDS at a nearby
college. How would the nurse best define AIDS?
A) Acquired immunodeficiency syndrome is an infection by the human
immunodeficiency virus.
B) Acquired immunodeficiency syndrome is a fatal infection that profoundly
weakens the immune system.
C) Acquired immunodeficiency syndrome is a sexually transmitted disease.
D) Acquired immunodeficiency syndrome is an infectious disease transmitted in
blood and body fluids.
Ans: B
Feedback:
Acquired immunodeficiency syndrome (AIDS) is an infectious and eventually fatal
disorder that profoundly weakens the immune system. Options A, C, and D are incorrect
even though they are true statements. They are not complete answers and are not the
best answer.
8. When learning about HIV/AIDS, the student should be able to differentiate the two
subtypes of virus by ____.
A) Means of transmission
B) HIV-1 is more prevalent than HIV-2 subtypes
C) The fact that it is a mutated virus originally thought to be bovine in nature
D) Cure rate of the virus
Ans: B
Feedback:
Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and
frequently, producing multiple substrains that are identified by letters from A through O.
HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and
development of AIDS is longer. HIV-1 is more prevalent in the United States and in the
rest of the world. Western Africa is the primary site of infection with HIV-2. There is no
cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a
simian virus. Transmission of the virus is not a characteristic.
Page 4
9. A 17-year-old client with a diagnosis of HIV presents at the public health clinic
complaining of pharyngitis, rash on the palms and soles of his feet, and diarrhea. What
would the nurse suspect the client is suffering from?
A) AIDS dementia complex (ADC)
B) Acute retroviral syndrome (ARS)
C) Distal sensory polyneuropathy (DSP)
D) AIDS-related complex (ARC)
Ans: B
Feedback:
Some manifestations include fever; swollen and tender lymph nodes; pharyngitis; rash
about the face, trunk, palms, and soles; muscle and joint pain; headache; nausea and
vomiting; and diarrhea. In addition, there may be enlargement of the liver and spleen,
weight loss, and neurologic symptoms such as visual changes or cognitive and motor
involvement. The scenario does not describe symptoms of ARC, DSP, or ADC.
10. Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select
all that apply.
A) T4/T8 ratio
B) polymerase chain reaction
C) Western blot
D) p24 antigen test
E) ELISA test
Ans: B, D
Feedback:
It is now possible to measure a person's viral load, the number of viral particles in the
blood. The p24 antigen test and polymerase chain reaction test measure viral loads. The
ELISA is a screening test for HIV. The Western blot is a diagnostic test for HIV. The
T4/T8 ratio determines the status of T lymphocytes.
11. The nurse is talking with a group of teens about transmission of human
immunodeficiency virus (HIV). What body fluids does the nurse inform them will
transmit the virus? Select all that apply.
A) Semen
B) Urine
C) Breast milk
D) Blood
E) Vaginal secretions
Ans: A, C, D, E
Feedback:
There are only four known body fluids through which HIV is transmitted: blood, semen,
vaginal secretions, and breast milk. HIV may be present in saliva, tears, and
conjunctival secretions, but transmission of HIV through these fluids has not been
implicated, HIV is not found in urine, stool, vomit, or sweat.
Page 5
12. A female client informs the nurse that she is considering beginning sexual relations and
wants to know the best way to protect herself from a sexually transmitted infection and
HIV. What is the best response by the nurse?
A) “Using a condom (latex) and spermicidal jelly is one of the most effective ways to
decrease the risk of transmission of an STI and HIV.”
B) “Using a diaphragm with spermicidal jelly will also kill the bacteria and viruses
that transmit STIs and HIV.”
C) “Using a lamb skin condom will be the most effective way to decrease
transmission of STIs and HIV.”
D) “Douching immediately after intercourse will be the most effective way to kill
bacteria and viruses.”
Ans: A
Feedback:
Using a condom is one of the most effective ways to reduce the risk of HIV infection.
Condoms are available for both men and women. A diaphragm would not be the most
effective way because there is no protection for the penis or vagina. A lamb skin
condom is not effective to prevent the transmission of HIV. Douching after intercourse
is not an effective method to avoid transmission and does not offer protection from
secretions that are already present.
13. A client requires a blood transfusion for anemia and informs the nurse that he refuses
because he doesn't want to contract acquired immune deficiency syndrome (AIDS).
What is the best response by the nurse?
A) “It's always a possibility.”
B) “You don't want to die, do you?”
C) “The blood is screened very carefully; the risk is 1 in 2,000,000.
D) “If you don't have the transfusion, you are taking a greater risk.”
Ans: C
Feedback:
The American Red Cross (2012) and the National Institutes of Health (2011) state that
the risk for HIV infection in the United States from a blood transfusion is approximately
1 in 2,000,000. Informing the client that transmission is always a possibility does not
give him any information that will be relevant to his decision. Answers B and D is
nontherapeutic and bullies the client into taking the transfusion.
Page 6
14. A male client is having sexual relations with another male as well as using
methamphetamine and has contracted HIV. What concern does the nurse have for this
client?
A) The client is a drug addict and needs to stop using.
B) The client may infect other people because of his drug use.
C) The client may develop AIDS in a shorter period of time.
D) The client will remain HIV positive for a longer period of time.
Ans: C
Feedback:
A new strain of HIV, identified as 3-DCR HIV, was detected in a homosexual man in
New York. Scientists consider this new strain highly virulent because it converted the
man's initial HIV infection to full-blown AIDS in a matter of months; the new strain is
highly drug resistant. The infected man also used methamphetamine, which scientists
believe can accelerate the replication of the virus, especially in the brain. Although the
drug addiction and the transmission of HIV to other people is a concern, it does not
relate to what the question is asking. A positive outcome would be the client
maintaining his HIV status longer and not converting to AIDS.
15. A client is to have a hip replacement in 3 months and does not want a blood transfusion
from random donors. What option can the nurse discuss with the client?
A) Sign a refusal of blood transfusion form so the client will not receive the
transfusion.
B) Bank autologous blood.
C) Ask people to donate blood.
D) Using volume expanders in case blood is needed.
Ans: B
Feedback:
Signing the refusal form does not give the client any information about the options that
are available and place the client at risk. Banking autologous blood that is self-donated
is the safest option for the client. Directed donor blood may be no safer than blood
collected from public donors. Those who support this belief say that directed donors
may not reveal their high-risk behaviors that put the potential recipient at risk for
blood-borne pathogens such as HIV
Page 7
16. The nurse is administering an injection to a client with AIDS and, when finished,
attempts to recap the needle and sustains a needlestick to the finger. What is the priority
action by the nurse?
A) Obtain counseling.
B) Call the lab to draw the nurse's blood.
C) Fill out a risk management report.
D) Report the incident to the supervisor
Ans: D
Feedback:
Because postexposure protocols can reduce the risk of HIV infection if initiated
promptly, nurses must immediately report any needlestick or sharp injury to a
supervisor. Obtaining counseling will occur after all other procedures are adhered to.
The lab will draw blood from the client if required for documentation and other blood
transmitted disorders.
17. The nurse is gathering data from laboratory studies for a client who has HIV. The clients
T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis
pneumonia. What does this indicate to the nurse?
A) The client has converted from HIV infection to AIDS.
B) The client has advanced HIV infection.
C) The client's T4-cell count has decreased due to the Pneumocystis pneumonia.
D) The client has another infection present that is causing a decrease in the T4-cell
count.
Ans: A
Feedback:
AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV
infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to
1200/mm3 and the development of certain cancers and opportunistic infections. The
client does not have advanced HIV; they meet the criteria for the development of AIDS.
The T4-cell count is not decreasing due to an infection.
Page 8
18. A client who had sexual contact with a partner who is HIV+ recently develops flulike
symptoms such as a low grade fever, headache, and muscle pain. What does the nurse
suspect this client is experiencing?
A) Pneumocystis pneumonia
B) Influenza
C) AIDS
D) Acute retroviral syndrome
Ans: D
Feedback:
At the time of primary HIV infection, one third to more than one half of those infected
develop acute retroviral syndrome, also called acute HIV syndrome, which often is
mistaken for flu or some other common illness. Some manifestations include fever;
swollen and tender lymph nodes; pharyngitis; rash about the face, trunk, palms, and
soles; muscle and joint pain; headache; nausea and vomiting; and diarrhea. In addition,
there may be enlargement of the liver and spleen, weight loss, and neurologic symptoms
such as visual changes or cognitive and motor involvement. It is too soon after exposure
for the client to develop Pneumocystis pneumonia or AIDS.
19. A female client comes to the clinic and tells the nurse, “I think I have another vaginal
infection and I also have some wartlike lesions on my vagina. This is happening quite
often.” What should the nurse consult with the physician regarding?
A) Testing the client for the presence of HIV
B) Instructing the client to wear cotton underwear
C) Having the client abstain from sexual activity for 6 weeks while the medication is
working
D) Using a medicated douche in order to keep the vaginal pH normal
Ans: A
Feedback:
Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and
persistent vaginitis also may correlate with HIV infection. Wearing cotton underwear
can help with the prevention of candidiasis but does not address the recurrent vaginal
infection that may not be caused by a fungus. Abstaining from sexual intercourse does
not address the recurrent vaginal infection. A medicated douche can alter the normal
flora of the vaginal wall.
Page 9
20. A client with suspected exposure to HIV has been tested with the enzyme-linked
immunosorbent assay with positive results twice. What is the next step for the nurse to
explain to the patient for confirmation of the diagnosis?
A) Perform the p24 antigen test for confirmation of diagnosis.
B) Perform a Western blot test for confirmation of diagnosis.
C) Perform a polymerase chain reaction test for confirmation of diagnosis.
D) Perform a T4-cell count for confirmation of diagnosis.
Ans: B
Feedback:
The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is
positive when there are sufficient HIV antibodies; it also is positive when there are
antibodies from other infectious diseases. The test is repeated if results are positive. If
results of a second ELISA test are positive, the Western blot is performed. The p24
antigen test and the polymerase chain reaction test determine the viral load, and the
T4-cell count is not used for diagnostic confirmation of the presence of HIV in the
blood.
21. A client has been diagnosed with HIV and has been placed on antiretroviral therapy.
What does the nurse inform the client will be required for determining the progression
of the disease as well as guiding drug therapy?
A) The client will be required to stop the medication for 2 weeks and then have
laboratory studies drawn to determine if the antiretroviral therapy has cured the
disease.
B) Viral load and T4-cell counts will be performed every 2 to 3 months.
C) More antiretroviral medication will be added every 2 to 3 months.
D) The Western blot test will be monitored every 6 months to see if the virus is still
present.
Ans: B
Feedback:
Viral load testing is used to guide drug therapy and follow the progression of the
disease. Viral load tests and T4-cell counts may be performed every 2 to 3 months once
it is determined that a person is HIV positive. The medication should be adhered to and
not discontinued. There is no cure for the disease at this time. Antiretroviral therapy is
not generally changed or added to without reason or lack of response. The Western blot
is used for confirmation of the presence of the HIV virus.
Page 10
22. The client comes to the clinic to obtain the results from the test to determine if he is
infected with HIV. The physician informs the client that he has a CD4 cell count of 300
cells/mm3 and a high viral load. What does the nurse anticipate the physician will
discuss with the client?
A) Retroviral therapy is not warranted at this time.
B) The initiation of antibiotic therapy to prevent the development of an opportunistic
infection
C) The administration of an antifungal medication to prevent the development of an
opportunistic fungal infection
D) The initiation of antiretroviral therapy
Ans: D
Feedback:
Based on randomized trials, nonrandomized trials, and observational studies, the current
guideline is to initiate treatment if the client has a CD4 T-cell count less than 350 to 500
cells/mm3, whereas others will begin treatment with a CD4 cell count over 500
cells/mm3 based on expert opinions. Prophylactic antibiotic and antifungal drug therapy
is not warranted at this time and can cause drug resistance strains to emerge.
23. A client is informed that he will have to start on antiretroviral therapy, and the client is
concerned that he will not be able to afford the therapy. What can the nurse inform the
client is the largest source of public funding for HIV/AIDS care?
A) Medicaid
B) Medicare
C) Blue Cross/Blue Shield
D) AIDS Drug Assistance Program
Ans: A
Feedback:
Medicaid, a state-based medical assistance program for low-income clients, is the
largest source of public funding for HIV/AIDS care. Medicare is for clients that are over
age 65 years or disabled. Blue Cross/Blue Shield is a private insurance with a cap on
coverage. AIDS Drug Assistance Program is the third largest source of funding for HIV
in the United States for individuals who do not have health insurance that pays for drug
therapy.
Page 11
24. A client with HIV will be started on a medication regimen of three medications. Which
medication will be given that will interfere with the virus's ability to make a genetic
blueprint. What drug will the nurse instruct the client about?
A) Protease inhibitor
B) Integrase inhibitors
C) Reverse transcriptase inhibitors
D) Hydroxyurea (Hydrea)
Ans: C
Feedback:
Reverse transcriptase inhibitors are drugs that interfere with the virus's ability to make a
genetic blueprint. A protease inhibitor is a drug that inhibits the ability of virus particles
to leave the host cell. The integrase inhibitors are a class of drug that prevents the
incorporation of viral DNA into the host cell's DNA. Hydrea is a drug that is used as an
adjunct therapy that tries to halt the progression of AIDS.
25. A client has discussed therapy for his HIV-positive status. What does the nurse
understand is the goal of antiretroviral therapy?
A) Reverse the HIV+ status to a negative status.
B) Treat mycobacterium avium complex.
C) Eliminate the risk of AIDS.
D) Keep the CD4 cell count above 350/mm3 and viral load undetectable.
Ans: D
Feedback:
The goal of antiretroviral therapy is to keep the CD4 cell count above 350/mm3 and
bring the viral load to a virtually undetectable level. This level is no more than 500 or 50
copies, depending on the sensitivity of the selected viral load test. It is not possible to
reverse the status to a negative, and it cannot eliminate the risk of AIDS but can help
with prolonging the asymptomatic stage of HIV. Antiretroviral therapy does not treat
mycobacterium avium complex.
Page 12
26. A client on antiretroviral drug therapy is discussing with the nurse that sometimes he
“forgets to take his meds for a few days.” What should the nurse inform the client can
occur when the medications are not taken as prescribed?
A) The funding for the medications will cease if the client is not taking the meds
correctly.
B) The client is risking the development of drug resistance and drug failure.
C) The client will have to take the drugs intravenously to ensure compliance.
D) The client will have to take higher doses of the antiviral medications.
Ans: B
Feedback:
Clients who neglect to take antiretroviral drugs as prescribed risk development of drug
resistance. When drug levels are not adequately maintained, viral replication and
mutations increase. Noncompliant clients are one cause of antiretroviral drug therapy.
Funding will not cease for noncompliance. The medications are not all available in IV
form.
27. A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P.
jiroveci. What medication does the nurse expect that the client will take for the
treatment of this infection?
A) Trimethoprim-sulfamethoxazole (Bactrim, Septra)
B) Nystatin (Mycostatin)
C) Amphotericin B (Fungizone)
D) Fluconazole (Diflucan)
Ans: A
Feedback:
To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole
(Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat
candidiasis.
Page 13
28. The nurse is collecting objective data for a client with AIDS at the clinic. The nurse
observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa.
What does the nurse understand this finding indicates?
A) Kaposi's sarcoma
B) Candidiasis
C) Hairy leukoplakia
D) Coccidiomycosis
Ans: B
Feedback:
Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may
develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It
is often called thrush when located in the mouth. Inspection of the mouth, throat, or
vagina reveals areas of white plaque that may bleed when mobilized with a
cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer.
Hairy leukoplakia is also an indication of oral cancer. Coccidiomycosis causes diarrhea
in the immunosuppressed client.
29. A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers.
What severe complication should the nurse be alert for with cytomegalovirus?
A) Diarrhea
B) Hearing impairment
C) Blindness
D) Fatigue
Ans: C
Feedback:
CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does
not lead to hearing impairment. Fatigue and diarrhea may occur but is not as critical as
blindness.
Page 14
30. A client with cytomegalovirus infection tells the nurse at the clinic that he is starting to
have difficulty seeing and his glasses don't seem to be working as they used to. The
physician determines that the client is developing CMV retinitis. What medication does
the nurse anticipate the client will receive for this?
A) Zidovudine (AZT)
B) Fluconazole (Diflucan)
C) Azithromycin (Zithromax)
D) Foscarnet (Foscavir)
Ans: D
Feedback:
The drug foscarnet is used to treat CMV retinitis and is given by controlled IV infusion.
Alterations in renal function, fever, nausea, anemia, numbness in the extremities, and
diarrhea are the most common adverse effects. AZT is used in antiretroviral therapy to
prevent the conversion of HIV to AIDS. Zithromax is an antibiotic and not used to treat
CMV retinitis.
31. A client with AIDS is admitted to the hospital with severe diarrhea and dehydration.
The physician suspects an infection with Cryptosporidium. What type of specimen
should be collected to confirm this diagnosis?
A) Urine specimen for culture and sensitivity
B) Blood specimen for electrolyte studies
C) Stool specimen for ova and parasites
D) Sputum specimen for acid fast bacillus
Ans: C
Feedback:
A stool specimen for ova and parasites will give a definitive diagnosis. The organism is
spread by the fecal–oral route from contaminated water, food, or human or animal
waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude
of fluid quickly leads to dehydration and electrolyte imbalances.
Page 15
32. A client tells the nurse, “You know I have AIDS. I still cannot afford to tell my
employer because they will probably cancel my health insurance, then what would I
do?” What is the best response by the nurse?
A) “An employer cannot cancel your currently active health insurance on the basis of
AIDS.”
B) “I just wouldn't tell them. It is none of their business.”
C) “You have to tell them, it is not your right to allow them exposure to you. What if
you give it to someone?”
D) “I understand your dilemma, but I think you should tell them. I would want to
know.”
Ans: A
Feedback:
Despite HIV-specific confidentially laws, clients infected with AIDS fear that disclosure
of their condition will affect employment, health insurance coverage, and even housing.
An employer cannot cancel a client's currently active health insurance policy on the
basis of AIDS. However, employers are more apt to dismiss a worker with a known
HIV-positive status from employment to reduce future insurance premiums and death
payments. The other answers are nontherapeutic and not based in fact.
33. The nurse has four clients that come to the clinic for healthcare. Which one of these
clients has the highest risk factor for HIV infection?
A) A 46-year-old female who has been in a monogamous relationship for 9 years
B) A 22-year-old heterosexual male who has had one relationship for 2 years
C) A 34-year-old female who has donated blood on several occasion
D) A 26-year-old inmate who receives tattoos in prison
Ans: D
Feedback:
Contact with infected blood on body piercing, tattoo, and dental equipment places the
inmate at great risk because there is not an approved method for sterilization of the
equipment. The other answers do not eliminate the risk for HIV but are less likely.
34. The nurse is preparing to start an IV for a patient who is combative. What precautionary
measure should the nurse take in order to avoid a needlestick?
A) Have the patient placed in restraints so that he will not move.
B) Ask for assistance.
C) Refuse to start the IV.
D) Give the client a sedative prior to starting the IV.
Ans: B
Feedback:
If a client is uncooperative, ask for assistance when starting IV therapy. Restraints can
cause the client to become more agitated and less cooperative. Sedation can be
considered chemical restraint and can have side effects that are undesirable. Refusing to
start the IV will not allow the client to receive the care that he requires.
Page 16
35. A client will be having a hysterectomy and wants her daughter to donate the blood for
directed donor donation. What factor would eliminate her daughter from donating the
blood?
A) The daughter is 15 years of age.
B) The daughter weighs 124 lb.
C) The daughter is negative for HIV.
D) The physician has been notified of the procedure.
Ans: A
Feedback:
The donor must be at least 17 years of age, weigh 110 lb or more, and test negative for
HIV, and the client's physician must be informed of the procedure.
Page 17
1. Chapter 36
The family nurse practitioner is performing the physical examination of a client with a
suspected neurologic disorder. In addition to assessing other parts of the body, the nurse
should assess for neck rigidity. Which method should help the nurse assess for neck
rigidity correctly?
A) Moving the head toward both sides
B) Lightly tapping the lower portion of the neck to detect sensation
C) Moving the head and chin toward the chest
D) Gently pressing the bones on the neck
Ans: C
Feedback:
The neck is examined for stiffness or abnormal position. The presence of rigidity is
assessed by moving the head and chin toward the chest. The nurse should not maneuver
the neck if a head or neck injury is suspected or known. The neck should also not be
maneuvered if trauma to any part of the body is evident. Moving the head toward the
sides or pressing the bones on the neck will not help assess for neck rigidity correctly.
While assessing for neck rigidity, sensation at the neck area is not to be assessed.
2. The critical care nurse is giving report on a client she is caring for. The nurse uses the
Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female
client and reports to the oncoming nurse that the client has an LOC of 6. What does an
LOC score of 6 in a client indicate?
A) Comatose
B) Somnolence
C) Stupor
D) Normal
Ans: A
Feedback:
The GSC is used to measure the LOC. The scale consists of three parts: eye opening
response, best verbal response, and best motor response. A normal response is 15. A
score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in
a state of coma and not in any other state such as stupor or somnolence. The evaluations
are recorded on a graphic sheet where connecting lines show an increase or decrease in
the LOC.
Page 1
3. The nurse is caring for a comatose client. The nurse knows she should assess the client's
motor response. Which method may the nurse use to assess the motor response?
A) Observing the reaction of pupils to light
B) Observing the client's response to painful stimulus
C) Using the Romberg test
D) Assessing the client's sensitivity to temperature, touch, and pain
Ans: B
Feedback:
The nurse evaluates motor response in a comatose or unconscious client by
administering a painful stimulus. This action helps determine if the client makes an
appropriate response by reaching toward or withdrawing from the stimulus. The
Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined
for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve.
Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the
client and not motor response.
4. A female client undergoes a scheduled electroencephalogram (EEG). Which of the
following postprocedure activities should the nurse carry out for the client?
A) Allow the client to rest and shampoo the client's hair.
B) Provide the client with adequate caffeine-rich drinks.
C) Measure the level of consciousness (LOC) of the client.
D) Measure the heart and the pulse rate.
Ans: A
Feedback:
After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo
the client's hair to remove the glue used to affix electrodes to the scalp. The client is
advised not to take sedative drugs and caffeine-related drinks before the EEG, and there
is no reason to provide the client with them after the test. The nurse should not measure
the LOC, the heart rate, or the pulse rate of the client unless advised by the physician.
5. The nurse is caring for a client who is undergoing single-photon emission computed
tomography (SPECT). What is a potential side effect that this client may suffer?
A) Headache and pain in the neck
B) Claustrophobia
C) Allergic reaction to the imaging material
D) Allergic reaction to radioactive rays
Ans: C
Feedback:
SPECT obtains images of the brain after the client intravenously receives
radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A
potential risk of SPECT is the client's allergic reaction to the imaging material.
Headache is an aftereffect of a cisternal puncture, and claustrophobia may be
experienced by clients during a magnetic resonance imaging scan.
Page 2
6. A client is weak and drowsy after a lumbar puncture. The nurse caring for the client
knows that what priority nursing intervention should be provided after a lumbar
puncture?
A) Administer antihistamines to the client.
B) Provide adequate caffeine-rich drinks to the client.
C) Assess the level of consciousness (LOC) and the pupil response of the client.
D) Position the client flat for at least 3 hours.
Ans: D
Feedback:
A client who has undergone a lumbar puncture should be positioned flat for at least 3
hours and given adequate fluids, and this is a priority activity. These measures help
restore the cerebrospinal fluid volume extracted from the client. The client is
administered antihistamines to manage any allergic reactions that may occur from the
test. The nurse should assess the LOC or the pupil response of the client after a lumbar
puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral
vasodilation.
7. Which neurons transmit impulses from the CNS?
A) Sensory
B) Neurilemma
C) Dendrites
D) Motor
Ans: D
Feedback:
Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS;
motor neurons transmit impulses from the CNS. A membranous sheath called the
neurilemma covers the myelin of axons in peripheral nerves. Dendrites are threadlike
projections or fibers.
8. The brain stem holds the medulla oblongata. What is the function of the medulla
oblongata?
A) Transmits sensory impulses from the brain to the spinal cord
B) Controls striated muscle activity in blood vessel walls
C) Controls parasympathetic nerve impulses in the pons
D) Transmits motor impulses from the brain to the spinal cord
Ans: D
Feedback:
The medulla oblongata lies below the pons and transmits motor impulses from the brain
to the spinal cord and sensory impulses from peripheral sensory neurons to the brain.
The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor
activity (the control of smooth muscle activity in blood vessel walls).
Page 3
9. A client presents to the emergency department status postseizure. The physician wants
to know what the pressure is in the client's head. What test might be ordered on this
client?
A) Lumbar puncture
B) Echoencephalography
C) Nerve conduction studies
D) EMG
Ans: A
Feedback:
Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is
performed to obtain samples of CSF from the subarachnoid space for laboratory
examination and to measure CSF pressure. Echoencephalography records the electrical
impulses generated by the brain. Nerve conduction studies measure the speed with
which the nerve impulse travels along the peripheral nerve. Electromyography studies
the changes in the electrical potential of muscles and the nerves supplying the muscles.
10. A critical care nurse is documenting her assessment of a client she is caring for. The
client is status postresection of a brain tumor. The nurse documents that the client is
flaccid on the left. What does this mean?
A) The client has an abnormal posture response to stimuli.
B) The client is not responding to stimuli.
C) The client is hyperresponsive on the left.
D) The client is hyporesponsive on the left.
Ans: B
Feedback:
Flaccidity is when the client makes no motor response to stimuli. Flaccidity is a motor
assessment.
Page 4
11. A nurse is caring for a client with an injury to the central nervous system. When caring
for a client with a spinal cord insult slowing transmission of the motor neurons, which
deficits are anticipated?
A) A delayed reaction in identification of information due to slowed passages of
information to brain
B) A delayed reaction in cognitive ability to understand the relayed information
C) A delayed reaction in processing the information transferred from the
environment
D) A delayed reaction in response due to the interrupted impulses from the central
nervous system
Ans: D
Feedback:
The central nervous system is composed of the brain and the spinal cord. Motor neurons
transmit impulses from the central nervous system. A deficit in slowing transmission in
this area would slow the response of transmission leading to a delay in reaction. Sensory
neurons transmit impulses from the environment to the central nervous system, allowing
identification of a stimulus. Cognitive centers of the brain interpret the information.
12. The nurse is instructing a community class when a student asks, “How does someone
get super strength in an emergency?” The nurse is correct to instruct on the action of
which system?
A) Musculoskeletal system
B) Sympathetic nervous system
C) Parasympathetic nervous system
D) Endocrine system
Ans: B
Feedback:
The division of the autonomic nervous system called the sympathetic nervous system
regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous
system are called catecholamines. During an emergency situation or an intensely
stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles,
and lungs that need to react in the situation. The musculoskeletal system benefits from
the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles.
The parasympathetic nervous system works to conserve body energy not expend it
during an emergency. The endocrine system regulates metabolic processes.
Page 5
13. The nurse is caring for a client who is to have a lumbar puncture. What are the lowest
vertebrae that contain the spinal cord?
A) Coccyx
B) Second lumbar vertebrae
C) Eleventh thoracic vertebrae
D) Fifth lumbar vertebrae
Ans: B
Feedback:
The spinal cord ends between the first and second lumbar vertebrae.
14. The nurse is employed in a neurologist's office, performing a history and assessment on
a client experiencing hearing difficulty. The nurse is most correct to gather equipment to
assess the function of which cranial nerve?
A) Cranial nerve II
B) Cranial nerve VI
C) Cranial nerve VIII
D) Cranial nerve XI
Ans: C
Feedback:
There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or
auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve.
Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI
is the accessory nerve and is involved with head and shoulder movement.
15. The nurse is assessing the throat of a client with throat pain. In asking the client to stick
out the tongue, the nurse is also assessing which cranial nerve?
A) Cranial nerve I
B) Cranial nerve V
C) Cranial nerve XI
D) Cranial nerve XII
Ans: D
Feedback:
Assessment of the movement of the tongue is cranial nerve XII. Cranial nerve I is the
olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the
face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head
and shoulder and shoulder movement.
Page 6
16. When completing a neurologic examination on a client, which question is most essential
to evaluate the accuracy of the data?
A) When, if any, was your last narcotic use?
B) Do you have any history of forgetfulness?
C) Have you been diagnosed with any mental health issues?
D) Have you experienced any unusual sensations?
Ans: A
Feedback:
When completing a neurologic exam, it is essential to assess the use of morphine,
heroin, narcotic, or central nervous system depressant use because the use affects the
results of a neurologic examination. These types of drugs decrease the level of
consciousness. The nurse can observe forgetfulness and mental status. Experiencing
unusual sensations is good subjective data to have but is not essential to evaluate the
accuracy of objective data.
17. The nurse is caring for a client in the emergency department with diagnosis of head
trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the
client's face and torso. For which action, made by the nurse aide, would the nurse
provide further instruction?
A) The nurse aide used mild soapy water to clean the face.
B) The nurse aide moved the client's head to clean behind the ears.
C) The nurse aide cleaned the eye area from the inner to outer eye area.
D) The nurse aide cleaned the neck and upper chest area.
Ans: B
Feedback:
Further instruction would be provided to the nurse aide when the nurse aide attempted to
move the client's head to clean behind the ears. There should be no movement of the
client's head when there is a history of head trauma. Cleaning the client's face with
soapy water, cleaning the eye area, and cleaning the neck and upper chest are all
appropriate actions completed by the nurse aide.
Page 7
18. The nurse is caring for a stuporous client in the intensive care unit. Which assessment
finding is documented to reflect an improvement in the client's level of consciousness?
A) Conscious
B) Somnolent
C) Stuporous
D) Semicomatose
Ans: B
Feedback:
Somnolent or lethargic means that the client is drowsy or sleepy at inappropriate times.
This is an improvement from the stuporous state, which includes arousing the client
only with vigorous and repeated stimulation. A client that is conscious is alert and
responds to stimulation immediately. A client is documented as semicomatose when the
client only responds to superficial, relatively mild painful stimuli.
19. The nurse is assessing the assigned client's level of consciousness during morning
rounds. The nurse speaks the client's name, strokes the client's hand, and moves the
client's shoulder. There is a delay, and then the client states, “What do you want?”
Which level of conscious should the nurse document?
A) Conscious
B) Semicomatose
C) Somnolent
D) Stuporous
Ans: C
Feedback:
Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times.
This is an improvement from the stuporous state, which includes arousing the client
only with vigorous and repeated stimulation. A client that is conscious is alert and
responds to stimulation immediately. A client is documented as semicomatose when the
client only responds to superficial, relatively mild painful stimuli.
20. The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale.
Which score would indicate to the nurse that the client is in a semicomatose state?
A) A score of 20
B) A score of 15
C) A score of 9
D) A score of 4
Ans: C
Feedback:
A score of 9 indicates a semicomatose state. A score of 7 or less is considered a coma. A
normal response is documented as a 15. A score of 20 indicates inappropriate scoring. A
score of 4 carries an extremely poor prognosis.
Page 8
21. The nurse is assessing the client's pupils following a sports injury. Which of the
following assessment findings indicates a neurologic concern? Select all that apply.
A) Unequal pupils
B) Pupil reaction quick
C) Pinpoint pupils
D) Absence of pupillary response
E) Pupil reacts to light
Ans: A, C, D
Feedback:
Normal assessment findings includes that the pupils are equal and reactive to light.
Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic
impairment.
22. Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a
thin slice of a muscular body area?
A) Computed tomography (CT)
B) Magnetic resonance imaging (MRI)
C) Positron emission tomography (PET)
D) Single-photon emission computed tomography (SPECT)
Ans: A
Feedback:
A computer tomography scan uses x-rays and computer analysis to produce
three-dimensional views of the slices of the body. This is a good first test to obtain
information. An MRI uses radiofrequency waves to produce images of tissue. PET scans
use radioactive substances to examine metabolic activity and organ involvement.
SPECT is an imaging tool that examines cerebral blood flow.
23. The nurse is assisting the physician in completing a lumbar puncture. Which would the
nurse note as a concern?
A) Physician maintains aseptic procedure.
B) Cerebrospinal fluid is cloudy in nature.
C) Client states a piercing feeling.
D) Client states a pressure relief in the head.
Ans: B
Feedback:
The nurse would note a concern as being the cerebrospinal fluid as cloudy in nature.
Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic
procedure. A piercing feeling and pressure relief is a common feeling during and after
the procedure.
Page 9
24. The nurse is caring for a post–lumbar puncture client experiencing an intense headache.
The physician is notified and arriving to assess the client. If the physician chooses
aggressive treatment, which nursing action is anticipated?
A) Hanging an intravenous solution
B) Drawing venous blood to perform a blood patch
C) Applying ice to the back of the neck
D) Offering caffeinated drinks
Ans: B
Feedback:
Aggressive treatment would include performing a blood patch by instilling 20 to 30 mL
of the client's venous blood into the epidural space to seal the leak of CSF fluid.
Increasing fluid intake and instilling parenteral caffeine sodium benzoate are less
aggressive treatments. Applying ice to the head is a conservative treatment.
25. The physician's office nurse is caring for a client who has a history of a cerebral
aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the
aneurysm?
A) Myelogram
B) Electroencephalogram
C) Echoencephalography
D) Cerebral angiography
Ans: D
Feedback:
The nurse would anticipate a cerebral angiography, which detects distortion of the
cerebral arteries and veins. A myelogram detects abnormalities of the spinal canal. An
electroencephalogram records electrical impulses of the brain. An echoencephalography
is an ultrasound of the structures of the brain.
26. The nurse is working in an outpatient studies unit administering neurologic tests. The
client is surprised that paste is used to secure an electroencephalogram and asks how it
will be removed from the hair. The nurse is most correct to state which?
A) The paste is removed with acetone.
B) The paste is removed with a special soap.
C) The paste is removed with standard shampoo.
D) The paste is removed by flushing with warm water.
Ans: C
Feedback:
Standard shampoo is used to remove the paste, which attached the electrodes to the
head. Acetone is not used on the hair. There is no special soap needed. More than warm
water is needed to lift and remove the paste.
Page 10
27. The nurse is caring for a client with a significant allergy history to various medications
and shellfish. Because the client needs to have a diagnostic study with contrast, which
medication classification is anticipated?
A) Bronchodilator
B) Antihistamine
C) Cardiotonic
D) Antibiotic
Ans: B
Feedback:
Clients with an allergy history are administered a pretest dose of an antihistamine.
Antihistamines block histamine receptors and reduce the manifestations of an allergic
reaction. The other options are not administered in the pretest period.
28. A nurse is caring for a client with deteriorating neurologic status. The nurse is
performing an assessment at the beginning of the shift that reveals a falling blood
pressure and heart rate, and the client makes no motor response to stimuli. Which
documentation of neuromuscular status is most appropriate?
A) Abnormal posture
B) Flaccidity
C) Weak muscular tone
D) Decorticate posturing
Ans: B
Feedback:
The nurse would document flaccidity when the client makes no motor response to
stimuli. Abnormal posturing and weak motor tone would be documented specifically as
the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and
clenched fists with legs straight out.
Page 11
29. The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting
from the assessment findings that the client is lacking a connection because motor
impulses are interrupted from the brain to the spinal cord. It also appears that the client
lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has
the deficit?
A) Midbrain
B) Medulla oblongata
C) Pons
D) Subarachnoid space
Ans: B
Feedback:
The medulla oblongata lies below the pons and transmits motor impulses from the brain
to the spinal cord and sensory impulses from the peripheral sensory neurons to the brain.
The pons is part of the brainstem. The midbrain forms the forward part of the brainstem
and connects the pons and the cerebellum with the two cerebral hemispheres. The
subarachnoid space lies between the pia mater and the arachnoid membrane.
30. A nurse is completing a neurological assessment and determines that the client has
significant visual deficits. A brain tumor is considered. Considering the functions of the
lobes of the brain, which area will most likely contain the neurologic deficit?
A) Frontal
B) Parietal
C) Temporal
D) Occipital
Ans: D
Feedback:
The vision center is located in the occipital lobe. There is little other functioning that
may interfere with the visual process in the other lobes of the brain.
31. The nurse is assessing a client's ability to detect sensation in the upper extremity. Which
nursing actions would be appropriate? Select all that apply.
A) Place a warm cotton ball on the arm.
B) A light prick using a needle.
C) A gentle pinch using the fingers.
D) Drag the alcohol pad over the skin.
E) Touch the client with the pads of the finger.
Ans: A, C, D, E
Feedback:
Sensory function can be assessed in a number of ways as long as the client has the
ability to feel sensations. Common methods include placing a warm cotton balls on the
skin, gently pinching on the skin between fingers, dragging alcohol over the skin, and
touching the client with the pads of the fingers. The nurse would not use an instrument
that would break the skin.
Page 12
32. A nurse is working in a neurologist's office. The physician orders a Romberg test.
Which nursing action is correct?
A) Have the client touch his nose with one finger.
B) Have the client close his eyes and stand erect.
C) Have the client close his eyes and discriminate between dull and sharp.
D) Have the client close his eyes and jump on one foot.
Ans: B
Feedback:
In the Romberg test, the client stands erect with the feet close together and eyes closed.
If the client sways and appears to fall, it is considered a positive Romberg test. All of
the other options include components of neurologic tests, indicating neurologic deficits
and balance.
33. The nurse is caring for a client newly diagnosed with multiple sclerosis. The client
indicates that there is so much to understand at one time. The client indicates
understanding that there is a disruption in the covering of axons but does not remember
what the covering is called. Which nursing action is correct?
A) Tell the client not to worry about the fine details.
B) Tell the client that there is so much to learn; you can meet to discuss it again.
C) Tell the client that the covering is called myelin and that you can discuss at the
next meeting.
D) Tell the client that the disease process requires more research.
Ans: C
Feedback:
The nurse would be most correct in answering the question and then, if the patient is
tired, following up at the next meeting. It would also be appropriate to provide literature
to review at the client's leisure. Discounting the need to know information about the
disease process is belittling. Telling the client that more research needs to be done
discounts the valuable information which is known.
Page 13
34. The client is waiting in a triage area to learn the medical status of his family following a
motor vehicle accident. The client is pacing, taking deep breaths, and wringing the
hands. Considering the effects in the body systems, what effects does the nurse
anticipate in the liver?
A) The liver will cease function and shunt blood to the heart and lungs.
B) The liver will convert glycogen to glucose for immediate use.
C) The liver will produce a toxic by product in relation to stress.
D) The liver will maintain a basal rate of functioning.
Ans: B
Feedback:
When the body is under stress, the sympathetic nervous system is activated readying the
body for action. The effect of the body is to mobilize stored glycogen to glucose to
provide additional energy for body action.
Page 14
1. Chapter 37
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan
for this client reflects the client's problem eating due to jaw pain. To assist the client in
meeting the adequate nutritional needs, what should the nurse suggest?
A) Take small meals of nutrient and calorie-dense food.
B) Increase the intake of calcium and proteins.
C) Include additional servings of fruits and raw vegetables.
D) Include fish, liver, and chicken in diet.
Ans: A
Feedback:
To help a client with trigeminal neuralgia who suffers pain in the jaws meet his or her
nutritional needs, the nurse should offer small meals of soft consistency. Foods may be
pureed to minimize jaw movements when eating. There is no need for the client to
increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal
neuralgia. In addition, an increased intake of fruits and raw vegetables requires excessive
chewing, potentially increasing the incidence of jaw pain. The nurse should avoid
offering meat and fish in the diet because they also require excessive chewing by the
client.
2. An older client complains of a constant headache. A physical examination shows
papilledema. What may the symptoms indicate in this client?
A) Epilepsy
B) Trigeminal neuralgia
C) Hypostatic pneumonia
D) Brain tumor
Ans: D
Feedback:
Headache and papilledema are symptoms of a brain tumor, although these symptoms do
appear less often in the older adult. Symptoms of epilepsy include seizure activity,
whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles.
Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
Choices A, B, and C are not associated with papilledema or constant headache.
Page 1
3. A client you are caring for experiences a seizure. What would be a priority nursing
action?
A) Restrain the client during the seizure.
B) Insert a tongue blade between the teeth.
C) Protect the client from injury.
D) Suction the mouth during the convulsion.
Ans: C
Feedback:
The nursing action for a client experiencing a seizure should be to protect the client
from being injured. To ensure this, the nurse should turn the client to one side and not
restrain client's movements. Inserting a tongue blade between the teeth is not as
important as protecting the client from injury. The mouth and the pharynx of the client
should be suctioned only after the seizure.
4. You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client
also has an ascending paralysis. Knowing the potential complications of the disorder,
what should you keep always ready at the bedside?
A) Nebulizer and thermometer
B) Intubation tray and suction apparatus
C) Blood pressure apparatus
D) Incentive spirometer
Ans: B
Feedback:
Progressive GBS can move to the upper areas of the body and affect the muscles of
respiration. If the respiratory muscles are involved, endotracheal intubation and
mechanical ventilation become necessary. A spirometer is used to evaluate the client's
ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not
required because generally a client with GBS does not show signs of increased blood
pressure or temperature.
5. The critical care nurse is caring for a client with bacterial meningitis. The client has
developed cerebral vasculitis and increased ICP. What neurologic sequelae might this
client develop?
A) Damage to the nerves that facilitate vision and hearing
B) Damage to the vagal nerve
C) Damage to the olfactory nerve
D) Damage to the facial nerve
Ans: A
Feedback:
Neurologic sequelae in survivors include damage to the cranial nerves that facilitate
vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the
olfactory nerve, or the facial nerve.
Page 2
6. You are caring for a client with an inoperable brain tumor. What is a major threat to this
client?
A) Increased ICP
B) Decreased ICP
C) Hypervolemia
D) Hypovolemia
Ans: A
Feedback:
Nursing management depends on the area of the brain affected, tumor type, treatment
approach, and the client's signs and symptoms. If the tumor is inoperable or has
expanded despite treatment, increased ICP is a major threat. In this scenario, there are
no indications that volume either increased or decreased is an issue.
7. The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia
gravis. When administering medications to this client, what is a priority nursing action?
A) Assess client's reaction to new medication schedule.
B) Administer medications at exact intervals ordered.
C) Document medication given and dose.
D) Give client plenty of fluids with medications.
Ans: B
Feedback:
He or she must administer medications at the exact intervals ordered to maintain
therapeutic blood levels and prevent symptoms from returning. Assessing the client's
reaction, documenting medication and dose, and giving the client plenty of fluids are not
the priority nursing action for this client.
8. A client diagnosed with Huntington's disease has developed severe depression. What
would be most important for the nurse to assess for?
A) Loss of bowel and bladder control
B) Choreiform movements
C) Suicidal ideations
D) Emotional apathy
Ans: C
Feedback:
Severe depression is common and can lead to suicide, so it is most important for the
nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly
and include mental apathy and emotional disturbances, choreiform movements
(uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and
swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder
control. Assessing for these symptoms is appropriate but not as important as assessing
for suicidal ideations.
Page 3
9. The school nurse notes a 6-year-old running across the playground with his friends. The
child stops in midstride, freezing for a few seconds. Then the child resumes his progress
across the playground. The school nurse suspects what in this child?
A) An absence seizure
B) A myoclonic seizure
C) A partial seizure
D) A tonic-clonic seizure
Ans: A
Feedback:
Absence seizures, formerly referred to as petit mal seizures, are more common in
children. They are characterized by a brief loss of consciousness during which physical
activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight
movement of the head, arms, and legs occurs. These seizures typically last for a few
seconds, and the person seldom falls to the ground. Because of their brief duration and
relative lack of prominent movements, these seizures often go unnoticed. People with
absence seizures can have them many times a day. Partial, or focal, seizures begin in a
specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve
jerking movements.
10. The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor.
What teaching is important for the nurse to do with this client?
A) Optimizing nutrition
B) Managing muscle weakness
C) Explaining hospice care and services
D) Offering family support groups
Ans: C
Feedback:
The nurse explains hospice care and services to clients with brain tumors that no longer
are at a stage where they can be cured. Managing muscle weakness and offering family
support groups are important, but explaining hospice is the best answer. Optimizing
nutrition at this point is not a priority.
Page 4
11. Following a motorcycle accident, a client is brought to the emergency department with
multiple fractures. Which assessment finding would be most significant in determining
the client has also suffered a closed head injury with rising intracranial pressure?
A) Blood pressure 100/60 mm Hg
B) Lethargy
C) Nausea
D) Periorbital edema
Ans: B
Feedback:
Decreasing level of consciousness is one of the earliest signs of increased ICP. Without
a baseline for the BP, it is difficult to determine whether this is a significant change for
this client. Vomiting (usually without forewarning of nausea) when associated with a
head injury suggests increasing ICP. Perioribital edema is more suggestive of fluid
overload than ICP.
12. Which of the following assessment findings would indicate an increasing intracranial
pressure (ICP) in a client with head trauma? Select all that apply.
A) Stiff neck
B) Generalized pain
C) Glasgow Coma Scale of 15
D) Elevated systolic blood pressure
E) Brisk pupil response
F)
Wide pulse pressure
Ans: D, F
Feedback:
Elevated systolic blood pressure with widening pulse pressure is consistent with
Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad
include bradycardia and irregular breathing. Stiff neck is not a symptom associated with
ICP. Generalized pain is not significant with ICP unless related to complaint of
headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil
response are normal findings.
13. A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous
solution (IV) would the nurse anticipate hanging?
A) Dextrose 5% in water (D5W)
B) Half-normal saline (0.45% NSS)
C) One-third normal saline (0.33% NSS)
D) Mannitol (Osmitrol)
Ans: D
Feedback:
With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling
in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that
will move more fluid into the cells, worsening the ICP.
Page 5
14. A client with a brain tumor is complaining of a headache upon awakening. Which
nursing action would the nurse take first?
A) Elevate the head of the bed.
B) Complete a head-to-toe assessment.
C) Administer morning dose of anticonvulsant.
D) Administer Percocet as ordered.
Ans: A
Feedback:
The first action would be to elevate the head of the bed to promote venous drainage of
blood and CSF. Then, a neurological assessment would be completed to determine if
any other assessment findings are significant of increasing ICP. The administering of
routine ordered drugs is not a priority, and narcotic analgesics would be avoided in
clients with ICP issues.
15. Which assessment finding is most important in determining nursing care for a client
with bacterial meningitis? Select all that apply.
A) Cloudy cerebral spinal fluid
B) Pain and stiffness of the extremities
C) Purpura of hands and feet
D) Low white blood cell (WBC) count
E) Low red blood cell (RBC) count
F)
Low antidiuretic hormone (ADH) levels
Ans: A, C
Feedback:
The CSF will be cloudy if bacterial meningitis is the causative agent. Purpura indicates
a serious complication of bacterial meningitis (disseminated intravascular coagulation)
is occurring and may place the client at risk for amputation of those parts .Pain and
stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and
ADH would be expected.
Page 6
16. The nurse is caring for a client with Guillain-Barré syndrome. Which assessment
finding would indicate the need for oral suctioning?
A) Decreased pulse rate, respirations of 20 breaths/minute
B) Increased pulse rate, adventitious breath sounds
C) Increased pulse rate, respirations of 16 breaths/minute
D) Decreased pulse rate, abdominal breathing
Ans: B
Feedback:
An increased pulse rate above baseline with adventitious breath sounds indicate
compromised respirations and signal a need for airway clearance. A decrease in pulse
rate is not indicative of airway obstruction. An increase of pulse rate with slight
elevation of respirations (16 breaths/minute) is not significant for suctioning unless
findings suggest otherwise.
17. The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is
questioning how this process works. Which of the following statements by the nurse
best describes plasmapheresis in the management of this syndrome?
A) “Antibodies that triggered the autoimmune response are removed from your
blood.”
B) “The blood removal allows for replacement of cleaner blood from a healthy
person.”
C) “Blood transfusions are the gold standard for the treatment of this syndrome.”
D) “Plasma replacement dilutes the organisms that are causing the symptoms.”
Ans: A
Feedback:
Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood
transfusion) has emerged as a major treatment intervention. This process removes the
blood, filters out the antibodies that trigger the autoimmune disease, and then returns the
blood to the client. The blood removal is only a part of the process for filtering out
antibodies and is not a dilution process.
Page 7
18. The client presents to the walk-in clinic with fever, nuchal rigidity, and headache.
Which of the following assessment findings would be most significant in the diagnosis
of this client?
A) Change in level of consciousness
B) Vomiting
C) Vector bites
D) Seizures
Ans: C
Feedback:
Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis
secondary to West Nile virus. Change in LOC, vomiting, and seizures are all symptoms
of increased ICP and due not assist in the differentiating of cause, diagnosis, or
establishing nursing care.
19. A client is receiving baclofen (Lioresal) for management of symptoms associated with
multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing
which of the following?
A) Sleep pattern
B) Mood and affect
C) Appetite
D) Muscle spasms
Ans: D
Feedback:
Baclofen (Lioresal) is a drug used to manage symptoms of muscle spasticity and rigidity
in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS,
initially, Lioresal may cause drowsiness, but sleep is not the intended goal for this
therapy. Mood and appetite are not a factor in the administration of this drug.
20. The nurse is completing an assessment on a client with myasthenia gravis. Which of the
following historical recounting provides the most significant evidence regarding when
the disorder began?
A) Shortness of breath
B) Sensitivity to bright light
C) Muscle spasms
D) Drooping eyelids
Ans: D
Feedback:
Ptosis is the most common manifestation of myasthenia gravis. Muscle weakness varies
depending on the muscles affected. Shortness of breath and respiratory distress occurs
later as the disease progresses. Muscle spasms are more likely in multiple sclerosis.
Photophobia is not significant in myasthenia gravis.
Page 8
21. A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which
statement by the client would indicate a need for more teaching from the nurse?
A) “I will have progressive muscle weakness.”
B) “I will lose strength in my arms.”
C) “My children are at greater risk to develop this disease.”
D) “I need to remain active for as long as possible.”
Ans: C
Feedback:
There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS
usually begins with muscle weakness of the arms and progresses. The client is
encouraged to remain active for as long as possible to prevent respiratory complications.
22. Which of the following teaching points is a priority in the management of symptoms for
a client with Bell's palsy?
A) Avoid stimuli that trigger pain.
B) Use ophthalmic lubricant and protect the eye.
C) Encourage semiannual dental exams.
D) Complete the course of antibiotics as prescribed.
Ans: B
Feedback:
The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be
affected which results in incomplete closure and risk for injury. The eye can become dry
and irritated unless eye moisturizing drops and ophthalmic ointment is applied.
Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V
disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are
not used in the treatment of Bell's palsy because it is thought to be caused by a virus.
23. Which topic is most important for the nurse to include in the teaching plan for a client
newly diagnosed with Parkinson's disease?
A) Involvement with diversion activities
B) Enhancement of the immune system
C) Establishing balanced nutrition
D) Maintaining a safe environment
Ans: D
Feedback:
The primary focus in caring for Parkinson's disease is on maintaining a safe
environment. Parkinson's disease often has a propulsive gait, characterized by a
tendency to take increasingly quicker steps while walking and an inability to stop
abruptly without losing balance. Prevention of communicable diseases and establishing
a balanced nutrition is encouraged with any chronic disorder. Diversional activities can
be helpful in times of stress but not a priority.
Page 9
24. The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which
nursing assessment is primary during this time of medication change?
A) Observe for jaundice.
B) Assess for euphoria.
C) Monitor vital sign fluctuation.
D) Monitor for elevation of glucose levels.
Ans: C
Feedback:
Adverse effects of dopamine replacement drugs include cardiac dysrhythmias,
hypotension, muscle cramps, and GI distress. Vital signs should be monitored during
periods of medication adjustment, and changes such as orthostatic hypotension and
arrhythmias/palpitations should be reported. The nurse should monitor the liver
enzymes and BUN, but jaundice should not occur. During changes in dopamine levels,
the client may exhibit signs of paranoia or suicidal ideation not euphoria. Blood sugar
levels are not affected by dopamine replacement drugs.
25. The home health nurse is caring for a client with Parkinson's disease. The nurse
understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa
(Sinemet) to the medication regime should result in which purpose?
A) Slows the progression of the disease
B) Replaces dopamine
C) Relieves symptoms of dyskinesia
D) Prevents side effects from Sinemet
Ans: A
Feedback:
Selegiline (Eldepryl) increases dopaminergic activity and slows the progression of the
disease. Carbidopa-levodopa (Sinemet) is a dopamine replacement drug.
Anticholinergic drugs (such as Cogentin) are used to reduce the symptoms of dyskinesia
and other side effects.
Page 10
26. A client, who was adopted at birth, recently discovers that Huntington's disease is
prevalent in the biological family history. How can the nurse best assist the client in
dealing with personal fears?
A) Provide information of the progression of the disease.
B) Encourage client to verbalize fears.
C) Explain that inherited risk is 50%.
D) Offer genetic testing.
Ans: B
Feedback:
Huntington's disease is a hereditary disorder of the CNS that is progressive and has no
cure. Being able to verbalize fears and concerns that are real can be therapeutic for the
client. Providing information about genetic testing, inherited risk, and progression of the
disease will not alleviate fears and can be postponed until the client is ready for this
information.
27. A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client
verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern
is disturbed, and the choreiform movements are worsening. Which nursing diagnosis
best reflects the needs of this client?
A) Impaired Home Maintenance
B) Altered Nutrition
C) Hopelessness
D) Disturbed Sleep Pattern
Ans: C
Feedback:
Huntington's disease is an inherited disease that has progressive physical, emotional,
and mental involvement. There is no cure or course of treatment to preserve or prevent
disease progression. Death is eminent. This client feels hopeless and helpless and sees
no alternatives or choices available and is unable or unwilling to move forward with
living.
Impaired Home Maintenance is not significant. Altered Nutrition and Disturbed Sleep
Patterns are apparent, but unless the client is able to mobilize energy to move forward,
these problems cannot be resolved.
Page 11
28. A client, with a recent closed head injury, began experiencing partial (focal) seizures
and asks the nurse to explain why this is happening. Which is the best response from the
nurse?
A) “It is not uncommon for seizure activity to occur after head trauma.”
B) “Only a portion of your brain has been irritated.”
C) “Generalized seizures are much worse and involve the entire brain.”
D) “Electrical impulses become confused and chaotic resulting in a seizure.”
Ans: A
Feedback:
The client wants a simple explanation to help alleviate fears and concerns. Explaining
that seizures are common (or even normal) after head trauma can assist the client by
decreasing fears and open the door for further teaching about the disruption of impulses
and irritation in the brain due to the injury. Partial seizures involve a part of the brain
that is irritated; this is factual but does not answer the question asked. Generalized
seizures involve the entire brain from the onset and the electrical impulses are chaotic,
but this information is not significant to the question asked by the client.
29. A client falls to the floor in a generalized seizure with tonic-clonic movements. Which
is the first action taken by the nurse?
A) Insert an airway or bite block.
B) Manually restrain the extremities.
C) Turn client to side-lying position.
D) Monitor vital signs.
Ans: C
Feedback:
When a client begins to convulse, the highest priority is to maintain airway. This can
best be accomplished by turning client to side-lying position, which allows saliva and
emesis to drain from the mouth. Turning the client also allows the tongue to fall forward
opening the airway. More damage can occur if a bite block is inserted after the seizure
has begun. Manually restraining extremities is not recommended. Attempting to take
B/P is not recommended and pulse rate and respirations during the event will not be
beneficial. Monitor vital signs during the postictal phase.
Page 12
30. Following a generalized seizure in a client, which nursing assessment is a priority for
detailing the event?
A) Seizure began at 1300 hours.
B) The client cried out before the seizure began.
C) Seizure was 1 minute in duration including tonic-clonic activity.
D) Sleeping quietly after the seizure
Ans: C
Feedback:
Describing the length and the progression of the seizure is a priority nursing
responsibility. During this time, the client will experience respiratory spasms, and their
skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting
when the seizure began and presence of an aura are also valuable pieces of information.
Postictal behavior should be documented along with vital signs, oxygen saturation, and
assessment of tongue and oral cavity.
31. A client weighing 132 lb is brought to the emergency department in status epilepticus.
The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many
milligrams will be given to this client?
_______________________________ mg
Ans: 15 mg
Feedback:
Step 1: 2.2 lb / 1 kg = 132 lb / X kg
132 lb = 2.2 X
60 kg = X
Step 2: 1 kg / 0.25 mg = 60 kg / X mg
15 mg = X
32. A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain
tumor. Which nursing measure is primary in the postsurgical care of this client?
A) Assessing skull dressing for excess drainage
B) Time, distance, and shielding against radiation
C) Assess neurological findings.
D) Maintain airway via artificial ventilation.
Ans: C
Feedback:
Gamma-knife radiosurgery is a non-invasive alternative for treating tumors within the
brain. The nurse would be responsible for completing a neurological assessment on the
client and providing comfort measures as needed. There is no incision on the skull, and
no risk for radiation exposure to the nurse. The procedure eliminates surgical and
anesthesia complications and does not result in use of a ventilator or artificial airway
maintenance.
Page 13
33. The spouse of a client with terminal brain cancer asks the nurse about hospice. Which
statement by the nurse best describes hospice care?
A) “Hospice care uses a team approach and provides complete care.”
B) “Clients and families are the focus of hospice care.”
C) “The physician coordinates all the care delivered.”
D) “All hospice clients die at home.”
Ans: B
Feedback:
The most important component of hospice care is the focus that is placed on the care of
the client as well as the family. Hospice does take a team approach and coordinates care
through the hospice physician, but these are not the focus. Not all hospice clients wish
to die at home.
34. A client with increased intracranial pressure is receiving mannitol (Osmitrol) via
intravenous infusion. Which assessment finding is most important in determining the
effectiveness of this treatment?
A) Blood pressure is rising.
B) Level of consciousness is improving.
C) Urine output is increased.
D) Hyperpyrexia is resolving.
Ans: C
Feedback:
Mannitol is a hypertonic solution that helps to pull fluid from the cells into the vascular
system where the kidneys can eliminate as urine. The blood pressure should lower as the
fluid volume is depleted. Level of consciousness may improve as the ICP is lowered,
but the use of mannitol is for diuresis. Resolving fever is not significant with the use of
mannitol.
Page 14
1. Chapter 38
A client presents to the walk-in clinic complaining of a migraine. The client is
prescribed a neuronal stabilizer. What should the nurse suggest to the client?
A) Avoid crowds.
B) Take drugs only after meals at night.
C) Avoid caffeine and alcohol.
D) Use caution while driving or performing hazardous activities.
Ans: D
Feedback:
A client who is prescribed a neuronal stabilizer needs to exercise caution while driving
and avoid performing hazardous activities. A client taking nonsteroidal
anti-inflammatory drugs should be advised against taking caffeine and alcohol. The
client need not take the drug only at night after meals or be instructed to avoid crowds.
2. A client has just been diagnosed with a cerebral aneurysm. In planning discharge
teaching for this client, what instructions should be delivered by the nurse to the client?
A) Avoid heavy lifting.
B) Avoid fiber in the diet.
C) Take an antacid frequently.
D) Take an herbal form of feverfew.
Ans: A
Feedback:
A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional
situations, or straining of stools because these activities increase intracranial pressure
and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead
to constipation and straining with stools and would not be recommended. There would
not be a recommendation for antacids or feverfew in the discharge teaching.
3. A client has tension headaches. The nurse recommends massage as a treatment for
tension headaches. How does massage help clients with tension headaches?
A) Reduces hypotension
B) Increases appetite
C) Relaxes muscles
D) Relieves migraines
Ans: C
Feedback:
Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves
headache. However, this approach is not likely to help a client with migraine or cluster
headaches. Massage is not offered to clients with tension headaches to increase their
appetite or reduce hypotension.
Page 1
4. The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the
interaction of visitors or family members with the client with an aneurysm?
A) The interaction may cause the client to become violent.
B) The interaction may cause migraine in the client.
C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
D) The client may become emotional and lose interest in the treatment.
Ans: C
Feedback:
Although visitors' and family members' desire to interact with the client are well
intentioned, the stimulation can increase ICP or trigger a seizure. The nurse can suggest
that they take turns and stay briefly. Interactions are not likely to make the client violent
or emotional, which may cause the client to lose interest in the treatment. The
interactions also may not cause migraine in the client.
5. A client is prescribed warfarin. Client teaching has included instructions to avoid a diet
rich in foods that contain vitamin K. What sources of food should the nurse instruct the
client to avoid?
A) Fish, meats, and vegetable oils
B) Citrus fruits
C) Milk and dairy products
D) Cereals, soybeans, and spinach
Ans: D
Feedback:
Clients who take warfarin (Coumadin) must be informed that they should avoid foods
rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower,
spinach, and other green leafy vegetables; cereals; and soybeans. Other food groups are
not known to contain vitamin K. Milk and dairy products are good sources of calcium,
whereas citrus fruits are sources of vitamin C. Fish, meats, and oils are sources of
proteins and fats.
Page 2
6. A client diagnosed with migraine headaches asks the nurse what he can do to help
control the headaches and minimize the number of attacks he is having. What
instructions should the nurse give this client?
A) Identify and avoid factors that precipitate or intensify an attack.
B) Keep a record of activities following an attack.
C) When an attack occurs, stay in a brightly lit area.
D) Write down any adverse drug effects.
Ans: A
Feedback:
The nurse includes the following instructions: Follow the indications and dosage
regimen for medication and notify the physician of any adverse drug effects. Identify
and avoid factors that precipitate or intensify an attack. Keeping a food diary may help
identify foods that trigger attacks. Keep a record of the attacks, including activities
before the attack and environmental or emotional circumstances that appear to bring on
the attack. Lie down in a darkened room and avoid noise and movement when an attack
occurs, if that is possible.
7. You are caring for a client admitted with a stroke. Imaging studies indicate an embolus
partially obstructing the right carotid artery. What type of stroke do you know this client
has?
A) Ischemic
B) Hemorrhagic
C) Right-sided
D) Left-sided
Ans: A
Feedback:
Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood
to the brain; about 80% of strokes are the ischemic variety. Options B, C, and D are
incorrect.
Page 3
8. While making your initial rounds after coming on shift, you find a client thrashing about
in bed complaining of a severe headache. The client tells you the pain is behind his right
eye, which is red and tearing. What type of headache would you suspect this client of
having?
A) Migraine
B) Tension
C) Cluster
D) Sinus
Ans: C
Feedback:
A person with a cluster headache has pain on one side of the head, usually behind the
eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose),
and tearing and redness of the eye. The pain is so severe that the person is not likely to
lie still; rather he or she paces or thrashes about. The symptoms in the scenario do not
describe a sinus headache.
9. A family member comes to the clinic to talk to the nurse about a client who has had a
stroke on the right side of the brain. The family member is concerned because of the
deficits the client is exhibiting. The nurse knows that when a client experiences a stroke
on the right side of the brain, common deficits include what? Select all that apply.
A) Left-sided hemiplegia
B) Tendency to distractibility
C) Impairment of long-term memory
D) Hyperaware of deficits
E) Neglect of objects and people on the left side
Ans: A, B, E
Feedback:
Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic
deficits: spatial–perceptual defects; disregard for the deficits of the affected side require
special safety considerations; tendency to distractibility; impulsive behavior, unaware of
deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty
distinguishing upside down and right side up; impairment of short-term memory; and
neglect left side of body, objects and people on left side.
Page 4
10. A 76-year-old male client is brought to the clinic by his daughter. The daughter states
that her father has had two transient ischemic attacks (TIAs) in the past week. The
physician orders carotid angiography, and the report reveals that the carotid artery has
been narrowed by atherosclerotic plaques. What treatment option does the nurse expect
the physician to offer this client to increase blood flow to the brain? Select all that
apply.
A) Balloon angioplasty of the carotid artery followed by stent placement
B) Removal of the carotid artery
C) Percutaneous transluminal coronary artery angioplasty
D) Carotid endarterectomy
Ans: A, D
Feedback:
If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a
carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed.
A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous
transluminal coronary artery angioplasty, may be performed alternatively to dilate the
carotid artery and increase blood flow to the brain, followed by stent placement. Options
B and C are not options to increase blood flow through the carotid artery to the brain.
11. The nurse is completing an assessment on a client with a history of migraines. The nurse
would identify which of the following factors as a possible trigger for a migraine
headache? Select all that apply.
A) Red wine
B) Nausea
C) Menstruation
D) Exposure to bright light
E) Change in environmental temperature
F)
Prolonged positioning
Ans: A, C
Feedback:
Research on the cause of migraines is ongoing; however, changes in reproductive
hormones (menstruation) and particular food/beverages can be a trigger for some
clients. Nausea is a symptom of a migraine. Exposure to bright light and changes in
environmental temperature are not triggers for migraine headaches. Prolonged
positioning can cause muscle fatigue and strain that trigger tension headaches.
Page 5
12. A client who complains of recurring headaches, accompanied by increased irritability,
photophobia, and fatigue is asked to track the headache symptoms and occurrence on a
calendar log. Which is the best nursing rationale for this action?
A) Cluster headaches can cause severe debilitating pain.
B) Migraines often coincide with menstrual cycle.
C) Tension headaches are easier to treat.
D) Headaches are the most common type of reported pain.
Ans: B
Feedback:
Changes in reproductive hormones as found during menstrual cycle can be a trigger for
migraine headaches and may assist in the management of the symptoms. Cluster
headaches can cause severe pain but is not the reason for tracking. Tension headaches
can be managed but is not associated with a monthly calendar. Headaches are common
but not the reason for tracking.
13. When providing teaching to a client who reports tension headaches, which of the
following instructions would be most beneficial to prevent onset of symptoms?
A) Apply cool or warm cloth to head or eyes.
B) Eliminate use of bright lights when working.
C) Avoid certain foods.
D) Perform stretching exercises and frequent position change.
Ans: D
Feedback:
Tension headaches are often associated with prolonged tensed muscles. Application of
cool or warm cloths and avoidance of bright lights may help to reduce the headache
after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not
likely to prevent tension headaches.
14. A client who has experienced an initial transient ischemic attack (TIA) states: “I'm glad
it wasn't anything serious.” Which is the best nursing response to this statement?
A) “I sense that you are happy it was not a stroke.”
B) “People who experience a TIA will develop a stroke.”
C) “TIA symptoms are short lived and resolve within 24 hours.”
D) “TIA is a warning sign. Let's talk about lowering your risks.”
Ans: D
Feedback:
TIA is a warning sign and can be used to empower clients to make life changes to lower
the risks. Sensing the client is happy is a psychotherapeutic response but does not lead
to teaching and learning for health promotion. TIAs can lead to a stroke for
approximately one third of the clients but is not a definitive result and presents as a
frightening statement without empowering change. TIA symptoms are short lived, but
this is a factual statement that does not provide additional information to the client.
Page 6
15. A client is being assessed for a possible transient ischemic attack (TIA). Which of the
following assessment findings suggests to the nurse that the client is experiencing a
TIA?
A) Unilateral ptosis
B) Respiratory distress
C) Severe headache
D) Nausea and vomiting
Ans: A
Feedback:
A client with a TIA may experience impaired muscle coordination or paralysis on one
side. Respiratory distress and severe headache are not associated with TIA. Nausea and
vomiting is not a usual symptom of TIA.
16. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce
the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment
to include which of the following?
A) Cholesterol-lowering drugs
B) Anticoagulant therapy
C) Monthly prothrombin levels
D) Carotid endarterectomy
Ans: B
Feedback:
Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac
dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if
indicated to manage atherosclerosis. Prothrombin and international normalized ratio
(INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy.
Carotid endarterectomy would be anticipated only when the carotids have narrowing
from plaque.
17. A client is brought to the emergency department with symptoms of a cerebrovascular
accident (CVA). The nurse would anticipate which diagnostic evaluation to be
completed prior to initiation of treatment?
A) Prothrombin level
B) Chest x-ray
C) Brain CT scan or MRI
D) Lumbar puncture
Ans: C
Feedback:
CT scan or MRI differentiates CVA from other disorders and can differentiate between
ischemic or hemorrhagic strokes. PT level would be done if the client is receiving
anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are
indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.
Page 7
18. A client with a cerebrovascular accident (CVA) is having difficulty with eating food on
the plate. Which is the best nursing action to be taken?
A) Perform a vision field assessment.
B) Reposition the tray and plate.
C) Assist the client with feeding.
D) Know this is a normal finding for CVA.
Ans: A
Feedback:
The nurse should perform a vision field assessment to evaluate the client for
hemianopia. This finding could indicate damage to the visual area of the brain as a result
of evolving CVA. Repositioning the tray and assisting with feeding would not be the
best nursing action until new finding has been evaluated. Hemianopia can be associated
with a CVA but, when presenting as a new finding, should be evaluated and reported
immediately.
19. A client has been found unresponsive at home for an undetermined period of time. A
cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster
be used to restore functioning. The nurse knows that successful use of TPA in a client
with CVA requires which of the following? Select all that apply.
A) The symptoms are no longer evolving.
B) Presence of an ischemic stroke
C) Used concurrently with heparin therapy
D) Administer intramuscular for faster response.
E) Administer within 3 hours of onset of symptoms.
F)
Administer for hemorrhagic strokes.
Ans: B, E
Feedback:
TPA is a thrombolytic agent that can limit neurologic deficits if given IV within 3 hours
of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolve) may
take days and would not be appropriate for the use of TPA. TPA is not used in
conjunction with other anticoagulants and would never be used to treat a hemorrhagic
stroke (promotes more bleeding).
Page 8
20. The nurse is assisting a client, with a right-sided brain infarction, to transfer from the
wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this
transfer?
A) Wheelchair placed so client leads with his left side
B) Wheelchair placed on the right side of the bed facing the foot
C) Wheelchair placed on the left side of the bed facing the head
D) Wheelchair placed on the right side of the bed facing the head
Ans: B
Feedback:
A right-sided brain infarct can result in left-sided weakness or paralysis. The wheelchair
should be positioned to allow the client to lead with the right side of the body.
21. Following the use of a thrombolytic agent in the management of cerebrovascular
accident (CVA) client, which is the priority nursing assessment?
A) Pulse
B) Respirations
C) Airway
D) Blood pressure
Ans: D
Feedback:
The use of tissue plasminogen activator (TPA), a thrombolytic agent, has been found to
limit the neurologic deficits when given within 3 hours after onset of an ischemic CVA.
Blood pressure is a critical assessment factor during the first 24 hours to determine
intracerebral hemorrhage, which is a major complication associated with thrombolytic
use. Airway is always a priority but not significant with thrombolytic use. Pulse and
respirations can also indicate signs of hypovolemic shock resulting from hemorrhage.
Page 9
22. The client with hemiplegia is at risk for impaired walking. Which nursing intervention
would best assist this client in preventing complications associated with lower extremity
impairment?
A) Occupational therapy daily
B) Use of walker for ambulation
C) Use of high-top tennis shoes throughout the day
D) Whirlpool tub baths and massage therapy
Ans: C
Feedback:
Hemiplegic clients are at risk for the development of plantar flexion, which would
impede ambulation. High-top tennis shoes act as splints, providing support to the
ankle/foot, and prevent plantar flexion contractures by maintaining the extremity in
proper anatomic position. Occupational therapy is an important factor in rehabilitation
after a stroke but not significant in preventing complications with walking. Whirlpool
tub baths and massage therapy are soothing and assist in reducing muscle tension but
not significant in prevention of walking impairment. The client must have strength in
both upper extremities to be able to use a walker safely.
23. Which of the following goals is the priority in the care planning of a client with
cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?
A) To prevent contractures and joint deformities
B) To decrease risk for ineffective cerebral tissue perfusion
C) To develop appropriate coping mechanisms
D) To increase activity tolerance
Ans: A
Feedback:
The long-term outcome for rehabilitation is directed toward maintaining
musculoskeletal functioning. The risk for ineffective cerebral tissue perfusion is of most
concern during the acute phase rather than rehab phase of care. Developing appropriate
coping mechanisms in dealing with loss of body function or image is important but not
as significant as musculoskeletal integrity. Activity tolerance should increase during
rehab but not a primary concern.
Page 10
24. Which nursing assessment finding is most indicative of a hemorrhagic stroke?
A) Client history of atrial fibrillation
B) Sudden onset of breathing alterations
C) Symptoms evolving over 24 to 48 hours
D) Client history of hyperlipidemia
Ans: B
Feedback:
Hemorrhagic strokes are less common than ischemic strokes and usually present with
sudden onset and have the most impact on breathing, blood pressure, and heart rate.
Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic
strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48
hours until symptoms complete.
25. A video fluoroscopy has determined that the appropriate diet for the client with a left
cerebrovascular accident (CVA) should include honey thickened liquids. Which of the
following is the priority nursing diagnosis for this client?
A) Risk for Fluid Volume Deficit
B) Risk for Aspiration
C) Impaired Swallowing
D) Altered Nutrition: Less Than Body Requirements
Ans: C
Feedback:
Impaired Swallowing was evident on the video fluoroscopy. Risk for Aspiration,
Altered Nutrition, and Fluid Volume Deficit can occur but are not the primary diagnosis
at this point in time.
26. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of
greatest importance in prioritizing nursing care to this client?
A) Complaint of headache off and on for past month
B) No bowel movement since yesterday
C) Nausea
D) Frequent voiding
Ans: C
Feedback:
Nausea needs to be controlled to prevent vomiting, which can greatly increase the
intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for
past month is significant and probably attributes to the evaluation at hand. Having no
bowel movement since yesterday is not significant; although, every effort should be
made to prevent constipation. Frequent voiding is expected especially with the use of
osmotic diuretics.
Page 11
27. The client with a cerebral aneurysm asks the nurse, “What's the big fuss over a
headache?” Which is the best response from the nurse regarding to a cerebral aneurysm?
A) “Don't worry. The aneurysm has probably been there since birth.”
B) “The headache can be an indication that the aneurysm is growing.”
C) “A headache means your aneurysm is leaking blood into the brain.”
D) “Your physician wants to evaluate the location and condition of the aneurysm.”
Ans: D
Feedback:
Keeping the client calm and quiet is an important aspect of care. Explaining the need for
further evaluation is factual. The nurse should avoid saying “don't worry” or telling a
client how to feel—this is not a therapeutic response. The aneurysm is growing or
leaking are both inappropriate responses from a nurse and can lead to increased concern
and anxiety for the client.
28. A client is brought into the emergency department with a diagnosis of ruptured cerebral
aneurysm. Which assessment data provides the most important information in preparing
for the nursing care of this client?
A) Blood pressure 180/98 mm Hg
B) Alert and oriented times three
C) Grade V on the Hunt-Hess Scale
D) Complaint of severe splitting headache
Ans: C
Feedback:
The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides
the most accurate assessment as listed. An elevated blood pressure is anticipated with a
cerebral aneurysm. Being alert and oriented provides little assessment value without
additional neurologic data. Complaint of severe headache is subjective and not as
significant as the Hunt-Hess Scale.
29. A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache.
Which client statement would indicate a need for additional teaching from the nurse?
A) “I use this to prevent migraines.”
B) “I take this when I get a headache.”
C) “It constricts the blood vessels in my head.”
D) “It alleviates my sensitivity to light and sound.”
Ans: A
Feedback:
Imitrex is a serotonin receptor agonist that stimulates serotonin receptors in the brain
and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and
other symptoms associated with migraines. Imitrex is used during an attack and is not
indicated for preventative migraine therapy.
Page 12
30. An elderly client, who has fallen several times at home, is admitted for possible
transient ischemic attack (TIA). Which assessment finding is most significant in
determining care for this client?
A) Becomes confused during the night
B) Drooling from side of mouth
C) Bruit heard over carotids
D) Irregular heart rhythm
Ans: B
Feedback:
Facial droop and drooling from the side of the mouth can indicate progression of
symptoms or evolving CVA. It is not unusual for elderly clients to become confused
when placed in a new environment and would indicate a need for further assessment.
Bruits over the carotids may indicate altered blood flow to the brain but may not be a
new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or
other cardiac disorders.
31. A client with atrial fibrillation is placed on Coumadin to reduce the potential of
developing a cerebrovascular accident (CVA). The international normalized ratio (INR)
is 1.5. What does this finding indicate to the nurse?
A) Therapeutic range is achieved.
B) Coumadin will be increased.
C) Coumadin will be decreased.
D) INR is too high.
Ans: B
Feedback:
Ideally, the INR will be therapeutic at 2.0 to 3.0. Because the level is low, the nurse can
anticipate the increase in Coumadin dosage.
32. A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular
accident (CVA). Which assessment by the nurse provides the most significant finding in
differentiating between ischemic and hemorrhagic strokes?
A) A unit of fresh frozen plasma is infusing.
B) Neurological checks are ordered every 2 hours.
C) Keppra is ordered for treatment of focal seizures.
D) Oropharyngeal suctioning as needed.
Ans: A
Feedback:
FFP is used in the treatment of clotting deficiencies as seen with over dose of
anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2
hours does not differentiate between types of strokes. Focal seizures can occur with any
stroke and would not differentiate. Suctioning is a nursing action taken to maintain
airway and does not indicate a specific type of stroke.
Page 13
33. A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain
MRI reveals an infarct. The nurse understands these symptoms to be suggestive of
which of the following findings?
A) Transient ischemic attack (TIA)
B) Left-sided cerebrovascular accident (CVA)
C) Right-sided cerebrovascular accident (CVA)
D) Completed Stroke
Ans: B
Feedback:
When the infarct is on the left side of the brain, the symptoms are likely to be on the
right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is
no longer the diagnosis. There is not enough information to determine if the stroke is
still evolving or is complete.
34. A client has experienced a transient ischemic attack (TIA) and presents with carotid
bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid
endarterectomy?
A) Encourage deep breathing and coughing.
B) Observe for facial swelling.
C) Anticipate need for endotracheal intubation.
D) Resume antilipemic drugs.
Ans: C
Feedback:
Surgical approach to the neck area can result in swelling and blockage of the airway.
This is especially significant with bilateral carotid endarterectomy. The nurse needs to
be observant and prepared for immediate intubation if the airway becomes obstructed.
Encouraging deep breathing and coughing is not significant because general anesthesia
is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute
postoperative period.
Page 14
1. Chapter 39
The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the
following indicates the presence of/or leaking of cerebral spinal fluid?
A) Change in the level of consciousness (LOC)
B) Signs of increased intracranial pressure (IICP)
C) Halo sign
D) Swelling
Ans: C
Feedback:
To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the
nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
Change in the LOC and signs of IICP are part of the neurologic assessment and do not
assist in detecting any CSF drainage. The presence of swelling does not assist in
detecting CSF drainage.
2. Which of the following types of hematoma results from venous bleeding with blood
gradually accumulating in the space below the dura?
A) Epidural
B) Subdural
C) Intracerebral
D) Cerebral
Ans: B
Feedback:
A subdural hematoma results from venous bleeding, with blood gradually accumulating
in the space below the dura. An epidural hematoma stems from arterial bleeding, usually
from the middle meningeal artery, and blood accumulation above the dura. An
intracerebral hematoma is bleeding within the brain that results from an open or closed
head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A
cerebral hematoma is bleeding within the skull.
3. You are caring for a client with a spinal cord injury. What test reveals the level of spinal
cord injury?
A) Radiography
B) Myelography
C) Neurologic examination
D) Computed tomography (CT) scan
Ans: C
Feedback:
A neurologic examination reveals the level of spinal cord injury. Radiography,
myelography, and a CT scan show the evidence of fracture or compression of one or
more vertebrae, edema, or a hematoma.
Page 1
4. The nurse is admitting a client from the emergency department with a reported spinal
cord injury. What device would the nurse expect to be used to provide correct vertebral
alignment and to increase the space between the vertebrae in a client with spinal cord
injury?
A) Cervical collar
B) Cast
C) Traction with weights and pulleys
D) Turning frame
Ans: C
Feedback:
Traction with weights and pulleys is applied to provide correct vertebral alignment and
to increase the space between the vertebrae. A cast and a cervical collar are used to
immobilize the injured portion of the spine. A turning frame is used to change the
client's position without altering the alignment of the spine.
5. A client with impaired physical mobility has been hospitalized. What nursing
intervention helps reduce the potential for formation of thrombi and renal calculi in a
client with impaired physical mobility?
A) Provide a well-balanced diet.
B) Position the client.
C) Keep the client hydrated.
D) Help the client perform exercises.
Ans: C
Feedback:
The nurse should keep the client hydrated. Adequate hydration reduces the potential for
the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and
elements necessary for energy and to sustain cellular growth and repair. Positioning the
client helps avoid joint contractures and foot drop. Active and passive exercise
maintains joint flexibility and reduces muscle atrophy and atony.
Page 2
6. A mother brings her 6-year-old to the emergency department (ED) after the child fell off
the bike. The physician diagnoses a concussion. The mother asks the nurse what a
concussion is. What should the nurse's response be?
A) “A concussion is a blow to the head that bruises the brain.”
B) “A concussion is a blow to the head that is hard enough for the brain to bounce off
the other side of the skull.”
C) “A concussion is a blow to the head that is minor and has no real consequences.”
D) “A concussion is a blow to the head that jars the brain, resulting in diffuse and
microscopic injury to the brain.”
Ans: D
Feedback:
A concussion results from a blow to the head that jars the brain. It usually is a
consequence of falling, striking the head against a hard surface such as a windshield,
colliding with another person (e.g., between athletes), battering during boxing, or being
a victim of violence. A concussion results in diffuse and microscopic injury to the brain.
Options A, B, and C are incorrect because they give incorrect information to the mother.
7. You suspect that a newly admitted client is in spinal shock. What are the symptoms of
spinal shock? Select all that apply.
A) Bladder distention
B) Poikilothermia
C) Loss of hunger sensation
D) Circulatory failure
E) No perspiration below the level of the injury
Ans: A, B, E
Feedback:
In addition to paralysis, manifestations include pronounced hypotension, bradycardia,
and warm, dry skin. If the level of injury is in the cervical or upper thoracic region,
respiratory failure can occur. Bowel and bladder distention develop. The client does not
perspire below the level of injury, which impairs temperature control. The client
manifests with poikilothermia, body temperature of the environment. Symptoms of
spinal shock do not include loss of hunger sensation or circulatory failure.
Page 3
8. The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology
class. What would the nursing instructor describe as an arterial bleed with rapid
neurologic deterioration?
A) Extradural hematoma
B) Epidural hematoma
C) Subdural hematoma
D) Intracranial hematoma
Ans: B
Feedback:
An epidural hematoma stems from arterial bleeding, usually from the middle meningeal
artery, and blood accumulation above the dura. It is characterized by rapidly progressive
neurologic deterioration.
9. When caring for a client who is post–intracranial surgery what is the most important
parameter to monitor?
A) Extreme thirst
B) Intake and output
C) Nutritional status
D) Body temperature
Ans: D
Feedback:
It is important to monitor the client's body temperature closely because hyperthermia
increases brain metabolism, increasing the potential for brain damage. Therefore,
elevated temperature must be relieved with an antipyretic and other measures. Options
A, B, and C are not the most important parameters to monitor.
Page 4
10. You are caring for a client who has had intracranial surgery and is being discharged
home. What instructions would you give the client besides instructions on the
medication?
A) Understand that headaches are uncommon.
B) You can cover the incision with your hair.
C) You can expect swelling above the incision.
D) Expect sensory changes, such as hearing a clicking sound, around the bone flap.
Ans: D
Feedback:
In addition, the nurse must provide the following verbal and written instructions: Watch
for signs of intracranial bleeding and infection (expect swelling around the eye and
below the incision). Expect sensory changes such as hearing a “clicking” sound around
the bone flap, which will disappear as healing takes place. Understand that headaches
also are common, but notify the surgeon if a mild analgesic such as acetaminophen
(Tylenol) fails to relieve them. Care for the surgical site as directed by the physician.
Some recommendations include keeping the incision clean, avoiding scrubbing the
incision, securing remaining hair away from the incision, resuming shampooing the hair
when the staples or sutures are removed, and wearing a hat when outside to avoid
sunburn until hair growth resumes. Maintain safety precautions at home, including
ambulating only with assistance and ensuring well-lit and clutter-free rooms. Do not
drive until the risk of seizures has been eliminated. Engage in exercises that promote
strength and endurance. Use techniques to ensure bowel and bladder elimination.
Follow feeding and/or nutritional suggestions. Keep follow-up appointments for
measuring anticonvulsant blood levels, electroencephalograms, and continued medical
care and evaluation. This information is usually given to the client on a take-home
instruction sheet.
11. The nurse is caring for a client who was discovering unconscious after falling off a
ladder. The client is diagnosed with a concussion. All testing is normal, and discharge
instructions are compiled. Which instructions have been compiled for the spouse?
A) Tylenol may be administered for aches.
B) Observe for any signs of behavioral changes.
C) A light meal may be eaten if desired.
D) Follow up with regular physician is encouraged.
Ans: B
Feedback:
All of the options are typical for a client being discharged with a concussion. The
instruction that is emphasized is to observe for any signs of behavior changes, which
may indicate an increase in the client's intracranial pressure. A concussion results in
diffuse or microscopic injury to the brain with symptoms that may evolve.
Page 5
12. The nurse and physician are viewing a brain scan, which indicates bleeding at the point
of impact to the skull and edema on the opposite side. The client is sleeping but can be
aroused. The client has no memory of accident. The nurse provides all details to the next
shift and is most accurate to report which type of injury?
A) Coup injury
B) Contusion
C) Head injury
D) Contrecoup injury
Ans: D
Feedback:
The nurse most accurately reports a contrecoup injury because the client has this type of
dual brain injury. The client has experienced not only a direct strike to the brain but the
brain ricochets in the skull to the opposite side causing damage and inflammation at that
location as well. The client experienced a head injury, which is a general term. The
injury is a contusion because it is more serious than a concussion and leads to structural
injury to the brain. It is inaccurate to report a coup injury because this reveals injury to
the brain itself from a direct strike to the head.
13. The nurse is working on the neurologic unit at a local hospital. The nurse has four
clients assigned who sustained head injuries as a result of an industrial accident. Which
client would the nurse anticipate the physician sending for specialized care?
A) The client with history of seizures
B) The client who was in a bike accident last summer
C) The client who played soccer in college
D) The client whose father has Parkinson's disease
Ans: C
Feedback:
The client who has history of playing many years of a physical sport such as soccer and
use the head to redirect the ball may have had years of injury to the brain. When
concussions occur repetitively, even though they may have not shown injury at that
time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy,
which can produce neurodegeneration, will need specialized care. The client who has a
history of seizures may have no brain injury. The client who was in a previous accident
may have had injury, but it is not of a repetitive nature. The client with a father who has
Parkinson's disease will have regular follow-up care.
Page 6
14. A client has sustained a head injury and is unconscious in the emergency room. A
family member of the client arrives and is providing details of the client's medical
history. Which information is of most concern to the nurse?
A) The client is a heart transplant recipient.
B) The client's medications include warfarin (Coumadin).
C) The client is HIV positive.
D) The client has a history of concussions from playing hockey.
Ans: B
Feedback:
The nurse is most concerned that the client is prescribed warfarin (Coumadin) because
this is a blood thinner. Due to the action of the medication, the client is at a high risk for
intracranial bleeding. The cardiovascular system will be assessed, but that is not the area
of greatest concern at this time. The nurse will care for the HIV positive client using
standard precautions. A history of concussions may indicate past brain damage, but the
potential for active bleeding is the highest concern.
15. A nurse is reviewing a CT scan of the brain, which states that the client has arterial
bleeding with blood accumulation above the dura. Which of the following facts of the
disease progression is essential to guide the nursing management of client care?
A) Symptoms will evolve over a period of 1 week.
B) Monitoring is needed as rapid neurologic deterioration may occur.
C) The crash cart with defibrillator is kept nearby.
D) Bleeding continues into the intracerebral area.
Ans: B
Feedback:
The nurse identifies that the CT scan suggests an epidural hematoma. A key component
in planning care is the understanding that rapid neurologic deterioration occurs.
Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key
information. An intracerebral hematoma is bleeding within the brain, which is a
different area of bleeding.
16. The nurse is caring for a client who continues to have increasingly high intracranial
pressure. Which complication is expected unless intracranial pressure is resolved?
A) Additional inflammation occurs in the brain.
B) Blood vessels dilate circulating blood.
C) Herniation occurs through the foramen magnum.
D) Venous congestion occurs causing peripheral edema.
Ans: C
Feedback:
Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate
downward through the foramen magnum. Inflammation occurs from damage to the
brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial
pressure. Peripheral edema is not a concern.
Page 7
17. The nurse is caring for a client following intracranial surgery. In the plan of care, the
nurse states to remove antiembolism stockings. What would the nurse do to accurately
complete this intervention?
A) Remove the antiembolism stockings nightly and reapply by 8 AM.
B) Place the antiembolism stockings on the lower extremities as tolerated.
C) Remove the antiembolism stockings briefly every 8 hours.
D) Apply the antiembolism stocking prior to ambulation daily.
Ans: C
Feedback:
The nurse is correct to identify time frames on nursing interventions. When caring for a
client using antiembolism stockings following surgery, the correct intervention is to
remove antiembolism stockings briefly every 8 hours. Antiembolism stockings promote
circulation and decrease the risk of a thrombus or embolus.
18. The nurse is caring for a postoperative client who had surgery to decrease intracranial
pressure after suffering a head injury. Which assessment finding is promptly reported to
the physician?
A) The client has periorbital edema and ecchymosis.
B) The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute;
respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
C) The client's level of consciousness has improved.
D) The client prefers to rest in the semi-Fowler's position.
Ans: B
Feedback:
The assessment finding promptly reported to the physician is the information which may
cause complications. It is important to report the elevation in client temperature (100.9°
F) because hyperthermia increases brain metabolism, increasing the potential for brain
damage. It is not unusual for the client to experience periorbital edema and ecchymosis
secondary to the head injury and surgery. Improved level of consciousness is a positive
outcome of the treatment provided. There is no complication related to semi-Fowler's
position.
Page 8
19. The intensive care unit has four clients received from a violent motor vehicle accident.
When assessing the clients, which client would the nurse assess first?
A) The client with an open head injury
B) The client with a basilar fracture
C) The client with a concussion
D) The client with a coup injury
Ans: B
Feedback:
Of the four clients, the client whom the nurse would assess first would be the client with
a basilar fracture due to location of the fracture being at the base of the skull. This
location is especially dangerous because it can cause edema of the brain near the spinal
cord and can interfere with circulation of cerebral spinal fluid. An open head injury
causes a potential for infection but are less likely to have an increased intracranial
pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs
when the brain is struck directly.
20. The nurse received report from a previous shift. One of her clients was reported to have
a history of basilar skull fracture with otorrhea. What assessment finding does the nurse
anticipate?
A) The client has cerebral spinal fluid (CSF) leaking from the ear.
B) The client has ecchymosis in the periorbital region.
C) The client has an elevated temperature.
D) The client has serous drainage from the nose.
Ans: A
Feedback:
Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can
create a pathway from the brain to the middle ear due to a tear in the dura. As a result,
the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear
fluid in the ear canal. Ecchymosis and periorbital edema can be present as a
manifestation of bruising from the head injury. An elevated temperature may occur from
the head injury and is monitored closely. The client may have serous drainage from the
nose especially immediately following the injury.
Page 9
21. The nurse is evaluating the transmission of a report from a paramedic unit to the
emergency room. The medic reports that a client is unconscious with edema of the head
and face and Battle's sign. What clinical picture would the nurse anticipate?
A) Edema to the head and a blackened eye
B) Edema to the head with a large scalp laceration
C) Edema to the head with fixed pupils
D) Edema to the head with bruising of the mastoid process
Ans: D
Feedback:
Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not
related to periorbital bleeding, lacerations, or fixed pupils.
22. The nurse is orienting a new nurse to the neurologic unit. When instructing on the
typical care provided to a client with head injuries, which type of medications are
frequently administered? Select all that apply.
A) Loop diuretics
B) Anticonvulsants
C) Corticosteroids
D) Analgesics
E) Antibiotics
F)
Antidepressants
Ans: B, D, E
Feedback:
The nurse working on this specialty unit needs to be knowledgeable of the medication
classifications, side effects, and therapeutic outcomes. Osmotic diuretics such as
mannitol are commonly administered to decrease intracranial swelling. Anticonvulsants
are administered to prevent seizure activity. Corticosteroids are less frequently used
since new research data shows poor outcomes. Analgesics are administered for pain
relief follow traumas. Antibiotics are administered to prevent infection. Antidepressants
are not a typical medication related to this injury.
23. The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia
clients. When instructing family members on the difference between the sites of
impairment, which location differentiates the two disorders?
A) The second cervical vertebrae
B) The first thoracic vertebrae
C) The seventh thoracic vertebrae
D) The first lumbar vertebrae
Ans: B
Feedback:
Tetraplegia is the impairment of all extremities and the trunk when there is a spinal
injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all
extremities below the first thoracic vertebrae.
Page 10
24. The nurse is caring for a client immediately after a spinal cord injury. Which assessment
finding is essential when caring for a client in spinal shock with injury in the lower
thoracic region?
A) Numbness and tingling
B) Respiratory pattern
C) Pulse and blood pressure
D) Pain level
Ans: C
Feedback:
Spinal shock is a loss of sympathetic reflex activity below the level of the injury within
30 to 60 minutes after insult. In addition to the paralysis, manifestations include
pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and
pain are not as high of a concern at this time due to the cord injury. Because the level of
impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
25. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the
following does the nurse recognize as the source of symptoms?
A) Autonomic nervous system
B) Central nervous system
C) Peripheral nervous system
D) Sympathetic nervous system
Ans: D
Feedback:
The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous
system response. Symptoms include severe hypertension, slow heart rate, pounding
headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous
system regulates “feed and breed” functions. The central and peripheral nervous system
is a component of the sympathetic nervous system.
Page 11
26. The nurse is caring for a client with a spinal cord injury leaving paralysis. When
planning care related to the musculoskeletal system, which considerations are
important? Select all that apply.
A) Bone demineralization
B) Contractures
C) Weight bearing
D) Spasticity
E) Limited range of motion
Ans: A, B, D, E
Feedback:
When planning care for clients with a spinal cord injury, the nurse is correct to
recognize the physiologic effects of limited mobility associated with having a spinal
cord injury. Bone demineralization occurs due to limited physical activity. Contractures
occur due to limited range of motion. Spasticity occurs from the misfiring of neurons.
Planning regarding weight bearing is not as important at this time.
27. The nurse is offering suggestions regarding reproductive options to a husband and
paraplegic wife. Which option is most helpful?
A) Adoption is an option to complete your family but not put your life in jeopardy.
B) Conception is not impaired; the birth process is determined with the physician.
C) Birth via surrogate is best because your baby can be implanted in another woman.
D) Sterilization is best; it would be difficult to care for a baby in your condition.
Ans: B
Feedback:
The nurse's role is to provide facts without inserting personal opinions. The fact is that
the woman can conceive and bear children. Suggesting adoption, a surrogate, and
sterilization is not appropriate. Providing information on that suggestion is appropriate.
28. The nurse is caring for a client who requires spine surgery to remove bone fragments
and fuse the vertebrae with bone from which location?
A) Iliac crest
B) Floating rib
C) Femur
D) Mandible
Ans: A
Feedback:
To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The
other options are incorrect.
Page 12
29. A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The
nurse is instructing on the benefits of cell transplantation therapy. Which early outcome
of treatment is anticipated?
A) Cell transplantation therapy produced a reduction in swelling and pain.
B) Cell transplantation therapy allowed organs to be brought from one person to
another.
C) Cell transplantation therapy improves the growth of new neurologic connections.
D) Cell transplantation therapy allows the replacement of nerve cells that are
damaged.
Ans: D
Feedback:
Nerve cells in the central nervous system lose the ability to regenerate when injured.
Consequently, there is a focus on finding cells that, when transplanted, can replace the
nerve cells that have been damaged. The early outcome of transplantation is the
replacement. A later outcome of the transplantation is that nerve transmission improves
and muscle functions improve or there is a reduction in symptoms.
30. A 58-year-old client has scheduled a sick visit to the physician's office, stating
symptoms of lower back pain with exacerbation upon movement. The nurse draws a
picture of the components of the spinal cord and surrounding structures and identified
potential causes of the pain. Which area of the drawing would the nurse emphasize?
A) Spinal cord pathway
B) Nucleus pulposus
C) Bony vertebrae
D) Associated musculature
Ans: B
Feedback:
Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The
nurse would emphasize the nucleus pulposus as a common area of problem. Stress
caused by poor body mechanics, age, or disease weakens an area in the vertebra,
causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate.
The spinal cord pathway can cause symptoms of numbness and tingling. The bony
vertebrae can present symptoms when fractures and bony fragments occur. Associated
musculature pulling can place the vertebrae out of alignment causing symptoms.
Page 13
31. A client presents to the emergency department stating numbness and tingling occurring
down the left leg into the left foot. When documenting the experience, which medical
terminology would the nurse be most correct to report?
A) Sciatic nerve pain
B) Herniation
C) Paresthesia
D) Paralysis
Ans: C
Feedback:
When a client reports numbness and tingling in an area, he is reporting a paresthesia.
The nurse would document the experience as such or place the client's words in
parenthesis. The nurse would not make a medical diagnosis of sciatic nerve pain or
herniation. The symptoms are not consistent with paralysis.
32. The nurse is caring for a client with a herniation of C4. What item does the nurse
anticipate to use if conservative therapy is used?
A) A cervical collar
B) Bandages and tape
C) A firm mattress
D) Traction equipment
Ans: A
Feedback:
A C4 injury is in the cervical spine region. A herniated cervical disk is treated
conservatively (not surgically) by immobilizing the cervical spine with a cervical collar.
Dressing supplies are not needed unless there is a wound. A firm mattress is appropriate
for a lumbar herniation. Traction equipment is not used on cervical vertebrae.
Page 14
33. The nurse is employed in the neurosurgeon's office assisting the physician in teaching.
The nurse is instructing a client who is very anxious stating, “What will happen if the
conservative treatment for the degenerative changes in my spine does not help my
lumbar pain.” The nurse is most correct to turn the teaching to which surgical
procedure?
A) A diskectomy
B) A laminectomy
C) A spinal fusion
D) Aggressive traction
Ans: C
Feedback:
The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the
vertebrae weakened by degenerative joint changes such as osteoarthritis and by a
laminectomy. A diskectomy provides pain relief by the removal of a ruptured disk. A
laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord.
From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc.
Aggressive traction is not a surgical option.
34. The nurse is working on a neurosurgical unit. Which of the following nursing
interventions are included in the plan of care following spinal surgery? Select all that
apply.
A) Monitor vital signs
B) Intake and output
C) Coughing and deep breathing
D) PEARLA
E) Neurovascular assessment of the lower extremity
F)
Dressing assessment
Ans: A, B, C, E, F
Feedback:
All of the following nursing interventions would be included in the plan of care except
for PEARLA. Assessment of the pupils is informative for a client with neurologic
symptoms resulting from a head injury.
Page 15
1. Chapter 40
A client with a neurologic deficit has been admitted to your unit. The nurse caring for
the client is assessing the client and observes significant changes in the client's status.
Which of the following action should the nurse perform immediately?
A) Use the Glasgow Coma Scale.
B) Use the Mini-Mental Status Examination.
C) Report the change to the physician.
D) Monitor the blood pressure.
Ans: C
Feedback:
When significant changes occur, the nurse should immediately report them to the
physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools,
such as the Mini-Mental Status Examination, to perform the neurologic assessments to
evaluate the client's status. The nurse maintains the blood pressure to ensure adequate
cerebral oxygenation.
2. When a nurse is caring for a client diagnosed with neurologic deficit who has begun
responding to those around him, what therapy should the nurse suggest to help
strengthen muscles that are under voluntary control?
A) Occupational therapy
B) Range-of-motion (ROM) exercises
C) Recreational therapy
D) Physiotherapy
Ans: A
Feedback:
Occupational therapy is designed to help strengthen muscles that are under voluntary
control. ROM exercises maintain joint flexibility and prevent permanent contractures.
Participation in recreational therapies increases socialization time.
3. A nursing instructor is teaching the senior nursing class about clients with neurologic
disorder. The instructor tells the students that these clients are at risk of disuse syndrome
due to musculoskeletal inactivity and neuromuscular impairment. What nursing
intervention helps prevent plantar flexion?
A) Use of parallel bars or a walker
B) Application of an abdominal binder
C) Use of a footboard
D) Use of a flotation mattress
Ans: C
Feedback:
A footboard positions the foot and ankle in such a way as to prevent plantar flexion.
Parallel bars help the client with impaired mobility to support body weight and move
forward before ambulating independently. An abdominal binder prevents dizziness and
faintness. A flotation mattress helps relieve pressure when the client is lying down and
sitting.
Page 1
4. You are caring for an 82-year-old client who needs bladder training. You know that
bladder training is difficult for older adult clients with neurologic deficit because of
what?
A) Urinary incontinence
B) Urinary retention
C) Decreased energy expenditure
D) Relaxation of the internal bladder sphincter
Ans: D
Feedback:
An age-related delay in the relaxation of the internal bladder sphincter may make
bladder training difficult. Urinary incontinence, urinary retention, and decreased energy
expenditure are not the factors that make bladder training difficult for older adult clients
with neurologic deficit.
5. What would the nurse do to best assist the client in increasing peristalsis and
encouraging defecation after suffering from a neurologic deficit?
A) Help the client to the bathroom at a particular time each day.
B) Administer a low-volume enema each day at the same time.
C) Encourage liquids throughout the day.
D) Encourage a high-fiber diet.
Ans: A
Feedback:
Helping the client to the bathroom at a particular time each day increases peristalsis and
encourages defecation because of the physical activity involved in getting out of bed.
Administering a low-volume enema stimulates a bowel movement. Increase in fluid
intake and a high-fiber diet will aid in normalizing bowel movements.
6. Which of the following assessment tools should the nurse use to perform a neurologic
assessment?
A) Cutaneous triggering
B) Mini-Mental Status Examination
C) Credé's maneuver
D) Mechanical lift
Ans: B
Feedback:
The nurse uses assessment tools such as the Mini-Mental Status Examination to perform
the neurologic assessment. Cutaneous triggering and Credé's maneuver are techniques
used in implanting a bladder training program. A mechanical lift is used to transfer a
client to and from the bed, wheelchair, or shower.
Page 2
7. A client is brought to the emergency department (ED) by family members who tell the
triage nurse that the client doesn't recognize them. The client is diagnosed with a
neurologic deficit. What other conditions are considered neurologic deficits? Select all
that apply.
A) Impaired speech
B) Abnormal bladder elimination
C) Muscle strength
D) Normal gait
E) Paralysis
Ans: A, B, E
Feedback:
A neurologic deficit a condition in which one or more functions of the central and
peripheral nervous systems are decreased, impaired, or absent. Examples include
paralysis, muscle weakness, impaired speech, inability to recognize objects, abnormal
gait or difficulty walking, impaired memory, impaired swallowing, or abnormal bowel
and bladder elimination.
8. What phase of a neurologic deficit begins when the client's condition is stabilized?
A) Recovery
B) Chronic
C) Terminal
D) Acute
Ans: A
Feedback:
The recovery phase begins when the client's condition is stabilized. It starts several days
or weeks after the initial event and lasts weeks or months. This makes options B, C, and
D incorrect.
Page 3
9. An emergency department nurse is admitting a client brought in by the paramedics after
falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse
knows the client is in the acute phase of neurologic deficit. What should the nurse know
about the medical management of this client?
A) Goal is to keep the client stable and prevent or treat complications, such as
pneumonia, and further neurologic impairment.
B) Goal is to plan a rehabilitation program in several domains according to the
client's abilities and limitations.
C) Goal is to admit the client to a hospital for treatment of complications.
D) Goal is to stabilize the client and prevent further neurologic damage.
Ans: D
Feedback:
The focus of management during the acute phase is to stabilize the client and prevent
further neurologic damage. The client with a CVA may require management of
hypertension or hypotension through drug therapy. The client with a head or spinal cord
injury may require respiratory support through mechanical ventilation or surgical
intervention to stabilize the injured area or remove bone fragments, blood clots, or
foreign objects. Sometimes, surgery is postponed until the client is stabilized and the
acute phase has passed. In other instances, surgery is performed during the acute phase
as a lifesaving measure. Option A is the aim of medical management of the recovery
phase; Options B and C are nursing goals, not medical goals for different phases of
neurologic deficit.
10. The nurse caring for a client in the chronic phase of a neurologic deficit knows that
nursing management focus on what?
A) Working with team members to plan a rehabilitation program
B) Retraining the client's bowel and bladder
C) Supporting the client during recovery
D) Preventing physical and psychological complications
Ans: D
Feedback:
Nursing management of clients in the chronic phase of a neurologic deficit focuses on
preventing physical and psychological complications. Planning a rehabilitation program
occurs during the recovery phase, as would retraining the client's bowel and bladder, if
possible, and supporting the client's recovery.
Page 4
11. The nurse is caring for clients on a neurologic floor. Which client goal is most
appropriate for the acute phase of a neurologic injury?
A) The client will use the adaptive devices to assist with feeding.
B) The client's vital signs will stabilize returning to baseline.
C) The client's skin will remain clean, dry, and intact.
D) The client will return to optimal level of functioning.
Ans: B
Feedback:
During the acute phase of a neurologic injury, the goal of nursing management is to
stabilize the client to prevent further neurologic damage. A client goal would be to have
the vital signs stabilize, indicating an improvement in status, and also returning to
baseline. Using adaptive devices would occur in the recovery or chronic phase of a
neurologic deficit. The client's skin and returning to optimal level of functioning is a
goal for later in the recovery process.
12. The nurse is planning care of a client admitted to the neurologic rehabilitation unit
following a cerebrovascular accident. Which nursing intervention would be of highest
priority?
A) Provide instruction on blood-thinning medication.
B) Praise client when using adaptive equipment.
C) Include client in planning of care and setting of goals.
D) Assess client for ability to ambulate independently.
Ans: C
Feedback:
The client in a rehabilitation setting has moved to the recovery phase. The highest
priority is to include the client in the rehabilitation plan. Tailoring the rehabilitation plan
to meet the needs of the client can promote optimal participation by the client in the
rehabilitative process. The other options are appropriate in certain situations but not the
highest priority.
Page 5
13. In which of the following disease processes is the nurse most likely to care for a client
in the chronic phase of a neurologic disease?
A) Transient ischemic attack (TIA)
B) Malignant brain tumor
C) Parkinson's disease
D) Pneumonia
Ans: C
Feedback:
The clients with Parkinson's disease are often admitted to the hospital for treatment of
complications. Sometimes, when their disease process progresses, they are also admitted
to a skilled nursing facility. A transient ischemic attack causes transient symptoms or
minor neurologic deficits. A malignant brain tumor typically causes debilitating
symptoms and spreads due to the malignant nature causing death. Pneumonia is a
complication of neurologic deficits, but itself is not a neurologic deficit. Pneumonia can
be resolved with antibiotics depending on the status of the client.
14. A client is brought to the emergency department in a confused state, with slurred
speech, characteristics of a headache, and right facial droop. The vital signs reveal a
blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24
breaths/minute. On which bodily system does the nurse focus the nursing assessment?
A) Cardiovascular system
B) Respiratory system
C) Endocrine system
D) Neurovascular system
Ans: D
Feedback:
The client is exhibiting signs of an evolving cerebrovascular accident, possibly
hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on
the neurovascular system assessing level of consciousness, hand grasps, communication
deficits, etc. Continual cardiovascular assessment is important but not the main focus of
assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited
are not from an endocrine dysfunction.
Page 6
15. Which nursing technique best allows the client with slight expressive aphasia to
communicate his feelings about using adaptive equipment in public?
A) Use a communication board to express thoughts.
B) Enlist a close family member to interpret words.
C) Sit beside client and patiently assist in interpreting communication.
D) Allow the client time to process the words to express and return later for the
conversation.
Ans: C
Feedback:
A client with slight expressive aphasia can communicate words and ideas with sufficient
time and patience on the part of the person listening. Sitting beside the client is
nonthreatening and working with the client to express his ideas is gratifying to the
client. If the client is able to do something for himself, it is best to allow time and assist
him in the task. With further expressive aphasia, a communication board may be used or
a family member may assist. Rarely does allowing time to process words and returning
promote communication.
16. A home health nurse is assisting the wheelchair-dependent, post–cerebrovascular
accident client in transition from the rehabilitative center to home. Which of the
following concerns would the nurse address first when assessing the client's home?
A) Steps to the front door
B) Tub for bathing
C) Throw rugs in the kitchen
D) Untrained companion staying with client
Ans: A
Feedback:
The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is
needed to transport the client from the vehicle to the inside of the home as well as safety
for leaving the home. Throw rugs can be removed and adaptive equipment can be
obtained for personal care. Untrained staff may be appropriate for brief periods of time.
Page 7
17. Which of the following occupations are anticipated to improve the functioning of a
client with a neurologic deficit? Select all that apply.
A) Occupational therapist
B) Speech therapist
C) Neurologist
D) Electrocardiography technician
E) Electroencephalogram technician
F)
Physical therapist
Ans: A, B, C, F
Feedback:
The following occupations work with the client with neurologic deficits and improve his
functioning: The occupational therapist improves fine motor movement and assists with
instructing on assistive devices. A speech therapist assists with language skills and the
ability to swallow. The neurologist prescribes medical care and coordinates the
treatment team. The physical therapist assists with ambulation and range of motion
strengthening muscles. Both an electrocardiography (ECG) technician and an
electroencephalogram (EMG) technician provide diagnostic testing, which provides data
to plan care. Both do not improve functioning.
18. The nurse is caring for a client with dysphagia. Which instruction to the family is most
important?
A) Do not open/crush a medication in a capsule.
B) Stir thickening products in liquids and serve immediately.
C) Raise client to a semi-Fowler's position.
D) Provide small bites at the client's pace.
Ans: A
Feedback:
Providing instruction to the family to not open or crush medications in a capsule is most
important for safety. A client can receive too much medication if the capsule is opened
and the contents distributed. The other options are good teaching points, but safety is
most important.
Page 8
19. Which basic of client care, occurring during the acute phase, is most helpful in
promoting the rehabilitation of a client following a debilitating cerebrovascular
accident?
A) Prevention of joint contractures
B) Promoting ability to critically think
C) Creating a positive environment
D) Use of adaptive equipment
Ans: A
Feedback:
First addressed in the acute phase, however, impacting the rehabilitative process is the
prevention of joint contractures. The nursing care provided at an early period can
prevent further complications in the rehabilitative phase. Promoting the ability to
critically think is not a priority in the acute phase. Creating a positive environment is
helpful in motivating the client. Using adaptive equipment is not a focus in the acute
phase of the disease process.
20. When using pharmacologic aids to assist with bowel training, which aid would the nurse
anticipate to be used first?
A) A mineral oil enema
B) A glycerin suppository
C) A bisacodyl suppository
D) Prune juice
Ans: B
Feedback:
When using a pharmacologic aid, the nurse would anticipate using the mildest form first
beginning with a glycerin suppository. Glycerin suppositories provide gentle, timely,
and effective relief. The glycerin suppository lubricates, irritates, and softens the fecal
matter. A mineral oil enema is instilled higher in the bowel and coats the stool and
stimulates the bowel. Prune juice is a fruit juice and not a pharmacological aid.
21. Which nursing intervention is most helpful when addressing the priority nursing
diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced
by visual deficits and absence of portions of the visual field?
A) Provide a well-lit environment.
B) Announce yourself when approaching the client.
C) Ensure a clutter-free walkway.
D) Instruct on adaptive plates with rims.
Ans: C
Feedback:
The most helpful nursing intervention for the Impaired Physical Mobility nursing
diagnosis is to ensure a clutter-free walkway. With the absence of the visual field, a
clutter-free walkway is a safety issue. All of the other interventions are also appropriate.
Page 9
22. The nurse is providing care to a client with neurologic problems and notices that the
client is experiencing a penile erection. Which nursing reaction is correct?
A) Excuse yourself and return later.
B) Inquire what the client is thinking about.
C) Ask the client if he would like a few minutes alone.
D) Perform duties professionally and explain that spontaneous erections are
unpredictable.
Ans: D
Feedback:
The nurse understands that the client with neurologic deficits, especially disturbed nerve
function to the genitalia, may have unpredictable penile erections. The correct action by
the nurse is to complete nursing duties and, either then or later, explain that spontaneous
erections are unpredictable. Excusing yourself, inquiring what the client is thinking
about, and asking if the client would like to be alone are inappropriate statements and
can alienate and embarrass the client.
23. The nurse is talking with a newly paralyzed client and his wife. The wife is trying to
raise the client's spirits and begins talking about the possibility of them having a baby.
When the wife is alone, which instruction in essential?
A) Continue to talk about a baby as it seems to give him hope.
B) Do not overwhelm the client with such a big decision.
C) There is a reduced ability for your husband to be able to father children.
D) We will provide you and the client with a counselor so that you can explore all
options.
Ans: C
Feedback:
It is essential that the wife understand that there may be difficulty in the client fathering
a baby. With such a devastating injury, it would be very difficult to raise the client's
hope and then be told that that possibility is taken away. The nurse would not encourage
the wife to tell the client something which may not be able to happen. The nurse would
not allow the client's wife to be misinformed by alluding to the fact that it is a big
decision. It is appropriate to consult a counselor to explore all options, but first the wife
and client must understand the facts.
Page 10
24. The home care nurse is evaluating a post–cerebrovascular accident (CVA) client 1 week
after returning to the home from a rehabilitation setting. Which of the following
statements, made by the client, most concerns the nurse?
A) “I am so happy to be home, but I am not able to go upstairs to my bedroom.”
B) “I find it difficult to get up so I am remaining in bed until the home health aide
comes.”
C) “My spouse goes to work in the morning and leaves my lunch at my bed stand.”
D) “A lot of family is coming to see me, which is nice but makes me very tired.”
Ans: C
Feedback:
The nurse analyzes the statements and compares them to Maslow's hierarchy of needs.
Leaving the lunch at the bed stand alludes to the fact that the client is alone during the
day and either stays in bed or is unable physically to obtain lunch from the kitchen.
Being in bed for an extended period is a concern for skin breakdown, and if the client is
physically weak, safety is a concern. Living arrangements can be made downstairs.
Waiting for a home health aide for assistance is appropriate as long as those
arrangements are made. Tiring the client with family visits is a concern but not a safety
issue.
25. Which client goal, established by the nurse, is most important as the nurse plans care for
a seizure client in the home setting?
A) The client will take the seizure medication at the same time daily.
B) The client will remain free of injury if a seizure does occur.
C) The client will verbalize an understanding of feelings that preempt seizure
activity.
D) The client will post emergency numbers on the refrigerator for ease of obtaining.
Ans: B
Feedback:
All of the goals are appropriate, but the most important goal is the long-term goal to
remain free of injury if a seizure occurs. Nursing interventions associated can include
notifying someone of not feeling well, lowering self to a safe position, protecting head,
turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure
begins, the client cannot implement self-protective behaviors. An established plan is
important in the care of a seizure client. The other options are acceptable goals for
nursing care.
Page 11
26. The nurse is assisting in the discharge process where a female, paralyzed client is
returning home with her husband and two children. Which of the following prescription
classifications, used prior to hospitalization, is most important to relate to the physician
when discharging?
A) Birth control pills
B) A rescue inhaler
C) An analgesic
D) An antihistamine
Ans: A
Feedback:
The nurse realizes that the female, paralyzed client has the ability to ovulate and become
pregnant. Birth control pills are needed until a decision regarding an additional
pregnancy is achieved. The other options are also important to consider but does not
have the significant consequences.
27. The nurse is evaluating the progression of a client in the home setting. Which activity of
the hemiplegic client best indicates that the client is assuming independence?
A) The client grasps the affected arm at the wrist and raises it.
B) The client arranges a community service to deliver meals.
C) The client ambulates with the assistance of one.
D) The client uses a mechanical lift to climb steps.
Ans: A
Feedback:
The best evidence that the client is assuming independence is providing range of
motions exercises to the affected arm by grasping the arm at the wrist and raising it. The
other options require assistance.
28. The nurse is caring for a 55-year-old client on a rehabilitated unit following a
cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises
when the client begins to cry. The client states she has always taken care of the family
and does not want to be a burden. Which nursing diagnosis would the nurse add to the
plan of care?
A) Ineffective Coping related to refusing to acknowledge physical limitations
B) Deficient Diversional Activity related to the inability to participate in family
activity
C) Impaired Home Maintenance related to inability to care for home setting
D) Ineffective Role Performance related to inability to function in family role
Ans: D
Feedback:
The nurse recognizes that the client is grieving the loss, whether temporary or
permanent, of the role of caregiver in the family. The client also states not wanting to be
a burden indicating a role reversal. The other options may also be relevant; however,
they are not as closely related to the client's statement.
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29. The nurse is talking with the mother of a client who is diagnosed with a traumatic brain
injury. The mother states that she has never seen the client lash out when frustrated or
throw things across the room. Which instruction, made by the nurse, is most correct?
A) “The client may be experiencing a change in affect due to the brain injury.”
B) “The client has demonstrated this behavior before and is now anticipated.”
C) “The client has underlying aggression problems, which manifest in behavior.”
D) “All traumatic brain injury clients act in this similar way.”
Ans: A
Feedback:
It is not unusual for the family to identify a change in affect following a traumatic brain
injury. This may include an alteration of lability of mood. Explaining this change to
family is important in helping them understand the client's actions. Stating that the client
has done this before and this is now anticipated does not provide the understanding and
the support for the mother. There is no information provided to confirm past aggression
problems. Not all traumatic brain injuries have a change in mood.
30. The nurse is caring for a client with neurologic deficits who is interested in
implementing a bowel training program. Which of the following does the nurse identify
as the first step?
A) Obtaining a laxative
B) Eating a select diet
C) Recording bowel movements
D) Providing privacy
Ans: C
Feedback:
The first step in implementing a bowel training program is identifying the body's typical
bowel habits. By keeping a journal of bowel movements over weeks, the client is able to
identify when a bowel movement is most likely to occur. All of the other options may
be included in a bowel training program at a later stage.
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31. The nurse is caring for a client with paraplegia in the acute care setting. The client's last
bowel movement was 4 days ago. Which nursing action is best to assist the client in
accomplishing the goal of an enema?
A) Tape the client's buttocks together so to retain the enema.
B) Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period.
C) Prop the client over a toilet to allow gravity to assist in the defecation process.
D) Insert the enema tubing high into the bowel to increase fecal mass elimination.
Ans: B
Feedback:
The best nursing action is to instill the enema solution slowly and allow a waiting
period. By doing so, the enema solution has the best opportunity to be effective. The
nurse would tape the buttocks together when administering a suppository. Propping the
client over the toilet would allow the enema solution to be expelled immediately. Enema
tubing is inserted carefully into the rectum and not advanced high into the colon.
32. The nurse is instructing the client on how to perform Credé's maneuver. In which
situation is this maneuver helpful?
A) When a client is experiencing a vagal response during a bowel movement
B) When a client is experiencing orthostatic hypotension upon arising
C) When a client is attempting to empty the bladder
D) When a client is experiencing numbness of the lower extremities
Ans: C
Feedback:
Credé's maneuver is intended to increase abdominal pressure and facilitates the
emptying of the bladder. The nurse instructs the client to bend at the waist or press
inward and downward over the bladder. The other options are not correct.
33. The nurse is instructing the paralyzed client on a method to stimulate the relaxation of
the urinary sphincter aiding in urinary elimination. Which instruction would be correct?
A) Lightly massage or tap the skin above the pubic area.
B) Press directly over the urinary bladder.
C) Bear down increasing abdominal pressure.
D) Pour water over the genitals.
Ans: A
Feedback:
Cutaneous triggering performed by massaging or tapping lightly over the pubic area
stimulates relaxation of the urinary sphincter. Pressing over the urinary bladder is a
component of the Credé's maneuver, which does not relax the urinary sphincter. Bearing
down with mouth and nose shut is a component to the Valsalva maneuver. Pouring
water over the genitals is ineffective in a paralyzed client.
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34. Which of the following would the nurse include in the rationale for the nursing
intervention to maintain body alignment? Select all that apply.
A) Maintaining body alignment prevents contractures
B) Maintaining body alignment promotes circulation
C) Maintaining body alignment assists in urinary elimination
D) Maintaining body alignment decreases pain
E) Maintaining body alignment decreases respiratory effort
Ans: A, D
Feedback:
Maintaining body alignment prevents contractures and decreases pain from
misalignment of the musculoskeletal system. In some cases, maintaining alignment may
promote circulation, assist in urinary elimination, and decrease respiratory effort but not
routinely to include in the general rationale.
35. The nurse is caring for a client with tetraplegia following a motor vehicle accident. A
family member of the client states, “I know there is grief associated with the loss of
independence, but how do I help my loved one to move past that?” The nurse is most
helpful to say which of the following?
A) “There is nothing you can do. It must come from the client.”
B) “Grief is a normal process. Let's discuss offering support throughout the process.”
C) “Ask your loved one what you can do and decorate the room to elevate mood.”
D) “Provide comfort foods, which expresses your love and support.”
Ans: B
Feedback:
The best response by the nurse is to confirm that what the client is experiencing is a
normal process and opening conversation. The nurse is also helpful to identify the
upcoming process that the client will be experiencing. Stating that there is nothing that
the family member can do closes communication and is inaccurate. The other responses
may be helpful but are not the best.
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1. Chapter 41
A client comes to the occupational health nurse complaining of eye irritation. The client
works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to
this client?
A) To control the amount of sunlight that enters the eye
B) To minimize the impact of the wind on the eye and to trap foreign debris
C) To clear the dust and particles from the surface of the eyes
D) To prevent the collection of tears over the surface of the eye
Ans: C
Feedback:
Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids
also spread tears over the surface of the eye, which helps bathe and lubricate the surface.
The eyelids protect against foreign bodies and adjust the amount of light that enters the
eye, whereas the eyelashes trap foreign debris.
2. A client, diagnosed with a cataract, comes into the clinic. What assessment should the
nurse observe in this client?
A) A burning sensation and the sensation of an object in the eye
B) Blurred or cloudy visual image
C) Inability to produce sufficient tears
D) A swollen lacrimal caruncle
Ans: B
Feedback:
When a cataract forms, the light is blocked from reaching the macula, and the visual
image becomes blurred or cloudy. The client does not experience any burning or the
sensation of an object in the eye, an inability to produce sufficient tears, or a swollen
lacrimal caruncle.
3. The client is having a Weber test. During a Weber test, where should the tuning fork be
placed?
A) On the mastoid process behind the ear
B) In the midline of the client's skull or in the center of the forehead
C) Near the external meatus of each ear
D) Under the bridge of the nose
Ans: B
Feedback:
The Weber test is performed by striking the tuning fork and placing its stem in the
midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning
fork is struck and placed on the mastoid process behind the ear. The tuning fork is not
placed near the external meatus of each ear or under the bridge of the nose.
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4. You are doing hearing tests at the local junior high school. Which of the following
indicates normal hearing in a child?
A) A client who first perceives sound at 20 dB
B) A client who first perceives sound at 40 dB
C) A client for whom the painful sound occurs at 80 dB
D) A client for whom the painful sound occurs at 100 dB
Ans: A
Feedback:
The lowest level of sound that normal persons may first perceive is 20 dB. The painful
sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at
which a person first perceives sound.
5. A client is having problems with dizziness and complains of the “room spinning.” The
physician performs the caloric stimulation test. The nurse knows that a diminished
response in one eye during the caloric stimulation testis indicative of what?
A) Inner ear disorder
B) Midd