Test Bank For Nursing A Concept Based
Approach to Learning 2nd Edition Volume I,
Pearson
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Module 1 Acid-Base Balance
The Concept of Acid-Base Balance
1) A client is brought to the Emergency Department after passing out in a local department store. The client has
been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this
client?
A) Metabolic acidosis
B) Respiratory alkalosis
C) Metabolic alkalosis
D) Respiratory acidosis
2) Which of the following risk factors exhibited by the client presenting in the Emergency Department would
place the client at risk for metabolic acidosis?
Select all that apply.
A) Abdominal fistulas
B) Chronic obstructive pulmonary disease
C) Pneumonia
D) Acute renal failure
E) Hypovolemic shock
3) A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The
nurse interprets this as which of the following?
A) Metabolic acidosis
B) Respiratory alkalosis
C) Respiratory acidosis
D) Metabolic alkalosis
4) The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result
indicates that the metabolic alkalosis is compensated?
A) pH 7.32
B) PaCO2 18 mmHg
C) HCO3 8 mEq/L
D) PaCO2 48 mmHg
5) A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered.
Which of the tests will provide the most accurate indicator of the client's acid-base balance?
A) Arterial blood gases (ABGs)
B) Pulse oximetry
C) Sputum studies
D) Bronchoscopy
6) The nurse is instructing a client with a history of acidosis on the use of sodium bicarbonate. Which client
statement indicates that additional teaching is needed?
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A) "I should contact the doctor if I have any gastric discomfort with chest pain."
B) "I need to purchase antacids without salt."
C) "I should use the antacid for at least 2 months."
D) "I should call the doctor if I get short of breath or start to sweat with this medication."
7) A client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a
religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult. I am
not going to stop now." The nurse is not knowledgeable about this particular religion. Which nursing action would
be appropriate?
Select all that apply.
A) Request a consult from a diabetes educator.
B) Tell the client that things are different now because of the diabetes.
C) Ask family members of the same religion to discuss fasting with the client.
D) Assess the meaning and context of fasting in the client's religion.
E) Encourage the client to seek medical care if signs of ketoacidosis occur in the future.
8) The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic
coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. What is the nurse's priority
response to the situation?
A) Stop the infusion and notify the physician because the client is in alkalosis.
B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.
C) Continue the infusion, because the client is still in acidosis, and notify the physician.
D) Increase the rate of the infusion and continue to assess the client for symptoms of acidosis.
9) The nurse is preparing to analyze a client's arterial blood gas results. List the steps in the order that the nurse
should follow when analyzing this laboratory test.
1. Look at the PaCO2.
2. Look at the pH.
3. Evaluate the relationship between pH and PaCO2.
4. Look for compensation.
5. Evaluate the pH, HCO3, and base excess for a possible metabolic problem.
6. Look at the bicarbonate.
7. Evaluate oxygenation.
Module 2 Cellular Regulation
The Concept of Cellular Regulation
1) The nurse is teaching a class to prospective parents about the roles that ribonucleic acid (RNA) and
deoxyribonucleic acid (DNA) play in the development of the human fetus. The nurse concludes that the parents
understand teaching when what is stated by the parents?
Select all that apply.
A) "RNA will determine what color eyes my baby has."
B) "DNA molecules form the genetic material."
C) "RNA is the messenger that carries DNA to the ribosomes."
D) "DNA is outside the nucleus of the cell."
E) "DNA plays a role in protein synthesis in our bodies.".
2) A nursing instructor is explaining the term hyperplasia to the class. Which statement, made by a nursing
student, indicates an understanding of why hyperplasia occurs with myocardial infarction?
A) "The cells of the muscle experience hyperplasia with the prolonged need for oxygen."
B) "The cells of the heart are metaplastic in response to muscle damage."
C) "The cells of the heart muscle have lost fluid."
D) "The cells of the heart muscle are responding to metabolic needs."
3) A nurse is caring for a client who has been diagnosed with skin cancer. Which nursing interventions will
reduce the growth of cancer cells and support normal cell function?
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Select all that apply.
A) Encouraging mobility and exercise
B) Encouraging increased rest and sleep
C) Assessing normal functioning of organ systems
D) Reducing oxygen supply to retard growth of cancer cells
E) Increasing calorie intake
4) The nurse is preparing to perform a health assessment on a 32-year-old client who has a family history of
cancer. Which questions should the nurse ask the client to assess for the early warning signs of cancer?
Select all that apply.
A) "Do you have a cough that is associated with seasonal allergies?"
B) "Have you noticed a change in your appetite?"
C) "Have you noticed any cuts that have not healed?"
D) "Have you had any changes in bowel or bladder habits?"
E) "Have you experienced any problems swallowing?"
5) The nurse is caring for a client who has been diagnosed with cancer. Which diagnostic tests may be helpful to
assist with treatment options?
Select all that apply.
A) Tumor markers
B) Urinalysis
C) Physical assessment
D) MRI
E) Stool analysis
6) The nurse instructs a group of community members about ways to reduce the development of cancer. Which
participant statements indicate that teaching has been effective?
Select all that apply.
A) "I should eat at least 2 servings of fruits or vegetables each day."
B) "Sunscreen should be applied before spending time outdoors."
C) "I need to cut down on my smoking."
D) "I need to get my home tested for radon."
E) "I need to keep my children away from smokers."
7) The nurse is caring for a client with leukemia. Which treatment should the nurse expect to be prescribed for
this client?
A) Diuretic therapy
B) Chemotherapy
C) Electrolyte replacement therapy
D) IV fluid therapy
8) The nurse is caring for an 18-year-old Asian client with a strong family history of breast cancer. What should
the nurse instruct the client regarding cancer prevention?
Select all that apply.
A) Encourage the client to learn more about the disease.
B) Talk to family members who have the disease.
C) Perform monthly breast self-examination.
D) Teach the side effects of cancer treatment.
E) Discuss cancer fears with the healthcare provider.
9) A client with anemia is prescribed synthetic erythropoietin. What should the nurse expect the therapeutic effect
of this treatment to be?
A) Increase in platelets
B) Increase in red blood cells
C) Decrease in white blood cells
D) Decrease in lymph fluid
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10) The nurse instructor is teaching a group of student nurses regarding human growth and development. The
instructor knows that teaching has been effective when a student states:
A) "The zygote undergoes differentiation to form a multicellular embryo, which becomes a fetus and then an
infant."
B) "Meiosis occurs only in the sex cells of the testes and ovaries."
C) "Mitosis is also known as the reduction division of the cell."
D) "When the two sex cells combine during fertilization, the total number of chromosomes (50) is present in the
offspring's cells."
Module 3 Comfort
The Concept of Comfort
1) The nurse is preparing to assess pain level for several clients. What will the nurse assess, in addition to the
client's physical experience of pain?
Select all that apply.
A) Religion
B) Friendship
C) Environment
D) Psychospirituality
E) Social interaction
2) The nurse provides an in-service to peers regarding situations that can affect the comfort level of the clients on
the unit. Which client statement indicates that the client's sense of well-being is negatively impacted?
A) "I feel like I have no energy today."
B) "I don't feel any physical pain today."
C) "I was able to sleep uninterrupted last night."
D) "I am so glad that playing cards takes my mind off my worries."
3) A client is experiencing severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain
scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Which type of pain should the
nurse suspect the client is experiencing?
A) Somatic pain
B) Referred pain
C) Visceral pain
D) Chronic pain
4) The nurse is caring for a 1-year-old child in the postoperative period. Which pain assessment tool should the
nurse use when assessing pain in this child?
A) Faces Pain Rating Scale
B) FLACC Behavioral Pain Assessment Scale
C) Oucher Scale
D) Poker Chip Tool
5) A child with injuries from a motor vehicle crash is crying, moaning, and thrashing about on the bed. The child's
assessment reveals guarding of the abdomen. The nurse suspects that the child is in severe pain and anticipates
which diagnostic test will be ordered for this client?
A) Barium enema
B) Electrolyte panel
C) PET scan
D) X-rays of the limbs
6) An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination
table. The parent attempts to comfort the toddler, but nothing is effective. What should the nurse do?
A) Allow the toddler to sit on the parent's lap and begin the assessment.
B) Allow the toddler to stand on the floor until the crying stops.
C) Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler's behavior.
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D) Instruct the parent to hold the toddler down tightly to complete the examination.
7) The nurse is caring for a postoperative client on a medical-surgical unit. An analgesic is ordered to be given
every 3-4 hours. What can occur if the nurse delays providing the client with the medication?
A) Increase in the client's pain tolerance
B) Increase in the chance of breakthrough pain
C) Decrease in the chance of withdrawal symptoms
D) Decrease in the chance of addiction
8) The nurse is designing a teaching plan for community members on ways to prevent chronic pain. Which
information should the nurse include in this teaching plan?
Select all that apply.
A) Eating a healthy diet
B) Obtaining adequate sleep
C) Avoiding illicit drug use
D) Limiting smoking before going to sleep
E) Avoiding repetitive movements
Module 4 Digestion
The Concept of Digestion
1) A client presents with delayed wound healing. During the digestion assessment, which is the most likely
nutrient deficit to be found in the client's diet?
A) Protein
B) Digestive enzymes
C) Insulin
D) Carbohydrates
2) Which client is at the highest risk of being admitted to the Emergency Department with severe nausea and
vomiting?
Select all that apply.
A) A 47-year-old with a 3-hour history of chest pressure
B) A 61-year-old reporting sudden onset of vertigo
C) A 72-year-old with an asthma exacerbation
D) A 23-year-old who sustained a head injury in a fall
E) A 19-year-old who is 6 weeks pregnant
3) The nurse anticipates that which condition requires surgery?
A) Hepatitis
B) Pancreatitis
C) Pyloric stenosis
D) Fecal impaction
4) The nurse is assigned to a 4-month-old client with vomiting and diarrhea brought to the pediatric clinic by his
mother. Temperature: 37° C, apical HR: 130, R: 40/min. Your abdominal assessment reveals a soft, concave
abdomen, 10 gurgles auscultated in 1 minute in all four quadrants, and tympani to percussion. Which
collaborative care action does the nurse anticipate?
A) Check the surgical call schedule and reserve an operating suite.
B) Place the infant NPO for a barium swallow.
C) Prepare a milk-based infant formula to replace fluids.
D) Complete a thorough digestion assessment interview with the mother.
5) A client is scheduled for a diagnostic test to determine digestion status. Which test does not require fasting or
other preparation?
A) Barium swallow
B) Amylase
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C) Endoscopy
D) Lipid panel
6) What statement made by the client would indicate understanding of discharge teaching for self-care after
hospitalization for acute pancreatitis?
A) "I will avoid onions, caffeine, and spices."
B) "I will take the antibiotics for 2 weeks."
C) "I will avoid alcoholic beverages."
D) "I will get immunized prior to my vacation."
7) Which intervention would best improve diet adherence of a 75-year-old Hispanic male immigrant recently
diagnosed with GERD?
A) Scheduling low-fat meal deliveries to the home
B) Providing printed diet information in Spanish
C) Interviewing the client to assess his current diet
D) Giving a list of foods to avoid to the client's wife
8) The nurse is considering nutritional support for a client experiencing severe side effects of chemotherapy.
Which independent and collaborative interventions will best limit the adverse digestive and nutritional effects of
chemotherapy?
A) Encourage client to drink 350 ml of clear liquids within 1 hour prior to meals.
B) Position the client flat during intermittent enteral nutrition feedings.
C) Verify that enteral nutrition and total parenteral nutrition (TPN) are never used concurrently.
D) Offer the client music therapy in addition to IV ondansetron.
Module 5 Elimination
The Concept of Elimination
1) The nurse is caring for a female client on a medical-surgical unit. The client tells the nurse, "I don't get any
sleep at night because I have to get up and use the bathroom every couple of hours!" Which of the following
explanations by the nurse would be most accurate to explain the client's nocturia?
A) "As you get older, there is a decrease in number of nephrons."
B) "As you get older, there is a decrease in the blood supply to your bladder."
C) "As you get older, you may have a decrease in bladder capacity."
D) "As you get older, there is a decrease in cardiac output, which can cause your symptoms."
2) A 53-year-old woman has high blood pressure that is not responding to medications. Where should you
auscultate if you suspect renal stenosis?
A) renal arteries
B) kidneys
C) ureters
D) internal urethral sphincter
E) bladder
3) The nurse is caring for a group of clients on a medical-surgical nursing unit. The nurse knows that which client
is most at risk for difficulty in urinary elimination?
A) The client with hypertension who takes a diuretic every day for her blood pressure
B) An 80-year-old male reporting frequent urination at night
C) A 25-year-old female client with low self-esteem
D) A client who had bladder cancer and now has a newly created ileal conduit
4) The nurse is caring for a client with a history of urinary tract infections (UTI). Which intervention should the
nurse implement for the client in helping to prevent future UTIs?
A) Instruct the client to completely empty the bladder.
B) Tell the client to increase sugar in the diet.
C) Encourage the client to take bubble baths.
D) Remind the client to wipe from back to front.
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5) The nurse is admitting a client to the medical unit for a urinary disorder. Which physical assessment technique
will the nurse use in assessing this client's urinary system?
Select all that apply.
A) Auscultation
B) Palpation
C) Inspection
D) Percussion
E) Ultrasound
6) The client with a urinary disorder is admitted to the urology unit of the hospital. Which of the following
urinalysis results would indicate a urinary tract infection?
A) pH 5.2
B) Negative glucose
C) WBC 10-15
D) Specific gravity 1.012
7) The nurse is preparing to discharge a client with urinary diversion. The nurse anticipates that the client will
require some teaching prior to going home. Which point will the nurse incorporate into the plan?
A) Instructing the client to notify the physician if the stoma is deep pink and shiny
B) Instructing the client that strands of blood may appear in the urine
C) The need to change the appliance every day
D) The importance of increasing fluid intake
8) The nurse is caring for an elderly male client who has returned to the unit following a resection of the prostate
(TURP). The client has a three-way indwelling catheter. The client tells the nurse that he has to urinate. Which of
the following nursing interventions is most appropriate?
A) Deflate and then reinflate the catheter balloon.
B) Irrigate the catheter.
C) Retape the catheter to the abdomen.
D) Reposition the catheter.
9) A nurse is caring for a client with congestive heart failure. The physician has ordered propranolol (Inderal) for
the client. Which instruction should the nurse include when administering a beta-adrenergic like propranolol
(Inderal) to the client?
A) "This medication must be taken on an empty stomach."
B) "You will need to discontinue the medication when your symptoms subside."
C) "This medication causes constipation. You should take a laxative every day."
D) "It is important to notify your physician if you experience urinary retention."
10) The nurse working on a medical unit is aware that a high pH, or more alkaline urine, could indicate which
condition?
A) Urinary tract infection
B) Diarrhea
C) Respiratory acidosis
D) Metabolic acidosis
Module 6 Fluids and Electrolytes
The Concept of Fluids and Electrolytes
1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem
fluid volume deficit and documents that the client is experiencing the following symptoms: tachycardia; pale, cool
skin; and a decreased urine output. The nurse knows that these symptoms are caused by:
A) The body's natural compensatory mechanisms.
B) Cardiac failure.
C) Pharmacological effects of a diuretic.
D) Effects of rapidly infused intravenous fluids.
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2) The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse
is reviewing the client's lab values and notes that the client's calcium levels have increased since before surgery.
Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia?
A) Measure vital signs every 8 hours.
B) Assist the client to ambulate around the room at least three times daily.
C) Irrigate the client's Foley catheter daily.
D) Assist the client to turn, cough, and deep breathe every 2 hours.
3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is
2.0 mg/dL. The nurse is planning care for this client. Which nursing intervention would address this client's
phosphorus level?
A) Enforce contact precautions.
B) Encourage consumption of a high-calorie carbohydrate diet.
C) Strain all urine.
D) Encourage consumption of milk and yogurt.
4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old
infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days.
Which nurse response is most appropriate?
A) "You should bring the infant in to be seen by the doctor."
B) "Give your baby at least 2 ounces of juice every 2 hours."
C) "Give your baby 50 mL of glucose water every hour."
D) "Measure your baby's urine output for 24 hours and call back tomorrow."
5) A home health nurse is seeing a client with congestive heart failure. The client is taking furosemide (Lasix).
The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Which food would the nurse
encourage this client to choose from the dinner menu?
A) Baked fish
B) Iced tea
C) Banana
D) Peas
6) The nurse is caring for a client receiving a blood transfusion. Ten minutes after the transfusion of a unit of
packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has
slight shortness of breath and feels warm to the touch. Which is the priority intervention for this client?
A) Decrease the rate of the transfusion.
B) Notify the client's physician.
C) Prepare to resuscitate the client.
D) Discontinue the transfusion.
7) A client is being seen in the Emergency Department for vomiting and diarrhea that has lasted 4 days. The
client's current weight is 154 pounds. The physician has diagnosed the client with a viral infection. The nurse has
been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse
that efforts to rehydrate this client have been successful?
A) 40 mL per hour
B) 20 mL per hour
C) 25 mL per hour
D) 30 mL per hour
8) An elderly client is admitted to the hospital after a fall. The client appears intermittently confused. What is a
primary concern of the nurse regarding fluid and electrolytes when caring for this client?
A) Risk of kidney damage
B) Risk of dehydration
C) Risk of stroke
D) Risk of bleeding
9) The nurse is caring for an elderly client who has been receiving intravenous fluids at 150 mL/hr. The nurse
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assesses that the client has crackles, shortness of breath, and jugular vein distention. The nurse would recognize
these findings as an indication of which complication of IV fluid therapy?
A) Speed shock
B) Fluid volume excess
C) Pulmonary embolism
D) An allergic reaction
10) When monitoring indicates that a client has a severe fluid and electrolyte imbalance, a nurse should be
prepared to execute physician's orders to:
Select all that apply.
A) Initiate intravenous therapy.
B) Initiate hypodermoclysis.
C) Administer antibiotics.
D) Administer diuretics.
Module 7 Health, Wellness, and Illness
The Concept of Health, Wellness, and Illness
1) A nurse, reflecting on her own sense of the meaning of wellness, identifies the seven components of wellness
as a useful tool in assessing health. What are some of these components?
Select all that apply.
A) Physical
B) Environmental
C) Emotional
D) Financial
E) Spiritual
2) In preparing a workshop on Healthy People 2020, what are some of the diseases a nurse should address as part
of the 42 topic areas covered in the report?
Select all that apply.
A) Cancer
B) HIV
C) Diabetes
D) Multiple Sclerosis
E) Heart Disease and Stroke
3) A nurse is assessing a female client to determine her level of wellness. The client states that she practices yoga
for relaxation several times a week, follows a nutritionally sound diet, and has a supportive, sound relationships
with her spouse and children. This client would exemplify:
A) An emergent high level of wellness in an unfavorable environment.
B) A high level of wellness in a favorable environment.
C) Protected poor health in a favorable environment.
D) An emergent high level of wellness in a favorable environment.
4) While teaching a class on health status the nurse educator reviews internal variables that affect health status.
What should the education include as examples of internal variables?
Select all that apply.
A) Gender
B) Spiritual and religious beliefs
C) Environment
D) Developmental level
E) Age
5) A nurse is teaching a group of couples a class on building positive relationships at a local community center.
The nurse is focusing this session on learning skills to be open-minded and respectful to those with opposing
opinions. On which component of wellness is the nurse focusing?
A) Physical
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B) Social
C) Environment
D) Emotional
6) A group of nurses have volunteered to go on a health mission to rural Haiti. The majority of the people the
nurses will be working with do not have access to health care and live in poverty. The nurses will be working with
clients who are experiencing which level of wellness?
A) An emergent high level of wellness in an unfavorable environment
B) Protected poor health in an unfavorable environment
C) Poor health in an unfavorable environment
D) Protected poor health in a favorable environment
7) The nurse is determining a plan of care for a client diagnosed with type 2 diabetes. Which client statement
shows that teaching has been effective?
A) "I will take medication for a week for this acute illness."
B) "I will have to take medications for this disease."
C) "This chronic disease will become worse and lead to death."
D) "I will have to make dietary changes to manage this chronic disease."
8) An occupational health nurse for a large corporation is planning programs to address health problems identified
in the Healthy People 2020 report. Which programs should the nurse include for the company employees at the
worksite?
Select all that apply.
A) Depression screening for all employees
B) An abuse screening program
C) A substance abuse education program
D) An immunization program
E) Injury and violence prevention
9) The nurse is completing an assessment on an adult client. The nurse is discussing the assessment with a coworker and states that the client's beliefs and actions regarding common health practices seem "weird." What is
the most appropriate action for the nurse to take at this time?
A) Repeat the assessment later in the day.
B) Determine the culture with which the client identifies.
C) Write a nursing diagnosis to address the "weird" beliefs and actions.
D) Communicate the findings to the health-care team.
10) A nurse is promoting participation in The Great American Smokeout for clients who are participating in a
smoking cessation class. The nurse knows this event may motivate many individuals to stop smoking by
promoting self-efficacy. Which client statement leads the nurse to expect a positive outcome for this particular
client?
A) "I am afraid of getting lung cancer like my father."
B) "I think this time will be different."
C) "I am going to do the best that I can, so that I won't get lung cancer."
D) "I know that this time I will quit smoking permanently."
Module 8 Immunity
The Concept of Immunity
1) The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection. The client asks
the nurse what defenses the body has against infection. The nurse responds that which physiological barrier helps
defend the body against microorganisms?
Select all that apply.
A) Moisturizing the skin
B) Adequate urinary output
C) Intact skin
D) Occasional smoking
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E) A surgical incision
2) A client, who has been given a yellow fever vaccine before traveling to the Amazon Basin, asks the nurse to
explain how the elements of the immune system will now provide protection. Which is the appropriate response
by the nurse?
Select all that apply.
A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the
immune system to attack it."
B) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells
and B cells."
C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies."
D) "The body's immune system eats away at the protective sheath (myelin) that covers the nerves."
E) "The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future
protection against yellow fever."
3) A nurse is volunteering in a health screening booth at the state fair. The nurse has assessed several clients and
determines that which client demonstrates the decline in responsiveness of the immune system of an older adult?
A) An 88-year-old client with pneumonia who has a temperature of 99.5°F
B) A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy
C) A 58-year-old client who complains of redness and itching after developing a rash from contact with poison
ivy
D) A 56-year-old client who has 8 mm induration at the site of a PPD skin test 72 hours earlier
4) A client who has been diagnosed with untreated HIV comes in complaining of fatigue and weight loss. What
are some important elements of the physical exam for evaluating the client's AIDS status?
Select all that apply.
A) Assess the general appearance.
B) Assess skin color, temperature, and moisture.
C) Assess hair loss.
D) Inspect the skin for evidence of rashes or lesions.
E) Inspect the mouth for lesions.
5) The nurse is caring for a client being seen at an urgent care clinic because of an infected arm. The client tells
the nurse he was bitten by a raccoon on a recent camping trip. The nurse expects treatment for this client to
include which of the following?
A) An injection of immunoglobulin
B) A tetanus toxoid injection
C) Mother's breast milk with antibodies in it
D) An immunization for rabies
6) The nurse is caring for a client in an allergy clinic. The nurse believes the client is having a reaction to a
specific antigen. Which lab test would the nurse assess in order to determine the possibility of a hypersensitivity
reaction?
A) Indirect Coombs' showing no agglutination
B) Patch test with a 1-inch area of erythema
C) 2% eosinophils in the WBC count
D) Rh antigen with negative results
7) The nurse is teaching a group of young parents at the local elementary school health fair about immunity and
the importance of vaccination. The nurse is giving the group an example of how active immunity is acquired.
Which scenario would provide a client with active immunity?
A) Receiving a rabies shot after being bitten by a rabid dog
B) Having measles
C) Receiving an injection of gamma globulin
D) Becoming ill with tetanus and receiving tetanus toxoid
8) The nurse is caring for a client who is taking an immunosuppressant agent for the treatment of an autoimmune
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disorder. Which client statement shows that teaching has not been effective?
A) "I should drink plenty of water to keep from getting dehydrated."
B) "I should drink a lot of grapefruit juice while on these medications."
C) "If I experience any joint pain, I should take ibuprofen for the pain as needed every 4 hours."
D) "I know to call the physician if I start experiencing a lot of bruising."
9) A nurse working with a 52-year-old woman who has been prescribed NSAIDs as part of her treatment for
rheumatoid arthritis should assist the client by:
Select all that apply.
A) Monitoring for signs of allergic reaction.
B) Assuring the client that there is no relationship between NSAIDs and heart disease.
C) Encouraging the client to take with a full glass of water, milk, or small snack to help avoid GI distress.
D) Monitoring for signs of renal problems.
E) Advising against abrupt discontinuation of drugs.
10) A nurse is caring for a client with leukocytosis. Which action by the nurse is most appropriate when caring for
this client?
A) Instruct the client on the use of an electric razor and soft toothbrush.
B) Assess for bleeding and bruising.
C) Assess for source of infection.
D) Place the patient in reverse isolation precautions.
Module 9 Infection
The Concept of Infection
1) The nurse is concerned that a client with bowel and bladder dysfunction is at risk for developing an infection.
Which actions should the nurse take to help reduce this client's risk for developing an infection?
Select all that apply.
A) Turn and reposition the client every 2 hours.
B) Monitor intake and output.
C) Provide hygienic care after episodes of incontinence.
D) Use standard precautions when handling linen after episodes of incontinence.
E) Cover wounds with antibiotic ointment and sterile gauze.
2) A nurse is planning an in-service on preventing infection for the hospital staff nurses on a medical-surgical
unit. Which nursing intervention is most effective in reducing the risk of infections?
A) Raising the temperature in the client's room
B) Assessing vital signs once daily
C) Wearing a mask for client care
D) Performing hand hygiene
3) The nurse is assessing an 80-year-old client who is recovering following a cholecystectomy. Which factor
would increase this client's susceptibility to infection?
Select all that apply.
A) Intact mucous membranes
B) Surgical incision
C) Dry skin
D) Active bowel sounds
4) The nurse is caring for a client who is being discharged following an appendectomy. Which instruction is the
most important for the nurse to teach this client regarding wound healing?
A) "Thoroughly irrigate the wound with hydrogen peroxide once a day."
B) "Apply a lubricating lotion to the edges of the wound twice a day."
C) "Add more fruits and vegetables to your diet."
D) "Notify the physician if you notice swelling, warmth, or tenderness at the wound site."
5) The nurse is caring for a client who is experiencing a systemic infection after a total knee replacement. Which
diagnostic tests will be used to validate the presence of this infection?
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Select all that apply.
A) Serum electrolyte levels
B) Urinalysis
C) White blood cell differential
D) White blood cell count
E) Wound culture
6) The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a
link in the chain of infection?
Select all that apply.
A) Place contaminated linens in a paper bag.
B) Use personal protective equipment (PPE).
C) Cover one's cough by placing the mouth in the elbow.
D) Wear sterile gloves for client care.
7) The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the
most common mode of transmission of infectious disease?
A) Children who are playing board games
B) Children who are sitting together eating meals
C) Children who are playing with the same toy
D) Children who don't wash their hands after using the bathroom
8) A pediatric client is receiving antibiotics for the treatment of Staphylococcus aureus. Which nursing
interventions are priorities when caring for this client?
Select all that apply.
A) Encourage adequate fluid intake.
B) Monitor for allergic reaction.
C) Assess renal and liver function.
D) Obtain a baseline electrocardiogram.
E) Monitor vital signs.
Module 10 Inflammation
The Concept of Inflammation
1) The nurse is caring for a client who has experienced a sports-related injury to his knee. During the morning
assessment, what signs of inflammation will the nurse most likely assess?
Select all that apply.
A) Pitting edema
B) Pallor
C) Swelling
D) Warmth
E) Pain
2) A client is admitted with airway edema, bronchoconstriction, and increased mucus production after being
exposed to an allergen. What care will the client need to address this inflammation to the respiratory system?
Select all that apply.
A) Turn and reposition every 2 hours.
B) Monitor oxygen saturation.
C) Administer oxygen as prescribed.
D) Restrict fluids.
E) Monitor lung sounds.
3) The nurse is providing instructions to a client who has a prescription for a nonsteroidal anti-inflammatory drug
(NSAID). What information is priority for the nurse to explain to the client about this medication?
A) "Take your medication on an empty stomach."
B) "Drink at least 8-10 glasses of water a day while taking your medication."
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C) "Constipation is common with your medication; include roughage in your diet."
D) "Take your medication with food."
4) The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic
reaction to inflammation?
Select all that apply.
A) Erythema
B) Edema
C) Pain
D) Tachypnea
E) Tachycardia
5) The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory
drugs (NSAIDs) for the treatment of their disease process. What are the primary laboratory tests the nurse will
assess prior to initiation of therapy?
Select all that apply.
A) Serum amylase
B) Electrolytes
C) Creatine clearance
D) Complete blood count (CBC)
E) Liver function tests
6) What could the nurse do to decrease the inflammation?
A) Anti-inflammatory medication
B) Diuretics
C) Opioid medication
D) Antibiotics
7) The nurse is caring for a client from India who has extensive deep tissue damage. The nurse notes that the
client is also vegan. Which dietary information should the nurse teach this client to enhance the healing process?
A) "A low-fat, high-carbohydrate, low-protein diet is best for healing."
B) "A high-fat, low-carbohydrate diet is best for healing."
C) "A high-carbohydrate, high-protein diet is best for healing."
D) "A diet high in protein and vitamin D is best for healing."
8) The nurse instructs an older client with arthritis on the side effects of nonsteroidal anti-inflammatory drug
(NSAID) therapy. Which client statement would indicate that teaching had been effective?
A) "I will Report any abnormal bruising."
B) "Caffeine will decrease the effectiveness of the medication."
C) "I cannot take other medications."
D) "If I have a change in my mood I will call the prescriber."
Module 11 Intracranial Regulation
The Concept of Intracranial Regulation
1) The nurse becomes concerned when a client who sustained a head injury from a motor vehicle crash begins to
demonstrate the following posture. What does this posture suggest to the nurse about the client's brain
functioning?
A) Altered level of consciousness
B) Developing a seizure disorder
C) Brain stem impairment
D) Corticospinal tract impairment
2) A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma
Scale (GCS) score of 6. Which interventions should the nurse prepare to implement?
A) Assess airway, breathing, and circulation.
B) Assess patency of the Foley catheter.
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C) Treat the client's pain.
D) Get a complete history from the client.
3) A school-age child is experiencing photophobia, a sore neck, chills, and fever. During a physical assessment,
the nurse uses the technique in the Exhibit. Why did the nurse use this technique when assessing the client?
A) It is a routine part of the physical assessment.
B) The client's symptoms indicated meningitis
C) The nurse was assessing range of motion of the neck.
D) The nurse was assessing optic nerve functioning.
4) The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure
(ICP) in preparation for an evaluation to be done by the neurosurgeon during morning rounds. Which diagnostic
test results should be on the medication record for the physician's review?
Select all that apply.
A) Bronchoscopy results
B) MRI result
C) Head CT scan with and without contrast
D) Electroencephalogram
E) Complete blood count of the cerebrospinal fluid
5) The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial
pressure. What actions should the nurse take to support this client's care need?
Select all that apply.
A) Limit the client's visitors.
B) Teach family to speak softly and minimize touching.
C) Elevate the head of the bed.
D) Provide all care quickly at one time to provide periods of rest.
E) Keep the room dark and quiet.
6) The nurse is planning care for an older client with a head injury sustained from a motor vehicle crash. Which
information should the nurse keep in mind when planning this client's care?
Select all that apply.
A) Anxiety, illness, and pain can alter the ability to learn.
B) Reflexes are less intense in an older client.
C) Impulse transmission and reactions to stimuli are slower.
D) The plantar and Achilles reflexes are hyperactive in this age group.
E) Impairment in vision and hearing should be taken into consideration.
7) A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which
classifications of medications should the nurse prepare to administer to this client?
Select all that apply.
A) Loop diuretics
B) Antibiotics
C) Anticonvulsants
D) Histamine H2 antagonists
E) Antipyretics
Module 12 Metabolism
The Concept of Metabolism
1) A client is experiencing health problems related to alterations in adrenal medulla function. On which areas
should the nurse focus when assessing this client?
Select all that apply.
A) Heart rate
B) Weight
C) Respiratory rate
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D) Skin integrity
E) Blood pressure
2) The nurse is teaching an in-service about metabolic disorders. Which person is at the greatest risk for
malnutrition as a result of hypermetabolism?
A) A client with chronic obstructive pulmonary disease
B) A client with osteoporosis
C) A client who is a vegetarian
D) A client who has dysphagia
3) The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While monitoring the blood
pressure, the nurse notes the client's hand begins to spasm. How should the nurse document this assessment
finding?
A) Trousseau sign
B) Chvostek sign
C) Turner's sign
D) Cullen's sign
4) While performing an endocrine assessment on a client suspected of having Cushing disease, the nurse asks the
female client if she has experienced recent weight changes. Which endocrine systems is the nurse assessing?
Select all that apply.
A) Gonads
B) Pituitary gland
C) Thyroid gland
D) Adrenal gland
E) Parathyroid gland
5) The nurse is reviewing the laboratory test results for a client with an endocrine disorder. For which tests should
the nurse expect to have current values on the medical record?
Select all that apply.
A) Prothrombin time
B) Albumin
C) Ammonia level
D) Liver functions studies
E) Hemoglobin and hematocrit
6) The client with diabetes mellitus reports having difficulty cutting his toenails because they are thick and
ingrown. What should the nurse recommend to this client?
A) Make an appointment with a podiatrist.
B) Offer to file the tops of the nails to reduce thickness after cutting.
C) Cut the nails straight across with a clipper after the bath.
D) Make an appointment with a nail shop for a pedicure.
7)An older client is diagnosed with disorders of fat metabolism, reduced absorption of fat-soluble vitamins, and
slightly elevated blood glucose level. When caring for this client, on which endocrine organ should the nurse
focus interventions?
A) Pituitary
B) Thyroid
C) Pancreas
D) Adrenal medulla
8) The nurse is caring for a client who has been prescribed calcitonin–human (Cibacalcin) nasal spray. What
should the nurse include in the plan of care for this client?
A) Take 1 hour before meals or 2 hours after meals.
B) Alternate nostrils used daily.
C) Take on an empty stomach in the morning with water.
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D) Remain in an upright position for 30 minutes after taking.
Module 13 Mobility
The Concept of Mobility
1) During the assessment of a client, the nurse finds that the client's lower extremities are both warm, sensation is
intact, and motion is unrestricted. What does this finding suggest to the nurse?
A) Skeletal muscle attached to bones via tendons is performing correctly.
B) Smooth muscle attached to bones via ligaments will require further assessment.
C) Cartilage connecting bones has a good blood supply.
D) Muscle connecting the axial skeleton is compromised.
2) A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse should plan which
priority action?
A) Implement low-level exercise program.
B) Assess pain management.
C) Teach relaxation techniques.
D) Refer to a dietitian.
3) A preadolescent patient who fell from a balance beam in Physical Education class reports ankle pain. The nurse
assesses edema and ecchymosis. What initial cause and intervention will be anticipated?
A) Neurological evaluation for Parkinson's disease
B) Rest, ice, compression and elevation (RICE) for ankle sprain.
C) Brace fitting for scoliosis
D) Colchicine for gout
4) The nurse detects an exaggerated concave curvature of the lumbar spine of a client. Which conclusion about
this assessment is correct?
A) Abnormal kyphosis is noted during range-of-motion assessment of a child.
B) Normal scoliosis is observed during the joint assessment of an older man.
C) Lordosis is commonly seen in the gait and posture assessment of a pregnant woman.
D) Crepitus is commonly found during the assessment interview of a middle-aged woman.
5) An older client is demonstrating signs of osteoporosis. The nurse should instruct the client on which tests to aid
in the diagnosis of this disorder?
Select all that apply.
A) Magnetic resonance imaging
B) Dual energy x-ray absorptiometry
C) Bone mineral density
D) Quantitative ultrasound
E) Computed tomography
6) A 78-year-old client hospitalized with spinal fusion surgery has a BMI of 34. Chronologically organize
interventions to minimize the effects of bed rest.
1. Active range-of-motion exercises
2. Ambulation
3. Passive range-of-motion exercises
4. Resistive exercises
5. Weight loss instruction
7) The mother of a preadolescent client is concerned because the child often reports non-specific "bone pain."
What can the nurse respond to this mother?
A) "Bone pain in children is caused from the pulling of muscles when bones grow quickly."
B) "The child needs to rest more when the bones hurt."
C) "Non-specific bone pain means there is a disease process somewhere else in the body."
D) "It is a symptom that needs further investigation and will be reported to the physician."
8) The nurse is giving discharge instructions on removing loose rugs in the home to a client with a total hip
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replacement. This is an example of which type of nursing intervention?
A) Independent: injury prevention
B) Independent: preservative functioning
C) Collaborative: promotion of comfort
D) Collaborative: family instruction
9) A 68-year-old client has decreased bone density. Which diagnostic test results will alert you to the need for
dietary education?
A) High calcitonin levels
B) High creatine kinase (CK) levels
C) Low phosphorus (P) levels
D) High growth hormone (GH) levels
10) A 34-year-old mother of three sustained a right distal radial fracture and a left tibia fracture. The nurse and
physical therapist will teach the client to use which mobility aide(s)?
A) Lofstrand crutches
B) Platform crutches
C) Walker
D) Axillary crutches
Module 14 Nutrition
The Concept of Nutrition
1) During a health assessment, a client states that carbohydrates and only low-fat foods are eaten, yet the client
continues to gain weight. What should the nurse consider before responding to this client?
Select all that apply.
A) Carbohydrates should only be eaten at breakfast.
B) Excess carbohydrates are converted to fat.
C) Eating too many carbohydrates can lead to obesity.
D) Limiting carbohydrates is the only way to not gain weight.
E) Carbohydrates should be high in fiber and low in sugar.
2) The nurse is preparing educational materials for a client with hypertension. On which dietary changes should
the nurse focus when preparing this material?
Select all that apply.
A) How to avoid all sodium in the diet
B) The effects of sodium on blood pressure
C) How to read nutritional labels
D) Recognizing foods that are low in sodium
E) Using the DASH eating plan
3) The nurse teaches a client who weighs 185 lb and is 5 feet, 3 inches tall on an eating plan to reduce the total
intake of calories per day. The body mass index that the nurse calculated to identify the type of eating plan to use
for this client is ________.
4) The nurse is planning care for a client whose waist circumference is 48 inches and height is 5 feet, 2 inches. On
which subject should the nurse consider providing health teaching to this client?
Select all that apply.
A) Chronic lung disease
B) Osteoarthritis
C) Type 2 diabetes mellitus
D) Heart disease
E) High blood pressure
5) The nurse is determining the care needs for a client with malnutrition. When planning this care, which
laboratory tests should the nurse identify as supporting this client's medical problem?
Select all that apply.
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A) Serum electrolytes
B) Total protein
C) Prealbumin
D) Arterial blood gases
E) Cholesterol
6) After reviewing the statistics for modifiable risk factors for nutritional disorders in an urban community, the
public health nurse creates a plan to address these factors over a period of months. Which risk factors should the
nurse include when making this plan?
Select all that apply.
A) Atherosclerotic heart disease
B) Ulcerative colitis
C) Osteoporosis
D) Macular degeneration
E) Hypertension
7) During a home visit, the nurse is concerned that an older client is at risk for nutritional health problems. What
did the nurse assess during the visit with the client?
Select all that apply.
A) Client's spouse recently died.
B) Client prepared a stew on the weekend and has been eating it for 4 days.
C) Client's adult children arrive to eat dinner together several times a week.
D) Client is prescribed 15 medications.
E) Client's Social Security payments have gone down over the last year.
8) The community health nurse reviews data collected during interviews with community members during a
health fair and decides to create an approach to improve iron intake. On which community members is the nurse
focusing with this plan?
Select all that apply.
A) Males in the 35-50 age range
B) Vegetarian community members
C) Children
D) Older community members
E) Adolescents
Module 15 Oxygenation
The Concept of Oxygenation
1) In a client with a tracheostomy, the nurse should monitor for complications related to the loss of which
protective mechanism?
A) Filtration and humidification of inspired air
B) The ability to cough
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages
2) What factors should the nurse assess in a client who has been diagnosed with lung disease but has no history of
smoking?
Select all that apply.
A) Participation in recreational activities
B) Cardiac status
C) Exposure to airborne pollutants
D) Exposure to second-hand smoke
E) Nutritional status
3) A firefighter has been admitted to the ED. He has no visible burn injuries. He is somewhat inattentive and
uncoordinated and is frequently attempting to get off the gurney and leave the ED. What might the nurse
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hypothesize about his condition?
Select all that apply.
A) The firefighter is exhibiting normal anxiety after a traumatic event and is ready for discharge.
B) The firefighter is showing signs of mild cerebral hypoxia related to smoke inhalation.
C) The firefighter has severe cerebral hypoxia.
D) The firefighter is suffering from ARDS.
E) Further tests are indicated to determine the extent of the problem.
4) What therapies may the nurse expect to provide to a client with asthma?
Select all that apply.
A) Ventilatory support
B) Oral and nasal suctioning
C) Instruction on aggravating factors
D) How to measure daily peak expiratory flow rates
E) Oxygen therapy
5) When auscultating the lungs of a client with shortness of breath, the nurse hears a low-pitched sound that is
continuous throughout inspiration. What does this lung sound indicate?
A) Narrow bronchi
B) Narrow trachea passages
C) Blocked large airway passages
D) Inflamed pleural surfaces
6) The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder.
Which laboratory finding would be most significant for this client?
A) Hemoglobin level 12 mg/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32
7) A client with chronic obstructive lung disease is prescribed oxygen 24% 2 L/min. What does the nurse
determine to be the best method of providing oxygen to this client?
A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask
8) The nurse is planning care for a client with shortness of breath. What should the nurse do to address the client's
activity intolerance?
A) Encourage activity.
B) Consult a dietitian for low-calorie meals.
C) Consult physical therapy for endurance and musculoskeletal function.
D) Encourage independence with activities of daily living.
9) A client is admitted for acute symptoms of asthma and lung inflammation. What would the nurse expect the
physician to prescribe to this client?
A) Xenopenex
B) Atrovent
C) Slo-Bid
D) Advair
10) The nurse is working in the nursery and finds a newborn's respiratory rate is 52 breaths per minute. What
action taken by the nurse is most appropriate at this time?
A) Notify the physician of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
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D) Continue to monitor the newborn per facility policy.
Module 16 Perfusion
The Concept of Perfusion
1) What will the nurse most likely assess in a client with right heart failure?
A) Leg cramps
B) Indigestion
C) Reduced circulation to the pulmonary structures
D) Reduced urine output
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What
should the nurse consider when planning for this client's potential health problem?
A) Cluster activities.
B) Instruct on deep breathing.
C) Medications appropriate to increase heart rate
D) Positioning to increase blood return
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to
be indicated for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
4) A client is admitted with complaints of lower extremity edema and occasional shortness of breath. Which
electrocardiogram finding supports that the client is at risk for an alteration in perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric
5) The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease. What should be
included in this teaching?
Select all that apply.
A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake.
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not sleeping well.
What should the nurse suspect this client is experiencing?
A) Pancreatic disease
B) Cardiac disease
C) Normal changes of aging
D) Signs of anemia
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about this
medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.
8) The nurse instructor is teaching a group of student nurses regarding the various layers of the heart. Which
statements will the nurse include?
Select all that apply.
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A) "The endocardium covers the entire heart and great vessels."
B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat."
C) "The outermost layer of the heart is the epicardium."
D) "The myocardium consists of myofibril cells."
E) "The myocardium has four layers."
9) A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute. What is the client's
cardiac output (CO) rounded to the nearest whole number?
10) A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse will hear the client's
murmur best at:
A) Right sternal border, second intercostal space.
B) Left sternal border, second intercostal space.
C) Right sternal border, third intercostal space.
D) Left sternal border, third to fifth intercostal space.
Module 17 Perioperative Care
The Concept of Perioperative Care
1) A client is informed that a surgical procedure is to be scheduled in 2 weeks. On what teaching should the nurse
focus to prepare the client for the surgery?
Select all that apply.
A) Maintaining a patent airway
B) Deep breathing and coughing
C) Caring for the surgical incision
D) Managing constipation
E) Managing pain
2) The nurse is discussing the various people whom the client will see when in the operating room suite. Which
individuals should the nurse emphasize when discussing this aspect of the surgical process with the client?
Select all that apply.
A) Surgeon
B) Postoperative nurse
C) Circulating nurse
D) Anesthesiologist
E) Social worker
3) The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which diagnoses
should the nurse select to plan for this client's immediate care needs?
Select all that apply.
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
C) Risk for Ineffective Airway Clearance
D) Risk for Imbalanced Nutrition: Less than Body Requirements
E) Risk for Imbalanced Fluid Volume
4) The postoperative recovery room nurse determines that a client in the postoperative phase of care can be
transitioned to Phase II of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain
a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the
preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently.
Using the following scale, this client's Aldrete score is ________.
The Aldrete score
Respiration
2 = Able to take deep breath and cough
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1 = Dyspnea/shallow breathing
0 = Apnea
O2 Saturation
2 = Maintains > 92% on room air
1 = Needs O2 inhalation to maintain O2 saturation > 90%
0 = Saturation < 90% even with supplemental oxygen Consciousness 2 = Fully awake 1 = Arousable on calling 0
= Not responding Circulation 2 = BP+ 20 mmHg preop 1 = BP+ 20-50 mmHg preop 0 = BP+ 50 mmHg preop
Activity 2 = Able to move 4 extremities 1 = Able to move 2 extremities 0 = Able to move 0 extremities
5) The postoperative care nurse reviews the documentation from the intraoperative phase and determines that
several areas are missing. Which areas did the nurse identify as being missing from the intraoperative
documentation?
Select all that apply.
A) Pain assessment
B) Start and stop times of anesthesia
C) Medication review
D) Antibiotic infusion times
E) Start and stop times of the procedure
6) The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor
vehicle crash. What information about this type of surgery will the nurse use to guide the client's care?
Select all that apply.
A) An organ is going to be removed.
B) This is an emergency surgery.
C) The client will be hospitalized longer.
D) The client is at risk for blood loss.
E) The client is at risk for hypothermia.
7) While receiving report from the operating room, the nurse learns that a client's surgical wound for gallbladder
removal is classified as III. What could have caused this wound classification?
Select all that apply.
A) The alimentary tract was not entered.
B) The wound is necrotic and infected.
C) Gallbladder contents spilled into the surgical site.
D) A break in sterility occurred during the surgery.
E) The alimentary, respiratory, genital, or urinary tract was entered.
8) The nurse is preparing an older client for surgery. On what should the nurse focus when preparing this client's
preoperative teaching?
Select all that apply.
A) Level of hearing
B) Including the family in the perioperative care plan
C) Teaching on deep breathing and coughing
D) Plans for discharge care
E) Actions to prevent pressure ulcers
Module 18 Sensory Perception
The Concept of Sensory Perception
1) A client recovering from surgery to repair fractured bones in the face tells the nurse that dinner "tastes
horrible." What should the nurse respond to this client?
A) "The meal on your tray is the best the cafeteria has to offer today."
B) "Let me see if I can order something else for you from the cafeteria."
C) "You do not have to eat anything you don't want to."
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D) "The facial injuries are affecting your sense of taste and flavor."
2) The nurse identifies potential safety concerns for a client with a sensory disorder. Which intervention should
the nurse include in this client's plan of care?
A) Teach how to adapt to the sensory deficit.
B) Identify assistive devices.
C) Provide meaningful interaction and stimulation.
D) Teach the need to take antibiotics as prescribed.
3) The nurse is planning care for an older client with early dry macular degeneration. What should the nurse
expect the client will be prescribed?
Select all that apply.
A) Laser surgery
B) Eye patches
C) Antioxidants
D) Eye drops
E) Zinc
4) A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. What will
the nurse use to assess this client?
A) Rosenbaum eye chart
B) Penlight
C) Cover-uncover test
D) Snellen eye chart
5) A client with impaired hearing is scheduled for a test to measure the compliance of the middle ear to sound
transmission. For which diagnostic test will the nurse instruct the client?
A) Tympanometry
B) Weber test
C) Rinne test
D) Whisper test
6) The nurse is preparing a seminar for community members on actions to protect sensory functioning when
aging. What should the nurse recommend regarding hearing tests for older adults?
A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months.
B) A hearing test is needed when changing medications.
C) A hearing test should be done biannually after the age of 60.
D) Have a hearing test every 10 years until age 50 and then every 3 years.
7) A client tells the nurse about plans to become pregnant. What should the nurse provide to ensure healthy
sensory functioning of the newborn?
A) Testing for rubella
B) The need to limit vitamin A intake
C) Importance of ingesting zinc
D) Avoiding foods high in folic acid
8) A client with glaucoma is experiencing sensory overload. What can the nurse suggest to reduce this client's
visual overstimulation?
A) Do not go outside during the daytime.
B) Wear sunglasses that block UVA and UVB rays.
C) Insert artificial tears several times a day.
D) Use an over-the-counter eye drop for irritation.
9) A nurse is caring for a client with a genetic nerve disorder who has a deficit when attempting to move the
tongue. When performing the nursing assessment, the nurse understands that this deficit relates to which cranial
nerve?
A) XII
B) XI
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C) VIII
D) VI
10) Which nursing action is most appropriate when communicating with a client who has a hearing deficit?
A) Overarticulating words in order for the client to understand
B) Using shorter phrases, which tend to be easier to understand than longer ones
C) Varying the volume of voice, which is easier to understand than one consistent volume
D) Writing ideas or pantomiming as appropriate in order for the client to understand
Module 19 Sexuality
The Concept of Sexuality
1) A 58-year-old female client is concerned that intercourse with her spouse has become increasingly painful.
What should the nurse explain about the changes in this client's body?
A) Cervical mucus is thicker after menopause.
B) Estrogen levels increase after menopause.
C) Sexual desire diminishes after menopause.
D) Vaginal lubrication decreases after menopause.
2) A female client tells the nurse about having difficulty with sexual relations because of a recent weight gain.
Which interventions should the nurse include when planning this client's care?
A) Sexual self-concept
B) Gender identity
C) Body image
D) Gender-role behavior
3) A female client tells the nurse about having no interest in sex since it has become painful. Which
intervention(s) would be appropriate to help the client with this problem?
Select all that apply.
A) Ask when the last Pap smear was performed.
B) Discuss the need to be screened for sexually transmitted infections.
C) Instruct on the use of artificial lubrication.
D) Encourage the client to discuss with the healthcare provider because there are medications to help with this
problem.
E) Suggest antibiotics to treat the pain.
4) During a physical assessment, a client tells the nurse that his penis "hurts" when the shaft is touched. What
should the nurse suspect is occurring with this client?
A) Urethral stricture
B) Acute orchitis
C) Inflammatory disease
D) Acute epididymitis
5) A female client complains of having a "strange discharge" from the vagina and "stinging" when voiding urine.
Which diagnostic test(s) would be useful to aid in the diagnosis of this client's disorder?
Select all that apply.
A) Biopsy
B) Urinalysis
C) Complete blood count
D) Serum hormone levels
E) Papanicolaou smear
6) During a sexual history, a female client tells the nurse that because she is in a committed relationship, sexual
relations are more satisfying and frequent. What should the nurse realize the client is describing?
A) Emptiness
B) A lack of intimacy
C) The feeling of connectedness
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D) Disconnection
7) An older client tells the nurse that he still has erections and wants to have sex with his wife, but she does not
have the same interest as he does. What should the nurse do to assist this client?
A) Explain that women lose interest in sex as part of the aging process.
B) Suggest that he wait awhile and the urge to have sex will pass.
C) Ask what he has been doing to fulfill himself sexually.
D) Encourage the client to ask his wife to discuss the lack of interest with her physician.
8) A female client is prescribed an androgen medication to treat an estrogen-sensitive type of breast cancer. What
should the nurse instruct this client about the medication?
Select all that apply.
A) There is an increased risk of multiple births.
B) Secondary male sex characteristics may develop.
C) Monitor weight weekly.
D) Report calf pain or dyspnea.
E) It must be taken with food.
Module 20 Thermoregulation
The Concept of Thermoregulation
1) Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia. What should the
nurse realize as the method by which these clients lost body temperature?
A) Vaporization
B) Insensible water loss
C) Convection
D) Insensible heat loss
2) During an assessment, a client who was a victim of an industrial accident has a mildly elevated body
temperature. To what should the nurse attribute the client's increase in body temperature?
A) Infection
B) Diet
C) Exercise
D) Stress
3) A client is experiencing an elevated temperature. What should the nurse include in this client's plan of care?
Select all that apply.
A) Administer warm intravenous fluids.
B) Apply warm blankets.
C) Provide dry clothing.
D) Increase oral fluid intake.
E) Administer antipyretic medication.
4) The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot
coffee. Which temperature assessment method should the nurse use?
A) Axillary
B) Temporal artery
C) Tympanic
D) Rectal
5) A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test(s) will the nurse
expect the client to have performed?
Select all that apply.
A) CT scan of the abdomen
B) Chest x-ray
C) Urinalysis
D) Complete blood count
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E) Bone scan
6) The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house
fire. What should be included in this client's plan of care?
Select all that apply.
A) Providing blankets
B) Keeping the room temperature warm
C) Restricting fluids
D) Encouraging fluids
E) Lowering room temperature
7) An older client admitted with pneumonia has a normal body temperature. What should the nurse realize as
being the reason for the inconsistency in body temperature?
A) The room is cold.
B) The client does not have pneumonia.
C) The temperature is not a valid indicator of the pathology of the illness.
D) The client is losing body heat.
8) A client is prescribed medication for an elevated body temperature. What would be appropriate for the nurse to
provide to the client?
A) Muscle relaxant
B) Antihypertensive
C) Sedative
D) Antipyretic
9) A client recovering from surgery begins to have an increase in body temperature and carbon dioxide level.
What should the nurse do first?
A) Assess for patent intravenous line.
B) Provide 100% oxygen with a nonrebreather mask.
C) Provide dantrolene.
D) Contact the anesthesiologist.
10) A nurse working in labor and delivery understands that newborns are at great risk for alterations of
thermoregulation. By drying the newborn immediately after birth, the nurse is protecting heat loss by which
method?
A) Convection
B) Conduction
C) Evaporation
D) Radiation
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