A client presents with reports of fatigue, myalgias, and a dry scaly facial rash. Based
upon these symptoms, the nurse anticipates the primary care provider will test for which
of the following?
IncorrectIncorrectIncorrectCorrect
Rheumatoid arthritis
Lyme disease
Chronic fatigue syndrome
Systemic lupus erythematosus
2
For a client admitted with Haemophilus influenzae type B, the nurse should anticipate
implementing which of the following transmission precautions?
IncorrectIncorrectCorrectIncorrect
Standard
Airborne
Droplet
Contact
3
A client with rheumatoid arthritis reports, “I am so tired all the time. I don’t know what
to do.” The nurse should recommend which of the following actions?
IncorrectCorrectIncorrectIncorrect
“Increase daily activity level.”
“Balance activities with rest periods.”
“Sleep for at least 8 hr per night.”
“Ask family members to help with household chores.”
4
A nurse recognizes which of the following clients as having the highest risk for
pneumonia?
IncorrectCorrectIncorrectIncorrect
A school-age child with a history of allergies and asthma
A middle-age client in a long-term care facility with dysphagia
An older adult client using an incentive spirometer following surgery
A young adult client with no history of pneumococcal vaccination
5
A client who sustained a fracture is admitted to the hospital. On assessment, the nurse
notes the client to have fatigue, easy bruising, and reports of generalized bone pain. The
nurse reviews the laboratory data and notes an increase in bone marrow B-lymphocyte
plasma cells, anemia, hypercalcemia, and an elevated BUN. These findings are most
likely indicative of which of the following diagnoses?
IncorrectCorrectIncorrectIncorrect
Leukemia
Multiple myeloma
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
6
A nurse is providing dietary instruction to a client diagnosed with AIDS, who has
symptoms of nausea and diarrhea as well as weight loss and muscle wasting. Which of
the following client statements indicates a need for further instruction?
IncorrectIncorrectIncorrectCorrect
“I will decrease my intake of roughage.”
“I will decrease my intake of spicy foods.”
“I will drink more fluids between meals.”
“I will drink more milk each day.”
7
A nurse is caring for a client with superior vena cava syndrome. The nurse anticipates
that the primary care provider will most likely prescribe
IncorrectIncorrectCorrectIncorrect
a restriction of fluids.
renal dialysis.
high dose radiation.
an infusion of normal saline.
8
A client is admitted with a report of a sore throat, enlarged lymph nodes, and fever. To
confirm the diagnosis of bacterial pharyngitis, the nurse should anticipate which of the
following diagnostic interventions?
IncorrectIncorrectCorrectIncorrect
Complete blood count
White blood cell count
Throat culture
Lymph node biopsy
9
A nurse is performing breast cancer screenings for several clients. The nurse should
recognize that which of the following clients is at the greatest risk for developing breast
cancer?
CorrectIncorrectIncorrectIncorrect
A client whose sister died of breast cancer at age 35
A client with onset of menarche at age 15
A client who experienced early surgical menopause
A client who has a history of six pregnancies
10
A nurse provides instruction to a client prescribed amoxicillin (Amoxil) for a respiratory
infection. Which of the following statements by the client indicates the need for further
teaching?
IncorrectCorrectIncorrectIncorrect
“My birth control pills are less effective while I am on this antibiotic.”
“The medication should be taken until all of my symptoms are gone.”
“The capsules may be opened and mixed with liquids if it is hard for me to
swallow them.”
“I will keep taking the medication until I have finished the entire bottle.”
11
A client newly diagnosed with HIV asks the nurse, “How long before I develop AIDS?”
Which of the following is an appropriate response by the nurse?
IncorrectIncorrectIncorrectCorrect
“It depends on how you contracted HIV initially.”
“No one knows for sure. Try to live each day to the fullest.”
“I don’t have that information. You will need to discuss that with your
primary care provider.”
“The time between diagnosis of HIV and development of AIDS varies
from months to years.”
12
A nurse is assessing a client who is positive for HIV. Which of the following clinical
findings should cause the nurse to suspect that the client's diagnosis of HIV has
progressed to AIDS?
CorrectIncorrectIncorrectIncorrect
Small purplish brown raised skin lesions
Fever and diarrhea lasting longer than 1 month
Persistent generalized lymphadenopathy
CD4+ cells decreased to 750 cells/mm3
13
A client notes a skin discoloration on her arm and asks her nurse about it. Which of the
following observations supports a suspicion of skin cancer?
CorrectIncorrectIncorrectIncorrect
A mole with an irregular shape and variegated colors of red, white, and
blue
A nevi with regular, well-defined borders and uniform light-brown color
A firm, flesh-colored nodule that moves and indents on palpation
A small, yellow, scaly macule that is dry and rough
14
A nurse is assigned to a client receiving chemotherapy who has laboratory data revealing
bone marrow suppression. To prevent complications of the chemotherapy, the nurse
should plan to implement which of the following interventions?
IncorrectIncorrectCorrectIncorrect
Treat the client for fever and chills with acetylsalicylic acid (Aspirin).
Monitor the client for fluid shifts and widespread edema.
Instruct the client to avoid eating fresh fruits and vegetables.
Teach the client to cover the skin when outdoors to minimize sun
exposure.
15
A nurse should know that which of the following individuals is most in need of receiving
a hepatitis B (HBV) vaccination?
CorrectIncorrectIncorrectIncorrect
A client who has unprotected sexual intercourse
An individual who resides in an institutional setting
An individual who works with hazardous chemical waste materials
A client who is preparing to travel to a foreign country
16
A nurse is providing care to a client with leukemia. The nurse reviews the client’s
laboratory data and finds the thrombocyte count to be 48,000/mm3. The nurse should
implement which of the following nursing interventions based on this finding?
IncorrectIncorrectIncorrectCorrect
Encourage the client to cough and deep breathe every hour while awake.
Place the client on neutropenic precautions and a low-bacteria diet.
Administer prescribed subcutaneous epoetin alfa (Epogen).
Test urine and stool for occult blood.
17
When a nurse is performing a breast examination, which of the following client findings
supports a suspicion of breast cancer?
IncorrectCorrectIncorrectIncorrect
Left breast larger than the right
Skin edema with an orange peel appearance
Presence of Montgomery’s tubercles
Painful moveable mass in the left lower breast quadrant
18
A nurse should know that which of the following clients is at the greatest risk for
developing skin cancer?
CorrectIncorrectIncorrectIncorrect
A client with superficial scar tissue
A client with seborrheic keratoses
A client with numerous facial freckles
A client with flesh-colored papules
19
A female client diagnosed with Hodgkin’s lymphoma is undergoing external radiation
treatment of the involved lymph node regions. Treatment will continue on an outpatient
basis. When preparing the client and the family for discharge, the nurse should include
which of the following in the discharge instructions?
IncorrectIncorrectIncorrectCorrect
Use an antibacterial soap to cleanse the skin affected by the radiation
every day.
Use lotions on the skin affected by the radiation to avoid any
inflammation.
Avoid conception for 1 year after the completion of radiation treatments.
Avoid direct sun exposure for 1 year after the completion of radiation
treatments.
20
Which of the following statements made by a client with systemic lupus erythematosus
indicates the need for further teaching by the nurse?
CorrectIncorrectIncorrectIncorrect
“I won’t be able to garden anymore.”
“I will go outside when it’s not too hot.”
“I will use a sunblock with a high SPF.”
“I won’t be able to go to a tanning salon anymore.”
21
A nurse understands that teaching has been effective when a client with systemic lupus
erythematosus identifies which of the following as a classic sign of a possible impending
exacerbation?
CorrectIncorrectIncorrectIncorrect
Fever
Butterfly rash
Fluid retention
Dyspnea
22
A client has an elevated prostate-specific antigen level. The nurse recognizes that which
of the following diagnostic tests will be most useful in diagnosing suspected prostate
cancer?
IncorrectIncorrectCorrectIncorrect
Palpation of testes and lymph nodes
Human chorionic gonadotropin level
Digital rectal examination
Duplex Doppler ultrasonography
23
A nurse is screening a client for cervical cancer. Which of the following factors indicates
the greatest risk for cervical cancer?
IncorrectIncorrectIncorrectCorrect
Hormone replacement therapy
The first pregnancy at 32 years of age
Frequent urinary tract infections
Infection with human papilloma virus
24
A nurse is reviewing the daily laboratory work of a female client with acute leukemia.
The nurse should notify the primary care provider of which of the following laboratory
findings?
IncorrectIncorrectIncorrectCorrect
Red blood cell count of 4.5 million/µL
Hemoglobin value of 11 g/dL
Hematocrit value of 35%
White blood count of 23,000/mm3
25
Which of the following should a nurse recommend to a female client as an initial
screening for cervical cancer?
IncorrectCorrectIncorrectIncorrect
Colposcopy
Papanicolaou smear
Endocervical curettage
Bimanual exam
26
A client is prescribed clindamycin (Cleocin) for acute pelvic inflammatory disease. The
nurse should report which of the following adverse reactions to the primary care provider
immediately?
CorrectIncorrectIncorrectIncorrect
Diarrhea
Restlessness
Hypertension
Hearing loss
27
A client is diagnosed with non-Hodgkin’s lymphoma and is receiving chemotherapy.
Which of the following assessments by the nurse indicates an unexpected adverse
response to therapy?
IncorrectIncorrectIncorrectCorrect
Mucositis is noted in the mouth upon oral examination by the nurse.
Loss of hair is observed with provision of morning care.
Client reports nausea and refuses to eat when meals are served.
Erythema and warmth noted with inspection of the central IV site.
28
A client is scheduled for a needle biopsy of the left lung. Following the procedure, the
nurse should give priority to which of the following actions?
IncorrectIncorrectCorrectIncorrect
Monitor the incision for signs of infection.
Position the client on his left side for 2 hr.
Assess breath sounds for signs of pneumothorax.
Medicate the client with prescribed analgesics.
29
A client with rheumatoid arthritis is receiving weekly methotrexate therapy. The nurse
should recognize which of the following as an indication that the client is responding
effectively to therapy?
IncorrectCorrectIncorrectIncorrect
Improved appetite with weight gain
Decreased joint pain and swelling
Increased resistance to infections
Reduced reports of lethargy
30
For a client diagnosed with HIV, which of the following laboratory findings suggests that
medication therapy is being effective in controlling disease progression?
IncorrectIncorrectCorrectIncorrect
WBC 3,500 cells/mm3
Lymphocytes 1,500 cells/mm3
Decreased viral load
Low CD4+/CD8+ ratio