Which method elicits the most accurate information during a physical assessment of an older
client? ( CORRECT ANSWER: ) Use reliable assessment tools for older adults
A client who has just tested positive for HIV does not appear to hear what the nurse is saying
during post-test counseling. Which information should the nurse offer to facilitate the client's
adjustment to HIV infection? ( CORRECT ANSWER: ) Discuss retesting to verify the results,
which will ensure continuing contact and give the patient support and hope, as well as time to
cope
The nurse is caring for a client with HIV who develops Mycobacterium avium complex. What is
the most significant desired outcome for this patient? ( CORRECT ANSWER: ) Return to pre-
illness weight
MAC is an opportunistic infection that presents like TB
MAC is a major contributing factor to development of wasting syndrome so adequate nutrition
and return to pre-illness weight is priority
A client who had abdominal surgery two days ago has prescriptions for IV morphine sulfate 4 mg
every 2 hours and clear liquid diet. Client complains of feeling distended and has sharp,
GRADED A+
,cramping gas pains. What nursing intervention should be implemented? ( CORRECT ANSWER: )
Assist the client to ambulate in the hall
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side
rails and staring at the television. Which nursing intervention should the nurse implement? (
CORRECT ANSWER: ) Turn off the television and darken the room.
Any visual stimuli or rotational movement should be minimized
A client who has chronic cough with blood-tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should be implemented in the immediate post-
procedural period? ( CORRECT ANSWER: ) NPO until gag reflex returns
Prior to bronchoscopy the nasal pharynx and pharynx are anesthetized and bronchoscope is
coated with lidocaine to inhibit gag reflex during insertion.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement? ( CORRECT ANSWER: ) Observe the
client for coughing colored sputum after drinking a small amount of colored water
What assessment finding should the nurse identify that indicates a client with an acute asthma
exacerbation is beginning to improve after treatment? ( CORRECT ANSWER: ) Wheezing
becomes louder as airways (that were initially so restricted wheezing was absent) successfully
respond to bronchodilators
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle
cell crisis. What is the most important nursing action to implement? ( CORRECT ANSWER: )
Evaluate the effectiveness of narcotic analgesics because pain management is priority for patient
during sickle cell crisis
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy.
Lab results reveal platelet count of 10,000/mL. What action should the nurse implement? (
CORRECT ANSWER: ) Check stools for occult blood because platelets less than 100,000/mL are
indicative of thrombocytopenia (a common side effect of chemotherapy)
GRADED A+
, A client is admitted for complaints of chest pain and aching for the past 4 days. The results for
serum creatinine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should
the nurse use to evaluate lab findings? ( CORRECT ANSWER: ) Myocardial damage that
occurred several days early is best validated by serum troponin levels.
**CK-MB and troponin are 2 most important cardiac markers for MI
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for
surgical placement of a permanent pacemaker. The client asks the nurse how this device will
help him. How should the nurse explain the action of a synchronous pacemaker? ( CORRECT
ANSWER: ) An electrical stimulus is discharged when no ventricular response is sensed.
Synchronous - impulse generated on demand or as needed according to patient intrinsic rhythm
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the
difficulty that he and his wife are having getting pregnant. What information is best for the nurse
to provide? ( CORRECT ANSWER: ) Smoking can decrease quantity and quality of sperm
The first semen analysis should be repeated to confirm sperm counts
Cessation of smoking improves general health and fertility
The nurse is providing postoperative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan? ( CORRECT ANSWER: ) Report
inflammation of the incision site or affected arm
Avoid lifting more than 4.5 kg (10lb) or reaching above head
A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The
nurse determines that the surgical consent form needs to be signed by the client. Which action
should the nurse implement? ( CORRECT ANSWER: ) Withhold the drug until the client
validates understanding of the surgical procedure and signs the consent form.
The HCP should explain procedure to client before arriving to the preoperative area
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
GRADED A+
client? ( CORRECT ANSWER: ) Use reliable assessment tools for older adults
A client who has just tested positive for HIV does not appear to hear what the nurse is saying
during post-test counseling. Which information should the nurse offer to facilitate the client's
adjustment to HIV infection? ( CORRECT ANSWER: ) Discuss retesting to verify the results,
which will ensure continuing contact and give the patient support and hope, as well as time to
cope
The nurse is caring for a client with HIV who develops Mycobacterium avium complex. What is
the most significant desired outcome for this patient? ( CORRECT ANSWER: ) Return to pre-
illness weight
MAC is an opportunistic infection that presents like TB
MAC is a major contributing factor to development of wasting syndrome so adequate nutrition
and return to pre-illness weight is priority
A client who had abdominal surgery two days ago has prescriptions for IV morphine sulfate 4 mg
every 2 hours and clear liquid diet. Client complains of feeling distended and has sharp,
GRADED A+
,cramping gas pains. What nursing intervention should be implemented? ( CORRECT ANSWER: )
Assist the client to ambulate in the hall
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side
rails and staring at the television. Which nursing intervention should the nurse implement? (
CORRECT ANSWER: ) Turn off the television and darken the room.
Any visual stimuli or rotational movement should be minimized
A client who has chronic cough with blood-tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should be implemented in the immediate post-
procedural period? ( CORRECT ANSWER: ) NPO until gag reflex returns
Prior to bronchoscopy the nasal pharynx and pharynx are anesthetized and bronchoscope is
coated with lidocaine to inhibit gag reflex during insertion.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement? ( CORRECT ANSWER: ) Observe the
client for coughing colored sputum after drinking a small amount of colored water
What assessment finding should the nurse identify that indicates a client with an acute asthma
exacerbation is beginning to improve after treatment? ( CORRECT ANSWER: ) Wheezing
becomes louder as airways (that were initially so restricted wheezing was absent) successfully
respond to bronchodilators
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle
cell crisis. What is the most important nursing action to implement? ( CORRECT ANSWER: )
Evaluate the effectiveness of narcotic analgesics because pain management is priority for patient
during sickle cell crisis
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy.
Lab results reveal platelet count of 10,000/mL. What action should the nurse implement? (
CORRECT ANSWER: ) Check stools for occult blood because platelets less than 100,000/mL are
indicative of thrombocytopenia (a common side effect of chemotherapy)
GRADED A+
, A client is admitted for complaints of chest pain and aching for the past 4 days. The results for
serum creatinine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should
the nurse use to evaluate lab findings? ( CORRECT ANSWER: ) Myocardial damage that
occurred several days early is best validated by serum troponin levels.
**CK-MB and troponin are 2 most important cardiac markers for MI
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for
surgical placement of a permanent pacemaker. The client asks the nurse how this device will
help him. How should the nurse explain the action of a synchronous pacemaker? ( CORRECT
ANSWER: ) An electrical stimulus is discharged when no ventricular response is sensed.
Synchronous - impulse generated on demand or as needed according to patient intrinsic rhythm
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the
difficulty that he and his wife are having getting pregnant. What information is best for the nurse
to provide? ( CORRECT ANSWER: ) Smoking can decrease quantity and quality of sperm
The first semen analysis should be repeated to confirm sperm counts
Cessation of smoking improves general health and fertility
The nurse is providing postoperative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan? ( CORRECT ANSWER: ) Report
inflammation of the incision site or affected arm
Avoid lifting more than 4.5 kg (10lb) or reaching above head
A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The
nurse determines that the surgical consent form needs to be signed by the client. Which action
should the nurse implement? ( CORRECT ANSWER: ) Withhold the drug until the client
validates understanding of the surgical procedure and signs the consent form.
The HCP should explain procedure to client before arriving to the preoperative area
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
GRADED A+
