NURSING MISC NCLEX Exam 2 Test Bank Questions and Answers

NURSING MISC NCLEX Exam 2 Test Bank Questions and AnswersNURSING MISC NCLEX Exam 2 Test Bank Questions and AnswersA client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places the highest priority on telling the client to report which sensation during the procedure? A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? Ear The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Endocrine A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional healthcare team focus on? Select all that apply. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Eye The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? Gastrointestinal The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assess 8 ment finding? A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? Hematological A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. Immune 1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 2. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 3. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 4. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 5. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 6. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 7. A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? 8. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 9. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. 10. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 11. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 12. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 13. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? 14. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 15. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 16. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? 17. A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? 18. A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? 19. A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? 20. Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? 21. The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? 22. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? 23. A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? 24. The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? 25. A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? 26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? 27. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? 28. The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 29. A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 30. The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? Integumentary A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? Musculoskeletal The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Neurological 1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 2. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 3. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 6. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 7. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 8. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 9. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? " 10. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 11. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 12. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 13. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 14. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 15. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 16. A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 17. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 18. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 19. The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 20. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 21. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 22. The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 23. The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 24. The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 25. A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 26. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 27. The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 28. The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 29. Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 30. The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 31. The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 32. The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 33. The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 34. The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 35. A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 36. A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 37. The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. 38. The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 39. The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? 40. A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? Oncology 1. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 2. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 3. client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 4. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? 5. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 6. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? 7. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. 8. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 9. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 10.The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? 11. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 12. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. 13. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 14. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? 15. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 16. A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. 17. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 18. The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 19. The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 20. The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. 21. The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply. 22.The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? 23. The nurse is teaching a client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. Which statement should the nurse include in the teaching? 24. A client has been hospitalized for removal of a cervical radiation implant used to treat cancer. The implant is removed, and the nurse provides home ca