An adult male client is admitted for Pneumocystis jiroveci pneumonia secondary to AIDS. While
hospitalized, the client receives IV pentamidine therapy. In preparing this client for discharge, which
important aspect regarding his medication therapy the nurse explain? It will be necessary to continue
prophylactic doses of IV or aerosol pentamidine every month
An elderly female client grimaces and demonstrates guarding behavior but denies experiencing pain
when asked by the nurse to rate her pain on a numeric scale. Which action should the nurse take next?
Ask the client to describe how she is feeling
The nurse is teaching a client who was recently diagnosed with gout how to manage the disease. Which
information should the nurse include in this client's teaching plan? Fluid intake should increase to
at least 3 liters per day
Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis
in a postoperative client? Advise the client to perform leg exercises regularly
A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's
syndrome is going to affect her job performance. Which instruction should the nurse provide this client?
Use a space heater to keep the workspace warm
A client experiences an ABO incompatibility reaction after receiving multiple blood transfusions. An ABO
incompatibility reaction is an example of which type of hypersensitivity? Antibody-Cytotonic
After reviewing the admission assessment of a client with chronic pain, which interventions should the
nurse include in this client's plan of care. SATA - Determine client's subjective measure of pain using a
numerical pain scale
- Assist the client to ambulate as much as possible during waking hours
- Implement a 24 hours schedule of routine administration of prescribed analgesic
- Provide comfort measures such as topical warm application and tactile massage
The chest x ray for a client who is admitted for pneumonia shows pleural effusion with decreased air
flow in the entire left upper; lobe. After auscultating the left upper lobe, which breath sounds that verify
the x ray findings should the nurse document? Pleural friction rub
Pathology in which part of the ear results in sensorineural hearing loss? Cochlear apparatus
An elderly client diagnosed with chronic obstructive pulmonary disease for years ago presents in the ED
with shortness of breath, cyanosis, and greenish colored sputum. His initial arterial blood bases on room
air are: pH 7.39, pO2 46, pCO2 53, and HCO3 32. Which description best characterizes this client's
presentation problem? Chronic respiratory acidosis
,A client with a 30 year history cigarette smoking has developed emphysema. Which pathophysiological
mechanism results in the greatest interference with normal gas exchange for this client? Alveolar wall
destruction by proteolytic enzymes from macrophages
A client who has asthma (a reactive airway disease) asks the nurse about the role of leukotrienes in the
process. Leukotrienes have which immune response? Tighten airway and produce mucus
A client diagnosed with acute respiratory distress syndrome (ARDS) is receiving oxygen 8 L/min via nasal
cannula and has these arterial blood gases: pH 7.35, pCO2 45, pO2 75, HCO3 24. Based on these ABGs,
which intervention should the nurse implement? Continue to monitor the client
The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible
etiologies for this value, what question should the nurse ask the client? How much water and ice chips
do you have each day?
Which question should the nurse ask a client with systemic lupus erythematosus (SLE) in order to
determine if the client is experiencing an impending disease exacerbation? Have you had a fever in
the past few weeks?
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider? Lower back pain and
hypotension
A client with pernicious anemia takes supplemental folate and self administer monthly vitamin B12
injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse
review? CBC (Complete blood count)
The nurse is assigned to care for four clients. Which client is at an increased risk for metabolic alkalosis?
An older female client with small bowel obstruction who has vomited for 3 days
In assessing a client with ulcers on the lower extremity, which finding indicate that the ulcers are likely to
be venous, rather than arterial, origin? Irregular ulcer shapes and severe edema
In an effort to respond to an increasing myocardial workload, the cells of the left ventricle increase in
size. Which term best describes the left ventricle's adaptive change? Hypertrophy
A female client with rheumatoid arthritis (RA) comes to the clinic with swelling of her wrists after she
braced herself against a fall in the bathroom. What pathophysiological mechanism should the nurse
explain to the client regarding to RA? T cell generate cytokine production and antigen antibody
reactions that trigger inflammatory responses
A client with chronic gout reports pain in several joints and has tophi on the hands. The nurse develops a
plan to manage the client's pain based on which understanding of the underlying pathology of these
manifestations? Excess uric acid results in urate crystal deposits in the tissues
An older male reports to the clinic nurse that he sometimes feels chest pressure and becomes
breathless. He further describes an event where he had to sit for about one hour before he felt better.
He is asymptomatic at rest, but is concerned that he has had a heart attack. The clinical picture is
consistent with which cardiac ischemic event? Unstable angina
,An older man with end stage COPD is brought to the ED by his wife because of increasing shortness ob
breath and signs of respiratory distress. The client is using his portable oxygen at 2 L/minute per nasal
cannula. During the admission process, which action should the nurse take first? Inquire if the client or
his wife has increased the oxygen flow
two hours after thoracic surgery and chest tube insertion, a client is transferred from the post anesthesia
care unit to the surgical unit. Which assessment finding requires immediate intervention by the nurse?
Subjective verbal report of feeling pressure in the chest
A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has
an extremely high temperature. Which action should the nurse implement? Prepare ice packs for
placement in the client's axillary area
On the second postoperative day following abdominal surgery, a client's temperature increases. Based o
this finding, which assessment should the nurse complete first?
The nurse is preparing discharge instructions for an older female client who is going home after a hip
replacement. The client tells the nurse that she can hardly wait to get home and see her cat. Which
instruction regarding the cat is most critical to the client's safety at home? Do not bend over and
pick up the cat. Teach him to jump up so that you can reach him
the nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of
eschar. The wound care prescription states: clean the wound and then apply collagenase. Collagenase is
a debriding agent. The prescription does not specify a cleansing method. Which technique should the
nurse use to clean the pressure ulcer? Irrigate the wound with sterile NS
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the
nurse is turning the client, the wound dehiscenses and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Prepare the client to return to the operating room
An older adult male is brought to the ED by his daughter because he has been experiencing chest pain
for the last 4 hours. He is diagnosed with ST elevation myocardial infarction (STEMI) and was admitted 3
weeks ago for gastrointestinal bleeding. Until the client can be transferred to the percutaneous coronary
intervention unit, which assessment is most important for the nurse to monitor? Cardiac rate and rhythm
The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred
vision. Which outcome should the nurse include in the plan of care for this client? The client's
daily blood pressure will be less than 140/80 mmHg this month
The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this
client most likely to exhibit? Bilateral basilar crackles
Which common physiological change that occurs with aging is likely to influence an older adult's
nutritional status? Diminished sense of smell
An older client is admitted to a long term care facility. Upon admission the client is oriented but fatigued,
is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding
requires further assessment? Confusion to time, place, and environment
, During report an older female client, who had a right total hip replacement three days ago, is described
as intolerant of pain. When assessing the client, the nurse finds that the client can't straighten her right
foot which is pointing outward from the body. Which action should the nurse take? Call the
healthcare provider immediately and report that the client's prosthesis is most likely dislocated.
While assessing the skin on a older adult, the nurse notices hyperpigmented freckles on the client's
hands and arms. Which additional nursing assessment are indicated? No additional assessment
needed
A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours. The patch was
applied 48 hours ago and the client now reports experiencing breakthrough pain. What action should
the nurse implement? Leave the patch in place and administer a prescribed PRN analgesic
Which information should the nurse include when giving discharge instructions to a client following a left
eye cataract extraction with lens implant? Administer a stool softener
An adult male client is admitted for Pneumocystis jiroveci pneumonia secondary to AIDS. While
hospitalized, the client receives IV pentamidine therapy. In preparing this client for discharge, which
important aspect regarding this medication therapy should the nurse explain? IV pentamidine may
offer protection to other AIDS related conditions, such as Kaposi's sarcoma
An adult male client who was recently diagnose with glaucoma tells the nurse that he fells like he is
driving through a tunnel. The client expresses great concern about going blind. Which nursing instruction
is most important to provide this client? Maintain prescribed eye drop regimen
Twelve hours following orthopedic surgery on his leg, a male client begins to have acute chest pain and
difficulty breathing. Which action should the nurse take first? Take the client's vital signs and
auscultate lungs sounds
An adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the
park with friends. How should the nurse respond? Advise less weight bearing to prevent joint
destruction
To reduce risk for hypovolemic shock in a postoperative client, which intervention is most important for
the nurse to implement? Ensure that the IV is infusion at the prescribed rate
A client is receiving an infusion labeled Heparin Sodium 20,000 units in D5W 500 mL at the rate of 35
mL/hour. How many units of heparin is the client receiving per hour? 1400 unit
A client receives a prescription for vitamin K 2 mg daily. The pharmacy delivers a vial labeled vitamin K 5
mg/single use vial. The instructions read: reconstitute with 2.7 mL of sterile water to yield 2 mg/mL. How
many mL should the nurse administer? ( Enter the numerical value only 1
While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's
laboratory values? Culture for sensitive organisms
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent
drainage from the wounds. Before reporting this finding to the HCP, the nurse should evaluate which
laboratory value? Neutrophil count
hospitalized, the client receives IV pentamidine therapy. In preparing this client for discharge, which
important aspect regarding his medication therapy the nurse explain? It will be necessary to continue
prophylactic doses of IV or aerosol pentamidine every month
An elderly female client grimaces and demonstrates guarding behavior but denies experiencing pain
when asked by the nurse to rate her pain on a numeric scale. Which action should the nurse take next?
Ask the client to describe how she is feeling
The nurse is teaching a client who was recently diagnosed with gout how to manage the disease. Which
information should the nurse include in this client's teaching plan? Fluid intake should increase to
at least 3 liters per day
Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis
in a postoperative client? Advise the client to perform leg exercises regularly
A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's
syndrome is going to affect her job performance. Which instruction should the nurse provide this client?
Use a space heater to keep the workspace warm
A client experiences an ABO incompatibility reaction after receiving multiple blood transfusions. An ABO
incompatibility reaction is an example of which type of hypersensitivity? Antibody-Cytotonic
After reviewing the admission assessment of a client with chronic pain, which interventions should the
nurse include in this client's plan of care. SATA - Determine client's subjective measure of pain using a
numerical pain scale
- Assist the client to ambulate as much as possible during waking hours
- Implement a 24 hours schedule of routine administration of prescribed analgesic
- Provide comfort measures such as topical warm application and tactile massage
The chest x ray for a client who is admitted for pneumonia shows pleural effusion with decreased air
flow in the entire left upper; lobe. After auscultating the left upper lobe, which breath sounds that verify
the x ray findings should the nurse document? Pleural friction rub
Pathology in which part of the ear results in sensorineural hearing loss? Cochlear apparatus
An elderly client diagnosed with chronic obstructive pulmonary disease for years ago presents in the ED
with shortness of breath, cyanosis, and greenish colored sputum. His initial arterial blood bases on room
air are: pH 7.39, pO2 46, pCO2 53, and HCO3 32. Which description best characterizes this client's
presentation problem? Chronic respiratory acidosis
,A client with a 30 year history cigarette smoking has developed emphysema. Which pathophysiological
mechanism results in the greatest interference with normal gas exchange for this client? Alveolar wall
destruction by proteolytic enzymes from macrophages
A client who has asthma (a reactive airway disease) asks the nurse about the role of leukotrienes in the
process. Leukotrienes have which immune response? Tighten airway and produce mucus
A client diagnosed with acute respiratory distress syndrome (ARDS) is receiving oxygen 8 L/min via nasal
cannula and has these arterial blood gases: pH 7.35, pCO2 45, pO2 75, HCO3 24. Based on these ABGs,
which intervention should the nurse implement? Continue to monitor the client
The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible
etiologies for this value, what question should the nurse ask the client? How much water and ice chips
do you have each day?
Which question should the nurse ask a client with systemic lupus erythematosus (SLE) in order to
determine if the client is experiencing an impending disease exacerbation? Have you had a fever in
the past few weeks?
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider? Lower back pain and
hypotension
A client with pernicious anemia takes supplemental folate and self administer monthly vitamin B12
injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse
review? CBC (Complete blood count)
The nurse is assigned to care for four clients. Which client is at an increased risk for metabolic alkalosis?
An older female client with small bowel obstruction who has vomited for 3 days
In assessing a client with ulcers on the lower extremity, which finding indicate that the ulcers are likely to
be venous, rather than arterial, origin? Irregular ulcer shapes and severe edema
In an effort to respond to an increasing myocardial workload, the cells of the left ventricle increase in
size. Which term best describes the left ventricle's adaptive change? Hypertrophy
A female client with rheumatoid arthritis (RA) comes to the clinic with swelling of her wrists after she
braced herself against a fall in the bathroom. What pathophysiological mechanism should the nurse
explain to the client regarding to RA? T cell generate cytokine production and antigen antibody
reactions that trigger inflammatory responses
A client with chronic gout reports pain in several joints and has tophi on the hands. The nurse develops a
plan to manage the client's pain based on which understanding of the underlying pathology of these
manifestations? Excess uric acid results in urate crystal deposits in the tissues
An older male reports to the clinic nurse that he sometimes feels chest pressure and becomes
breathless. He further describes an event where he had to sit for about one hour before he felt better.
He is asymptomatic at rest, but is concerned that he has had a heart attack. The clinical picture is
consistent with which cardiac ischemic event? Unstable angina
,An older man with end stage COPD is brought to the ED by his wife because of increasing shortness ob
breath and signs of respiratory distress. The client is using his portable oxygen at 2 L/minute per nasal
cannula. During the admission process, which action should the nurse take first? Inquire if the client or
his wife has increased the oxygen flow
two hours after thoracic surgery and chest tube insertion, a client is transferred from the post anesthesia
care unit to the surgical unit. Which assessment finding requires immediate intervention by the nurse?
Subjective verbal report of feeling pressure in the chest
A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has
an extremely high temperature. Which action should the nurse implement? Prepare ice packs for
placement in the client's axillary area
On the second postoperative day following abdominal surgery, a client's temperature increases. Based o
this finding, which assessment should the nurse complete first?
The nurse is preparing discharge instructions for an older female client who is going home after a hip
replacement. The client tells the nurse that she can hardly wait to get home and see her cat. Which
instruction regarding the cat is most critical to the client's safety at home? Do not bend over and
pick up the cat. Teach him to jump up so that you can reach him
the nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of
eschar. The wound care prescription states: clean the wound and then apply collagenase. Collagenase is
a debriding agent. The prescription does not specify a cleansing method. Which technique should the
nurse use to clean the pressure ulcer? Irrigate the wound with sterile NS
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the
nurse is turning the client, the wound dehiscenses and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Prepare the client to return to the operating room
An older adult male is brought to the ED by his daughter because he has been experiencing chest pain
for the last 4 hours. He is diagnosed with ST elevation myocardial infarction (STEMI) and was admitted 3
weeks ago for gastrointestinal bleeding. Until the client can be transferred to the percutaneous coronary
intervention unit, which assessment is most important for the nurse to monitor? Cardiac rate and rhythm
The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred
vision. Which outcome should the nurse include in the plan of care for this client? The client's
daily blood pressure will be less than 140/80 mmHg this month
The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this
client most likely to exhibit? Bilateral basilar crackles
Which common physiological change that occurs with aging is likely to influence an older adult's
nutritional status? Diminished sense of smell
An older client is admitted to a long term care facility. Upon admission the client is oriented but fatigued,
is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding
requires further assessment? Confusion to time, place, and environment
, During report an older female client, who had a right total hip replacement three days ago, is described
as intolerant of pain. When assessing the client, the nurse finds that the client can't straighten her right
foot which is pointing outward from the body. Which action should the nurse take? Call the
healthcare provider immediately and report that the client's prosthesis is most likely dislocated.
While assessing the skin on a older adult, the nurse notices hyperpigmented freckles on the client's
hands and arms. Which additional nursing assessment are indicated? No additional assessment
needed
A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours. The patch was
applied 48 hours ago and the client now reports experiencing breakthrough pain. What action should
the nurse implement? Leave the patch in place and administer a prescribed PRN analgesic
Which information should the nurse include when giving discharge instructions to a client following a left
eye cataract extraction with lens implant? Administer a stool softener
An adult male client is admitted for Pneumocystis jiroveci pneumonia secondary to AIDS. While
hospitalized, the client receives IV pentamidine therapy. In preparing this client for discharge, which
important aspect regarding this medication therapy should the nurse explain? IV pentamidine may
offer protection to other AIDS related conditions, such as Kaposi's sarcoma
An adult male client who was recently diagnose with glaucoma tells the nurse that he fells like he is
driving through a tunnel. The client expresses great concern about going blind. Which nursing instruction
is most important to provide this client? Maintain prescribed eye drop regimen
Twelve hours following orthopedic surgery on his leg, a male client begins to have acute chest pain and
difficulty breathing. Which action should the nurse take first? Take the client's vital signs and
auscultate lungs sounds
An adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the
park with friends. How should the nurse respond? Advise less weight bearing to prevent joint
destruction
To reduce risk for hypovolemic shock in a postoperative client, which intervention is most important for
the nurse to implement? Ensure that the IV is infusion at the prescribed rate
A client is receiving an infusion labeled Heparin Sodium 20,000 units in D5W 500 mL at the rate of 35
mL/hour. How many units of heparin is the client receiving per hour? 1400 unit
A client receives a prescription for vitamin K 2 mg daily. The pharmacy delivers a vial labeled vitamin K 5
mg/single use vial. The instructions read: reconstitute with 2.7 mL of sterile water to yield 2 mg/mL. How
many mL should the nurse administer? ( Enter the numerical value only 1
While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's
laboratory values? Culture for sensitive organisms
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent
drainage from the wounds. Before reporting this finding to the HCP, the nurse should evaluate which
laboratory value? Neutrophil count
