ATI MED SURG PROTECTED EXAM 2023 REAL EXAM QUESTION ANS WELL DETAILED AND 100% EXPLANED ANSWERS

ati-med-surg-proctored-exam-2023-real-exam-questions-with-well-detailed-and-explaned-answer-key ATI MED SURG Proctored EXAM 2023 REAL EXAM Questions WITH WELL Detailed AND Explaned Answer KEY ATI MED SURG PROCTORED EXAM 2023 REAL EXAM QUESTIONS WITH WELL DETAILED AND EXPLANED ANSWER KEY 1.A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? A. Positive Western blottest Rationale:The client is already identified as HIV positive.Therefore,another value is the priority. B. CD4-T-cellcount180cells/mm3 Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunecompromised and is a thigh risk for infection.Therefore,this value is the priority for the nurse to report to the provider. C. Platelets150,000/mm3 Rationale:The client's plateletcount is with in the expected reference range.Therefore,another value is the priority. D. WBC5,000/mm3 Rationale:The client's WBC count is with in the expected reference range.Therefore,another value is the priority. 2.A nurse is assessing a clien twhoisadmittedforelectivesurgeryandhasahistoryofAddison'sdisease.Whichof the following findings should the nurse expect? A. Hyperpigmentation Rationale:Addison'sdiseaseisanendocrinedisorderthat occurswhentheadrenalglandsdonotproduce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body. B. Intentiontremors Rationale:Intentiontremorsmaybeseeninmultiplesclerosis,aneuromusculardisorderthatprimarily affects the central nervous system. C. Hirsutism Rationale:Addison'sdiseaseresultsinlossofbodyhair,calledvitiligo. D. Purplestriations Rationale:Purplestriationsontheskinoftheabdomen,thighs,andbreastsareacommonmanifestationin Cushing's syndrome. Hyperpigmentation can be seen as well. 3.A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tinglingsensationinthehands,thesolesofthefeet,andaroundthelips.Forwhichofthefollowingfindingsshould the nurse assess the client? Page1 A. Chvostek'ssign Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, thesoles of thefeet,and aroundthe lips,typicallyappearingbetween24and48hr after surgery.ToelicitChvostek'ssign,thenurseshouldtaptheclient'sfaceatapointjustbelowand in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia. B. Babinski'ssign Rationale:Babinski'ssignisadiagnostictestforbraindamageoruppermotorneurondamage.Itis positive if the toes flare up when the nurse strokes the plantar aspect of the foot. C. Brudzinski'ssign Rationale:Brudzinski'ssignisanindicationofmeningealirritation,suchasinclientswhohavemeningitis. With the client supine, the nurse should place one hand behind his head and places her other handonhischest.Thenursethen raisestheclient'sheadwithherhandbehindhishead,while the hand on his chest restrains him and prevents him from rising. Flexion of the client's lower extremities constitutes a positive sign. D. Kernig'ssign Rationale:Kernig'ssignisanindicationofmeningealirritation,suchasinclientswhohavemeningitis. The nurse performs the maneuver with the client supine with his hips and knees in flexion. The inability to extend the client's knees fully without causing pain constitutes a positive test. 4.Anurseisreviewinglaboratoryvaluesforaclientwhohassystemiclupuserythematosus(SLE).Whichofthe following values should give the nurse the best indication of the client's renal function? A. Serumcreatinine Rationale:Arenalfunctiondisorderreducestheexcretionofcreatinine,resultinginincreasedlevelsof blood creatinine. Creatinine is a specific and sensitive indicator of renal function. B. Bloodureanitrogen(BUN) Rationale: The BUN is used as a gross index of glomerular function and the production and excretion of urea.High-proteindiets,rapid-proteincatabolism,anddehydrationareconditionsthatwillcause an elevation in the BUN. This is not the best indication of the client's renal function. C. Serumsodium Rationale:Serumsodiumisaffectedbyurinaryoutputbutmayalsobefalselyaffectedbyhemodilutionand hemoconcentration. This is not the best indication of the client's renal function. D. Urine-specificgravity Rationale:Duetothebody'scompensatorymechanismsandabilitytomaintainglomerularfiltrationrate (GFR) until 75% of renal function is lost, this is not the best indication of the client's renal function. Page2 5.Anurseisassessingaclientwhohas alonghistoryof smokingandissuspectedofhavinglaryngealcancer.The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia. Rationale:Dysphagia,difficultyswallowing,isalater manifestationofcancerofthelarynx. Itoccursasthe tumor grows in size and impedes the esophagus. B. hoarseness. Rationale: Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestationofcancerofthelarynxbecausethetumorimpedestheactionofthevocalcords during speech. The voice may sound harsh and lower in pitch than normal. C. dyspnea. Rationale:Dyspnea,shortnessofbreath,isalatermanifestationoflaryngealcancer. Itoccursasthetumor grows in size and impedes the airway opening. D. weightloss. Rationale:Weightlossisalatermanifestationoflaryngealcancer,usuallyindicativeofmetastasis. 6.Anurseinaclinic isassessingaclient whohas AIDSandasignificantlydecreasedCD4-T-cellcount.Thenurse should recognize that the client is at risk for developing which of the following infectious oral conditions? A. Halitosis Rationale:Halitosis(foul-smellingbreath)isnotaninfectiousoralcondition andisfrequentlytheresultof poor dental health, poor oral hygiene, or gastrointestinal problems. B. Gingivitis Rationale:Gingivitisisinflammationofthegumorgingivaandistypicallycausedbyirritationfromdental plaque and poor oral hygiene. C. Xerostomia Rationale:Xerostomia(drymouth)istypicallyanadverseeffectofmedicationsthathaveanticholinergic properties. It is not an infectious oral condition. D. Candidiasis Rationale: Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults,andclients whoseimmunesystemshavebeencompromisedbyillness,suchasAIDS,or medications. 7.AnurseisreviewingtheCBCfindingsforafemaleclientwhoisreceivingcombinationchemotherapyforbreast Page3 cancer.Whichofthefollowingfindingsshouldthenursereporttotheprovider? A. WBC2300/mm3 Rationale:ThisWBCfindingisbelowtheexpectedreferencerange.Chemotherapytreatmentcancause leukopenia; the nurse should report this finding to the provider and implement precautions to protect the client from infection. B. RBC5 million/mm3 Rationale:Thisfindingiswithintheexpectedreferencerange. C. Hemoglobin12g/dL Rationale:Thisfindingiswithintheexpectedreferencerange. D. Platelets155,000/mm3 Rationale:Thisfindingiswithintheexpectedreferencerange. 8.A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). Thenursenotesthattheclient'sindwellingurinarycatheterhasnotdrainedinthepasthour.Whichofthefollowing actions should the nurse take first? A. Notifytheprovider. Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if theoutputisbrightradandthick;however,thenurseshouldattemptadifferentinterventionfirst. B. Checkthetubingforkinks. Rationale:Whenprovidingclientcare,thenurseshouldfirstusetheleastrestrictiveintervention;therefore, thenurseshouldcheck thecathetertubingforkinks.Thenursemustensureconstantflowofthe bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen. C. Adjusttherateofthebladderirrigant. Rationale:Thenursemayneedtoincreasetherateofbladderirrigant tostimulateremovalofurineand clots; however, the nurse should use a less restrictive intervention first. D. Irrigatethecatheter. Rationale:Thenursemayneedtoirrigatethecathetertocheckforaninternalobstruction; however,the nurse should use a less restrictive intervention first. 9.Anurseispreparingaclientwhoistoreceivechemotherapyfortreatmentofovariancancer.Whichofthefollowing actions should the nurse plan to take? A. Telltheclienttoexpectdarkstoolsfollowingchemotherapy. Rationale: Page4 Thenurseshouldinstructtheclientthatdark-coloredstoolscanindicategastrointestinal bleeding as a result of chemotherapy-induced bone marrow suppression. B. Havetheclientfloss4timesdaily. Rationale: The nurse should encourage the client to gently floss the teeth once a day to promote oral hygieneandpreventmucositis.Excessiveorroughflossingcancausebleedingandirritatethe gingiva. C. Havetheclientswishwithcommercialmouthwashbeforetherapy. Rationale:Thenurseshouldtelltheclientnottousecommercialmouthwashesbecausethealcohol content can cause mucositis. D. Administeranantiemeticpriortotheprocedure. Rationale: The nurse can help prevent nausea and vomiting by administering an antiemetic prior to chemotherapy,andtotelltheclienttocontinuetakingmedicationuntilnauseaandvomiting resolve. 10. Anurseisprovidingdischargeteachingforaclientwhoispostoperativefollowingasimplemastectomy.Theclient is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Donotapplyheattotheareaof irradiation. Rationale:This instruction willhelpthe clientavoid tissuedamage.Radiatedtissuebecomesthinner and mightlack tissuereceptors thatwouldotherwisealerttheclienttoapotentialburninjury.When outdoors in sunlight, the client should wear protective clothing over the area of irradiation. B. Donotwashtheareaofirradiation. Rationale:Theclientmaywashthetreatmentareagentlywithwarm,nothot,waterandamildsoap.She should not scrub the treatment area or remove the radiation area markings. She should then pat the skin dry with a soft, clean towel without rubbing. C. Useanantibioticointmenttotreatskinbreakdown. Rationale:Theclientshouldnotuseantibioticointmentunlesstheradiotherapyproviderprescribesit. D. Lubricatetheskinlubricatedwithhypoallergeniclotion. Rationale:Theclientshouldnotuselotionunlesstheradiotherapyprovider prescribesit. 11. AA nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the followingactivitiesshouldthenurseanticipatebeingthemostdifficultforthisclienttoperform withherrighthand? A. Buttoningherblouse Rationale:Althoughthisarmmotionmainlyinvolvesthe hand,wrist,andelbowoftheaffectedarm,itis not the most difficult for the client to perform. Page5 B. Eatingherbreakfast Rationale:Althoughthisarmmotionmainlyinvolvesthe hand,wrist,andelbowoftheaffectedarm,itis not the most difficult for the client to perform. C. Combingherhair Rationale:Abductionofthearm isthemostdifficult,andusuallythelast,typeofmovementtobe regained by a client following a mastectomy. D. Brushingherteeth Rationale:Althoughthisarmmotionmainlyinvolvesthe hand,wrist,andelbowoftheaffectedarm,itis not the most difficult for the client to perform. 12. AA nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolatedandaloneinthisroom."Afteracknowledgingtheclient'sfeelingsofloneliness,whichofthe following responses should the nurse provide? A. "Iwillcomeandsitwithyoufor10minuteseach hour." Rationale:Sittingwiththeclienthourlycreatesexcessiveexposuretotheradiationsource. B. "Doyouhaveacellphoneyoucantalktofriendsandfamilyon?" Rationale:Aclientwhohasaradiationimplantmustremaininradiationisolation.Time anddistanceare the factors that reduce exposure to the source. After acknowledging the client's feelings of lonelinessandrecognizingthesenseofsocialisolation,thissolutionprovidesanappropriate, safe means of meeting the client's need for contact. C. "I'llaskthechargenursetoadmitsomeonetoyourroomforcompany." Rationale:Aclientwhohasaradiationimplantmustremaininradiationisolation. D. "You'rescheduledfordischargein2dayssothisisolationwillbeoversoon." Rationale:Thisresponseimpliesthattheclient'sfeelingsoflonelinessarenotvalid. 13. AAnurseiscaringforaclientwhohaschemotherapy-inducedperipheralneuropathy.Thenurseshouldexpect the client to report having experienced which of the following symptoms? A. Extremitiesthatturnedbluewhenexposedtocold Rationale:ExtremitiesthatturnbluewhenexposedtocoldisasymptomofRaynaud'sphenomenon,a disorder that causes constriction of the blood vessels in the fingers, toes, ears, and nose. B. Tinglingfeelingintheextremities Rationale:Peripheralneuropathyisaneurologicaldisorderresultingfromdamagetotheperipheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effectfromchemotherapy.Ifasensorynerveisdamaged,theclientislikelytoexperience Page6 pain,numbness,tingling,burning,oralossoffeelingintheextremities. C. Jerkingmovementsoftheextremities Rationale:Jerkingmovements,suchasataxia,maybeseenwithmanyneurologicconditionsaffectingthe client's ability to produce a smooth movement. D. Spasmsoftheextremities Rationale:Involuntaryspasmsmaybefoundwithsuchconditionsascerebralpalsy,trauma,cerebral infection, and certain degenerative disorders. 14. Anurseisassessingaclientwhoisadmittedwith hyperthyroidism.Theclientreportsa weightlossof5.4kg(12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? A. Provideaquiet,low-stimulusenvironment. Rationale:Thyroidcrisiscanoccurinresponsetoastressor,sothenurseshouldminimizestressful stimuli in the client's environment. B. Administeraspirinasprescribedforanysignofhyperthermia. Rationale: The nurse should plan to administer acetaminophen for fever because aspirin displaces the thyroidhormonefrom plasmaproteinsandresultsinactivethyroidhormoneintheblood,which may exacerbate a thyrotoxic crisis. C. Keeptheclient NPO. Rationale:Thenurseshouldencouragetheclienttoeatahigh-protein,high-caloriediettomaintainweight and prevent negative nitrogen balance. The nurse should also promote fluid intake to replace loss through diaphoresis and diarrhea. D. Observetheclientcarefullyforsignsofhypocalcemia. Rationale:Thenurseshouldrecognizehypocalcemiaisaclinicalfindinginhypoparathyroidism,and calcium levels do not play a role in preventing thyrotoxic crisis. 15. Anurseinaclinicisreviewingthelaboratoryvalues ofaclientwhohasprimaryhypothyroidism.Thenurseshould anticipate an elevation of which of the following laboratory values? A. Thyroidstimulatinghormone(TSH) Rationale:ThenurseshouldanticipatethatTSHwillbeelevated. B. FreeT4 Rationale:Thenurseshouldanticipatethattheclient'sleveloffreeT4willbedecreased. C. SerumT4 Rationale: Page7 Thenurseshouldanticipatethattheclient'sserum T4willbedecreased. D. SerumT3 Rationale:Thenurseshouldanticipatethattheclient'slevelserumT3willbedecreased. 16. AAnurseiscaringforaclientwhohasAddison'sdiseaseandisatrisk forAddisoniancrisis.Whichofthe following actions should the nurse take? A. Providealow-carbohydratediet. Rationale:ClientswhohaveAddison'sdiseasearepronetohypoglycemia.Theyshouldfollowa high-protein,high-carbohydratediettoensureadequatecaloricintakeandavoidweightloss, which is common with Addisonian crisis. B. Weightheclient daily. Rationale:Addison'sdiseaseisanendocrinedisorderthatcausesweightloss,muscleweakness,fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client’s daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis. C. Administeroralcorticosteroids. Rationale:ThenurseshouldadministerIVcorticosteroidstomanageAddisoniancrisisuntiltheclient isno longer at risk for dehydration, hypotension, and shock. D. Restrictfluidintake. Rationale:Duetotheriskfordehydration,thenurseshouldnotrestricttheclient'sfluidintake. 17. AAnurseiscaringforaclientwhoisintheimmediatepostoperativeperiodfollowingapartiallaryngectomy.Which of the following parameters should the nurse assess first? A. Painseverity Rationale:Thenurseshouldassesstheclient'spainleveltohelpprovideadequatepainmanagement; however, another assessment is the priority. B. Wounddrainage Rationale:Thenurseshouldassessthequantityandcharacterofdrainagefromthesurgicalwoundto monitor for hemorrhage; however, another assessment is the priority. C. Tissueintegrity Rationale: Headandnecksurgeriesoftenrequiretissueflapstoclosethesurgicalwound.Thenurse shouldmonitorcolorandcapillaryrefillintheareaoftheflap(s)tohelpdetermineviability; however, another assessment is the priority. D. Airwaypatency Rationale: Page8 Whenusingtheairway,breathing,circulationapproachtoclientcare,thenursedeterminesthat the priority assessment is airway patency. After head and neck surgery, a major, life-threateningcomplicationisairwayobstruction.Thepriorityactionsinvolveairway maintenance and gas exchange. 18. AA nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client hadaradioallergosorbenttest(RAST)completedonapreviousvisit.Thenurseshouldrecognizethatan elevationin which of the following immunoglobulins indicates a positive result? A. ImmunoglobulinG(IgG) Rationale:IgGassumesamajorroleinbloodborneandtissueinfections. B. ImmunoglobulinA(IgA) Rationale:IgAprotectsagainstrespiratory,gastrointestinal,andgenitourinaryinfections C. ImmunoglobulinE(IgE) Rationale:ARASTinvolvesmeasuringthequantityofIgEpresentintheserumafterexposuretospecific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST. D. ImmunoglobulinM(IgM) Rationale:IgMisthefirstimmunoglobulinproducedinresponsetobacterialandviralinfections. 19. Anurseiscaringforaclient whoisreceivingcisplatintotreatbladdercancer.Afterseveraltreatments,theclient reports fatigue. Which of the following actions should the nurse take? A. Checktheresultsoftheclient'smostrecentCBC. Rationale:Theclientmighthaveanemiaasaresultof myelosuppression(bonemarrowsuppression)from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher. B. Assesstheclientforahypersensitivityreaction. Rationale:Althoughanymedicationcancauseanallergicreactionanditcandevelopevenafterrepeated exposure to the medication, this medication is unlikely to cause fatigue. C. Evaluatetheclientforhypercalcemia. Rationale:Cisplatincancausehypocalcemia,nothypercalcemia;however,calcium imbalancesdonot typically cause fatigue. D. Examinetheclientforhepatomegaly. Rationale:Somechemotherapeuticagents(vinblastine,vincristine,paclitaxel)cancauseliverimpairment, but this effect is unlikely with cisplatin. Page9 20. Duringaroutine physicalexamination,a nurseobservesa1-cm (0.4-in)lesionon aclient'schest.Thelesion is raisedandflesh-coloredwithpearlywhiteborders.Thenurseshouldrecognizethatthisfindingissuggestive of which of the following types of skin cancer? A. Squamouscellcarcinoma Rationale:Asquamouscelltumorappearsasarough,thickenedulceratedtumorthatcanbleed. B. Basalcellcarcinoma Rationale:Abasalcelltumorusuallybeginsasasmall,waxynodulewithrolled,translucent,pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration. C. Malignantmelanoma Rationale:Amalignant melanoma is often varied in color, ranging from shades of red to white to blue. It typicallyhasanirregularborder andsurfaceandislargerthan6mm indiameter.Itoftenstarts as the benign growth of a nevus (mole) and there can also be satellite lesions nearby. D. Actinickeratosis Rationale:Actinickeratosisisapremalignantlesionthatmanifestsasamacule;islessthan10mmin diameter; and is dry, rough, scaly, and without ulceration. 21. AAnurseisassessingaclientwhohashyperthyroidism.Thenurseshouldexpecttheclienttoreportwhichof the following manifestations? A. Sensitivitytocold Rationale:Hyperthyroidismcausesanincreasedrateofbodymetabolism.Thenurseshouldexpectthe client to report heat intolerance, rather than cold sensitivity. B. Constipation Rationale:Hyperthyroidismcausesincreasedperistalsis,whichresultsindiarrhea. C. Frequentmoodchanges Rationale:Hyperthyroidismdevelopswhenthethyroidglandproducesanexcessofthethyroidhormones that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They often cannot sit quietly. D. Weightgainof4.5kg(10lb) in3weeks Rationale:Hyperthyroidismcausesanincreasedrateofbodymetabolism.Thenurseshouldexpectthe client to report weight loss, rather than weight gain. 22. AAnurseisteachingafemaleclientwhohasanewdiagnosisofsystemiclupuserythematosus(SLE).Thenurse Page10 shouldrecognizetheneedforfurtherteachingwhentheclientidentifieswhichofthefollowingasafactorthatcan exacerbate SLE? A. Sunlight Rationale: Exposure to sunlight and artificial ultraviolet light can cause for an exacerbation of SLE manifestations,especiallythecharacteristicskinmanifestationsoflesionsandbutterflyrash. B. Pregnancy Rationale:PregnancycancauseanexacerbationofSLE,probablyduetohormonalchanges.Theclient should be advised of the risks and must be monitored closely for effects on the renal and cardiovascular systems if she decides to get pregnant. C. Infection Rationale:Infectionisamajorstressoronthebodyandcan triggeranexacerbationoftheSLEdisease process.Inaddition,manyclientswhohaveSLEtakesteroidmedicationsthatplacethem at higher risk for infection. D. Exercise Rationale:Deconditioningandmuscleatrophyoccursasaresultoflackofmobility.Thenurseshould encourage client to engage in conditioning exercises alternated with periods of rest. 23. AAnurseiscaringforaclientwhohasjustbeendiagnosedwithcancerofthecolon.Theclientasksthe nurse severalquestionsaboutwhatthe providermightbeplanningtodo.Whichof thefollowingnursing responses should the nurse make? A. ProvidetheclientwitharticlesfromtheInternetthatexplaincoloncancerstages. Rationale:Thisactiondoesnotaddresstheclient'squestion. B. Assuretheclientthattheproviderwillexplainwhathasbeenplanned. Rationale:Thisresponsebythenurseblockscommunicationbyputtingtheclient'sconcernonholdand giving false reassurance. C. Explainthevariousoptionsavailablefortreatmentbasedonthecancerstage. Rationale:Itisnotwithinthenurse'sscopeofpracticetodiscusstreatmentoptionswiththeclient. D. Encouragetheclienttowritedownquestionstoasktheprovider. Rationale:Thenursedoesnotknowtheanswerstotheclient'squestions,sohelpingtheclienttoprepare questions for the provider addresses the client's needs. 24. AA nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingooophorectomyforuterinecancer.Whichofthefollowinginstructionsshouldthenurseincludeinthe teaching? Page11 A. APapanicolaou(Pap)testshouldbeperformedevery6months. Rationale:Thenurseshouldrecognizethatthistestisusedtodetectcancersofthe cervixoruterus.Ina total abdominal hysterectomy, the cervix and uterus have been removed. B. Artificiallubricationcanbeusedtotreatvaginalitchinganddryness. Rationale:Thenurseshouldinstructtheclientthatatrophicvaginalchangesoccurduetothelossof estrogenpostoperativelyandcanalsocausepainanddrynessduringsexualintercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production. C. Increasedvaginaldrainagetypicallyoccurs5daysfollowingsurgery. Rationale:Thenurseshouldinstructtheclientthatanyincreasesinvaginaldrainage,or changesinthe drainage characteristics (bloodier, thicker, foul-smelling), should be reported to the provider immediately as these can indicate postoperative complications. D. Resumesexualintercoursein2to3weeks. Rationale: The nurse should instruct the client that she and her partner can resume sexual relations after theincisionhashealedandafterreceivingareleasefromherprovider,whichtypicallyoccursin 4 to 6 weeks. 25. A nurse is caring for a client who is going to have a bone marrowbiopsyunder conscious sedation. The client expressesfearabouttheprocedureandasksthenurseifthebiopsywillhurt.Whichofthefollowingresponses should the nurse make? A. "Thebiopsycanbeuncomfortable,butIwilltrytokeepyouascomfortableas possible." Rationale:Theclientisseekinginformation.Thisopen-endedtherapeuticresponsegivestheclientthe information that the client needs to cope, reassures the client of the nurse's presence, and encourages further communication. B. "Relax,you'llbeasleepformostoftheprocedureandyouwon'trememberathing." Rationale:Theclientisseekinginformation.Thisnontherapeuticresponsedevaluestheclient'sfeelings and makes two promises that the nurse cannot possibly keep. C. "Iwillcallyourdoctorandtellhim youstillhavequestionsabouttheprocedure." Rationale:Thisclosed-ended,nontherapeuticresponseputstheclient'sconcernsonholdandfocuseson an inappropriate person (the doctor). The client is seeking information that the nurse is able to give independently. D. "Icanunderstandbecauseyoumustbeveryworriedaboutwhatthebiopsywillshow." Rationale:Whilethisisanexampleofatherapeuticresponsethatfocusesontheclient'sfeelings,this response does not reassure the client on the procedure. 26. AAnurseiscaringforamiddleadultclientwhohasjustreceivedthediagnosisofendometrialcancer.Intakinga Page12 nursinghistory,whichofthefollowingmanifestationsislikelytobereportedbythisclient? A. Unilateralswellingontheposteriorofthevulva Rationale:Unilateralswellingontheposteriorofthevulvaisasymptomassociatedwithaclientwhohas a Bartholin cyst. B. Extremeabdominalpainwithintercourse Rationale:Extremeabdominalpainwithintercourseismostcommonlyassociatedwithendometriosis. C. Green,malodorousvaginaldischarge Rationale:Malodorous,vaginaldischargethatisgreenincolormaybetrichomoniasis.Asymptomof watery, bloody vaginal discharge may be related to endometrial cancer. D. Postmenopausalbleeding Rationale:Endometrialcancerinvolvescancerousgrowthoftheendometrium(liningoftheuterus).The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. 27. AAnurseiscaringforaclientwhoreturnstothenursing unitfrom therecoveryroom afterasigmoidcolon resection foradenocarcinoma.Theclienthadanepisodeofintraoperativebleeding.Whichfindingindicatestothe nursethat the client may be developing hypovolemic shock? A. Decreaseintherespiratoryratefrom 20to16/min. Rationale: A client who is experiencing shock will have an increased respiratory rate (20 breaths/min). Initially the client will be alkalotic with a PaCO2 32 mm Hg), but as shock progresses, the client will also have an increase in PaCO2 (45 mm Hg) resulting in acidosis, and a PaCO2 80%.Respirationswillbecomerapidandshallowandcrackleswillbehearduponauscultation. B. Decreaseintheurinaryoutputfrom 50mLto30mLperhour. Rationale:Aclientwhoisexperiencingshockwillhaveadecreaseinurinaryoutputduetothedecreasein cardiac output and diminished perfusion to the kidneys. Urine output steadily decreases (0.5 mL/kg/hr) until anuria occurs which requires dialysis. C. Increaseinthetemperaturefrom 37.5°C(99.5°F)to38.6°C(101.5°F). Rationale:Hyperthermiaisnotaninitialsignofhypovolemicshock.Oneoftheclassicsignsofshockis cool, moist skin. Hyperthermia is seen in septic shock. D. Increaseintheheartratefrom88to110/min. Rationale: Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the bodybecauseofbloodlossorinadequatebloodvolume.Inanefforttocompensateforthis,the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and maydevelop asystole. Page13 28. AAnurseiscaringforaclientwhois1-daypostoperativefollowinga leftlowerlobectomyandhasachesttubein place.Whenassessing the client's three-chamber drainage system,the nurse notes thatthere is no bubblingin the suction control chamber. Which of the following actions should the nurse take? A. Continuetomonitortheclientasthis isanexpectedfinding. Rationale:Theexpectedfindingwouldbeagentlebubblingofthewaterinthesuctioncontrolchamber. B. Addmorewatertothesuctioncontrolchamberofthedrainagesystem. Rationale:Morewatershouldnotbeaddedtotheclosedsystem. C. Verifythatthesuctionregulatorisonandcheckthetubingforleaks. Rationale:Alackofbubblingmayindicatethateitherthesuctionregulatoristurnedofforthatthereisa leak in the tubing. D. Milkthechesttubeanddislodgeanyclotsinthetubingthatareoccluding it. Rationale:Stripping,ormilking,canpulltoohardonthechestcavityandmaycauseatissueinjurytothe lung. Stripping is only done when specifically indicated. 29. AAnurseiscaringforaclientwhoisreceivingcisplatinfortreatmentofovariancancer.Theclient'smost recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the followingfortheclient?WBC 1,400/mm3 RBC 4.3x10¹² /LHgb 12.1g/dLHct 36.5%Platelets 170,000/mm3Albumin 4.5 g/dL A. Theclienthasanincreasedriskforbleeding. Rationale:Plateletsareanimportantcomponentinmaintainingtheintegrityofthevascularsystemand the clotting cascade. Clients who have a low platelet level are at increased risk of bleeding; however this client’s platelet count is within the expected reference range of 150,000 to 400,000/mm³. B. Theclientshouldreceiveadietwithincreasedprotein. Rationale:Proteinisanimportantcomponentofcellulardevelopmentandoverallhealthoftheclientwho isreceivingchemotherapy.Howevertheclient'salbuminleveliswithintheexpectedreference range of 3.5 – 5 g/dL, and does not indicate a need to increase protein at this time. C. Theclienthasanincreasedriskofinfection. Rationale: The low white blood cell count (expected range is 5,000 – 10,000/mm³) places the client at increasedriskforinfection.Thenurseshouldassesstheclient’sskinandmucousmembranes, lung sounds, and venous access sites every 8 hr for signs of infection. D. Theclientshouldreceiveanerythropoiesisstimulatingagent. Rationale:Theclient who is receiving chemotherapy is at increased risk for the development of anemia, evident by a decreased RBC level. However, an RBC level of 4.3 x 10¹²/L is within the expected reference range of 4.2 – 5.4 x 10¹²/L. Clients who are anemic as a result of chemotherapymayreceiveerythropoiesisstimulatingagentssuchasepoetinalfa,tostimulate Page14 RBC production and relieve symptomssuc has fatigueand shortness of breath. 30. AAstaffnurseisteachingaclientwhohasAddison'sdiseaseaboutthediseaseprocess.Theclientasksthe nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "Itiscausedbythelackofproductionofinsulinbythepancreas.." Rationale:A clientwhodoesnotproduceinsulinhastype1diabetesmellitus. B. "Itiscausedbythelackofproductionofaldosteronebytheadrenalgland." Rationale:Addison'sdiseaseiscausedbyalackofproductionoftheadrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland. C. "Itiscausedbytheoverproductionofgrowthhormonebythepituitarygland." Rationale:Aclientwhohasanoverproductionofthegrowthhormonehasacromegaly. D. "Itiscausedbytheoverproductionofparathormonebytheparathyroidgland." Rationale:Aclientwhohashyperparathyroidismproducesanexcessiveamountofparathormone. 31. AAnurseisassistingaclientwhohashypothyroidism withmealplanning.Whichofthefollowingfoodsshould the nurse recommend that the client add to her diet? A. Ripebananas Rationale:Ripebananasareanappropriatechoiceforclientswhohavediverticulitisorulcerativecolitis but not for hypothyroidism. B. Poachedeggs Rationale:Poachedeggsareanappropriatechoiceforclientswhohavediverticulitisorulcerativecolitis but not for hypothyroidism. C. Wholegrains Rationale:Constipationisaclassicmanifestationofhypothyroidism;therefore,thisclientshouldincrease her fluid and fiber intake. Whole grains provide ample amounts of fiber. D. Bakedchicken Rationale:Animalbasedproteinsourcesdonothelpwithconstipation,whichisaclassicmanifestationof hypothyroidism. 32. AAclinicnurseisperformingaphysicalassessmentonaclientwhohassystemiclupus erythematosus (SLE).Which of the following findings should the nurse expect? Page15 A. Agreycolored,non-purpuricpapularrash. Rationale:AtypicalrashofaclientwhohasSLEisinflamedandredinappearance. B. Adry,redrashacrossthebridgeofthenoseandonthecheeks. Rationale:A“butterfly”rashthatisdry,red,andraisedischaracteristicof SLE. C. Pittingedemaofthehandsandfingers. Rationale:Clientswhohavesclerodermahavepainless,symmetricedemaofthehandsandfingers. D. Subcutaneousnodulesontheulnarsideofthearm. Rationale:Clientswhohaverheumatoidarthritiscanhavesubcutaneousnodulesontheulnarsideofthe arm. 33. AAnurseiscaringforaclientwhohasmyelosuppressionafterreceivingchemotherapy.Thenurseshould monitor the client for which of the following adverse effects? A. Anorexiaandmalnutrition Rationale:Anorexiaandmalnutritionarenotdirectlyrelatedtomyelosuppression. Theyareadverse effects of chemotherapy. B. Bleedingfromthegums Rationale:Bleedingfromthegumsisdirectlyrelatedtomyelosuppressiondue toinhibitedbonemarrow production of blood cells and platelets. C. Diarrheaanddehydration Rationale:Diarrheaanddehydrationarenotdirectlyrelatedtomyelosuppression.Theyareadverse effects of chemotherapy. D. Fullbodyalopecia Rationale:Fullbodyalopeciaisnotdirectlyrelatedtomyelosuppression.It isanadverseeffectof chemotherapy. 34. AAnurseisprovidingteachingtoaclientwhohasneutropenia.Whichofthefollowinginformationshouldthe nurse include in the teaching? A. Eatplentyoffreshfruitsandvegetables. Rationale:Thenurseshouldinform aclientwhoisneutropenictoavoidfreshfruitsandvegetablesdueto the bacteria they can carry. B. Avoidcrowds. Rationale:Thenurseshouldinformtheclienttoavoidcrowdsduetohissuppressedimmunesystem. Page16 C. Performmildexercise,suchasgardening. Rationale:Thenurseshouldinstructtheclienttoavoidgardeningduebacteriacontainedinthesoil. D. Taketemperatureweekly. Rationale:Aclientwhoisneutropeniccanexperiencea1&degincreasefromhisbaselinetemperature, eveninthepresenceofinfection.Therefore,thenurseshouldrecommendtheclienttakehis temperature at least once daily. 35. AAnurseispreparingaclientforaradiationtreatmentwhoispostoperativefollowingamastectomy.The nurse should inform the client to expect which of the following adverse effects from the treatment? A. Alopecia Rationale:Alopeciaisanacuteadverseeffectofradiationtothebrain. B. Diarrhea Rationale:Diarrheaisanacuteadverseeffectofradiationtotheabdomenandpelvis. C. Fatigue Rationale:Thenurseshouldinformtheclienttoexpectfatiguewithherradiationtreatment.Fatigueoccurs regardless of the radiation target site. D. Anorexia Rationale:Anorexiaisanacuteadverseeffectofradiationtotheabdomenandpelvis. 36. AAnurseisreviewingthelaboratoryresultsofaclientwhowasadmittedwithahistoryofmultiplemyeloma. The nurse should expect to find an increase in which of the following laboratory values? A. Absoluteneutrophilcount(ANC) Rationale:ThenurseexpecttheANCofaclientwhohasahistoryofmultiplemyelomatodecrease. B. Calcium Rationale:Thenurseexpectthecalciumlevelofaclientwhohasahistoryofmultiplemyelomato increase due to the destruction of bone. C. Platelets Rationale:Thenurseexpecttheplateletcountof aclientwhohasahistoryofmultiplemyelomato decrease. D. WBCs Rationale:ThenurseexpecttheWBCcountofaclientwhohasahistoryofmultiplemyelomato decrease. Page17 37. Afterradiationtreatment,aclientreportsdryness,redness,andscalingofhisskinoccurringwithinthedesignated radiation treatment markings. The nurse should instruct the client to take which of the following actions? A. Applyhydratinglotions. Rationale:Thenurseshouldinstructtheclienttogentlyapplyhydratinglotionsthatdo notcontainmetal, alcohol, or perfume. B. Applymoistheat. Rationale:Itisnotappropriateforthenursetoinstructtheclienttoapplyheat,evenwithmoisture. Extremetemperaturecantraumatizenewcells. C. Sitinthesunfor10minperday. Rationale:Itisnotappropriateforthenursetoinstructtheclienttositinthesun.Extremetemperaturecan traumatize new cells. D. Washwithplainsoapandwater. Rationale:Itisnotappropriateforthenursetoinstructtheclienttowashwith plainsoapandwater.Soaps can be irritating to skin in the treatment area, and the friction of washing can traumatize new cells. Additionally, the markings are guidelines that should not be washed off. 38. AAchargenurseisteachingagroupofhealthcare workersabouthandhygienetopreventinfection.Whichof the following information should the charge nurse include in the teaching? A. Keepartificialnailstrimmed. Rationale:Healthcareworkersshouldnotwearartificialnailsduetothepossibilityoftransmissionof microorganisms when caring for the client. B. Usealcohol-basedhandrubsbeforeadministeringeyedropsforaclient. Rationale:Healthcareworkersshouldavoidusingalcohol-basedhandrubsbeforeadministeringeye drops because the alcohol can cause burning and redness of the client's eye. C. Washhandswithalcohol-basedhandrubswhencaringforaclientwhohas Clostridiumdifficile. Rationale:Healthcareworkersshouldwashhandswithsoapandwaterwhencaringforaclientwhohas C.difficile.Alcohol-basedhandrubsareineffectiveagainstthespore-formingorganism. D. Usechlorhexidinetowashhandsiftheclientisimmunosuppressed. Rationale:TheCDCrecommendshealthcareworkersusechlorhexidineforhandwashingwhenproviding care to a client who is immunosuppressed. 39. AAclientisreceivingtreatmentforstageIVovariancancerandasksthenursetodiscussherprognosis. Theclient plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses Page18 shouldthenursediscusswiththeclient? A. Good Rationale:Atthisadvancedstage,theprognosisforovariancancerisnotgood,evenwithaggressive treatment. B. Guarded Rationale:Atthisadvancedstage,theprognosisforovariancancerisnotguarded,evenwithaggressive treatment. C. Poor Rationale:Atthisadvancedstage,theprognosisforovariancancerispoor.Ovariancanceristheleading causeofdeathfromfemalereproductivecancers.Survivalratesarelowbecauseitisnotoften discovered until its late stages. D. Verygood Rationale:Atthisadvancedstage,theprognosisforovariancancerisnotverygood,evenwithaggressive treatment. 40. AAfemalemiddleadultclienttellsanursethatshetestedpositiveforamutantBRCA1gene.Thenurse should recognize that the client is at an increased risk for which of the following situations? A. DeliveringachildwhohasDownsyndrome Rationale:TheBRCA1geneisnotusedtodeterminethe probabilityofhavingachildwhohasDown syndrome. B. DevelopingAlzheimer'sdisease Rationale:The BRCA1geneisnotusedtodeterminetheprobabilityofdevelopingAlzheimer'sdisease. C. Developingbreastcancer Rationale: The BRCA1 gene is used to determine the probability of a client developing breast cancer. BRCA1genetictestingisusedforwomenwhohaveastrongfamilyhistoryofbreastcancer. D. Developingthyroidcancer Rationale:TheBRCA1geneisnotusedtodeterminetheprobabilityofdevelopingthyroidcancer. 41. AAnurseisplanningcareforaclientwhohasimmunosuppressionfollowingchemotherapy.Whichofthe following interventions should the nurse include in the plan of care? A. Insertanindwellingcathetertomonitorsedimentintheurine. Rationale:Thenurseshouldavoidinsertinganindwellingcathetertohelpprevent contaminationwith microorganisms that may cause an infection. Page19 B. Taketheclient'stemperatureoncepershift. Rationale:Thenurseshouldtaketheclient'stemperatureatleastevery4hrtomonitorforanincrease that might indicate an infection. C. Providetheclientwithfreshfruittoavoidconstipation. Rationale: The nurse should provide the client with fruit that is cooked to help prevent constipation becausefreshfruitandvegetablecanharbormicroorganismsthatcancauseaninfection. D. Limitthenumberofhealthcareworkersenteringtheroom. Rationale:Thenurseshouldlimitthenumberofhealthcareworkersenteringtheclient'sroomtoprevent possible overexposure to microorganisms that can lead to an infection. 42. AA nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer,and whohasneutropenia.Thenurseshouldincludewhichofthefollowing restrictionsintheclient'splan of care? A. Allvisitorsfromenteringtheclient’sroom Rationale: Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. However,itisonlynecessarytorestrictthosevisitors whowouldputtheclientatrisk,suchas visitors who have manifestations of a cold or other illness. B. Freshflowersandpottedplantsintheroom Rationale: Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromisedclientsareinstructednottoacceptsuchgiftsintotheroom.Inaddition, theclientis instructed to eatonlythoroughlycookedmeatsandthoroughlywashedfruitsand vegetables. Immunocompromised clients are more susceptible to infection and illness from food-borne bacteria than other clients. C. Oralfluidintaketobetweenmeals only Rationale: Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromisedasaresultofneutropenia,adecreasedwhitebloodcell(WBC)count. However, this has no relationship to fluid intake. D. Activitiesthatcouldresultinbleeding Rationale: Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromisedasaresultofneutropenia,adecreasedwhitebloodcell(WBC)count. However, this has no relationship to bleeding. 43. AAnurseiscaringforaclientfollowingatotallaryngectomy.Whichofthefollowingisthepriorityobservationin the client's care? Page20 A. Patencyoftheintravenousline. Rationale:Whileensuringpatencyoftheintravenouslineisincludedinthepostoperativeplanofcare,this is not the priority observation. B. Levelofpain. Rationale:Whilecollectingdataaboutaclient'slevelofpainisincludedinthepostoperativeplanofcare, this is not the priority observation. C. Integrityofthedressing. Rationale:Whileensuringtheintegrityoftheclient'sdressingisincludedinthepostoperativeplanofcare, this is not the priority observation. D. Needforsuctioning. Rationale:Usingtheairway,breathing,circulation(ABC)priority-settingframework,confirmingapatent airway is the priority observation for a postoperative client after a total laryngectomy. 44. AAnurseis caringforaclientscheduledtoreceive externalradiationto the neck forcancer of the larynx.During a pretreatment exam, the nurse explains to the client that the most likely side effect would be A. infertility. Rationale:Onlytheareaoftreatmentisaffectedbytheradiation,soinfertilitymayoccurwithradiationof pelvic or perineal area. B. diarrhea. Rationale:Onlytheareaoftreatmentisaffectedbytheradiation,sodiarrheamayoccurwithradiationof gastrointestinal area. C. dyspnea. Rationale:Onlytheareaoftreatmentisaffectedbytheradiation, sodyspnea(shortnessofbreath)may occur with radiation of chest or breast. D. dysphagia. Rationale:Radiationtherapydoesnothurtwhileitisbeinggiven.Butthesideeffectsthatpeoplemayget from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness. 45. AAnurseiscaringforaclientwhoisHIVpositiveandisonedaypostoperativefollowinganappendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A. Talkingtotheclientatthebedside Rationale: Page21 Standardprecautionsdonotrequirethenursetowearpersonalprotectiveequipmentwhileat the bedside of a client who is HIV positive and postoperative unless there is a risk of contact with body fluids. B. AdministeringanintermittentIVbolusmedication Rationale:Standardprecautionsrequirepersonalprotectiveequipmentwhenthereisariskofcontactwith body fluids. Administering an intermittent IV bolus does not present a risk of contact with body fluids. C. Completingadressingchange Rationale:Standardprecautionsrequirepersonalprotectiveequipmentwhenthereisariskofcontactwith body fluids. A dressing change does present a risk for coming into contact with body fluids. D. AdministeringanIMinjection Rationale:Standardprecautionsrequirepersonalprotectiveequipmentwhenthereisariskofcontactwith body fluids. The nurse should wear gloves when administering an IM injection to this client. 46. Anurseispreparingaclient whohasAIDSfordischarge.Whichof thefollowingstatementsshouldthenurse include in the discharge instructions? A. "Preventthespreadofinfectionwithgoodhouseholdcleaningpractices." Rationale:Theclientshouldfollowstandardprecautionsandusea1:10solutionofbleachtodisinfect areas that come into contact with blood and body fluids. B. "Disinfectequipmentcontaminatedwithbloodorbodyfluidsfortwenty-fourhours." Rationale: The client should wipe down equipment that has been in contact with blood or body fluids immediately,firstwithsoapandwaterandthenwitha1:10solutionofbleach.Theequipment does not require disinfecting for 24 hr. C. "Foodpreparationisnotyourresponsibility." Rationale:Theclientmayparticipateinfoodpreparationbutmust practicecarefulhandhygiene.Themost common form of transmission is direct exposure to body secretions and blood. D. "Burnsoileddressings." Rationale:Theclientshoulddisposeofsoileddressingsbyplacingtheminatiedplasticbagintheregular trash. 47. AAnurseisplanningapresentationaboutHIVforachurch-basedgroup.Whichofthefollowinginformationabout HIV transmission should the nurse include? A. Itisprimarilytransmittedthroughcasualcontact. Rationale:ThenurseshouldincludeintheteachingthatHIVisnottransmittedbycasualcontact,butby infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body Page22 fluidscomingintocontactwithmucousmembranesornon-intactskin. B. Itisprimarilytransmittedthroughaccidentalpuncturewounds. Rationale: The nurse should include in the teaching that HIV is not primarily transmitted by accidental puncturewounds,butbyinfectedblood,seminalfluid,vaginalsecretions,amnioticfluid,breast milk, and other body fluids coming into contact with mucous membranes or non-intact skin. C. Itisprimarilytransmittedthroughdirectcontactwithinfectedbodyfluids. Rationale: ThenurseshouldincludeintheteachingthatHIVistransmittedthroughdirectcontactwith infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk and other body fluids. D. Itisprimarilytransmittedthroughmosquitoes. Rationale:ThenurseshouldincludeintheteachingthatHIVisnottransmittedthroughmosquitoes,butby infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk, and other body fluids coming into contact with mucous membranes or non-intact skin. 48. Anurseisplanninganeducationalprogram aboutbasalcellcarcinoma.Whichofthefollowinginformationshould the nurse plan to include? A. Basalcellcarcinomahasalowincidenceofmetastasis. Rationale:Basalcellcarcinomaisalocalizedlesionthatseldommetastasizes. B. Basalcellcarcinomahasahighmortalityrate. Rationale:Basalcellcarcinomaiseasilydetectedandhasalowriskformortality. C. Basalcellcarcinomaisaggressiveandrapidgrowing. Rationale:Basalcellcarcinomaisslowgrowingandlocalized. D. Basalcellcarcinomadevelopsfromaneviormole. Rationale:Basalcellcarcinomadevelopsfromthebasilcelllayeroftheepidermis. 49. Anurseisprovidingteachingtoaclientaboutpreventingskincancer.Whichofthefollowingclient statements indicates a need for further teaching? A. "Eatingahighfiberdietwillreducemyriskfordevelopingskincancer." Rationale:Ahigh-fiberdietisrecommendedtoreducetheriskforcoloncancer. B. "Ishouldcheckmyskinmonthlyforanychanges." Rationale:Theclientshouldexaminehisskinmonthlytoincreasetheopportunityforearlydetectionof new lesions or skin changes that can develop into skin cancer. Page23 C. "Ishouldavoidtheuseoftanningbooths." Rationale:Theclientshouldavoidtanningboothsbecausetheycanincreasetheriskofskincancerdue to ultraviolet light exposure. D. "Ishouldusesunscreenevenoncloudydays." Rationale:Theclientshouldapplysunscreenonadailybasistoreducetheriskofskincancer. 50. Anurseisprovidingteachingtoaclientwhohasa newprescriptionfortamoxifento treatbreastcancer.Thenurse should include that which of the following is an adverse effect of this medication? A. Hotflashes Rationale:Hotflashesareacommonadverseeffectoftamoxifen.Otheradverseeffectsincludefluid retention and vaginal discharge. The nurse should advise the client these effects should subside when therapy is discontinued. B. Insomnia Rationale:Althoughtamoxifencancauselight-headednessanddepression,insomniaisnotanadverse effect of this medication. C. Increasedappetite Rationale:Lossofappetiteisanadverseeffectoftamoxifen. D. Constipation Rationale:Althoughtamoxifencancausenauseaandvomiting,constipationis notanadverseeffectof this medication. 51. AAnurseisteachingaboutadverseeffectsofanastrozolewithaclientwhohasadvancedbreastcancerandis postmenopausal.Whichofthefollowing adverseeffectsshould the nurserecommendtheclientreportto the provider? A. Weightgain Rationale:TheclientmayhaveanorexiaandotherGIsymptomswhenadministeredthismedication. B. Stomatitis Rationale:Theclientwhohasstomatitisisnotexperiencinganadverseeffectofthemedication. Chemotherapymedicationmaycausestomatitis. C. Cough Rationale:Theclientwhohasacoughisnotexperiencing anadverseeffectofthemedication;therefore, the cough may be related to other physical factors. D. Musculoskeletalpain Rationale: Page24 Theclientwhoisexperiencingmusculoskeletalpainshouldnotifytheprovider.Musculoskeletal pain is a common adverse effect that affects 50% of clients that is possibly caused from estrogen deprivation. 52. AA nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initialsymptomsexperiencedwithHIVinfection.Whichofthefollowingmanifestationsshouldthenurse includein the explanation of initial symptoms? A. Pneumocystislunginfection Rationale:Thenurseshouldexplainthatpneumocystislunginfectionisnotaninitialsymptom ofHIV infection, but is linked in category C where the client is to have AIDS. B. Flu-likesymptomsandnightsweats Rationale:Thenurseshouldexplainthattheinitialsymptomsmayincludeflu-likesymptomsandnight sweats in category A of HIV infection. C. Fungalandbacterialinfections Rationale:Thenurseshouldexplainthatfungalandbacterialinfectionsarenotinitialsymptoms,butare linked in category B of HIV infection. D. Kaposi'ssarcoma Rationale:ThenurseshouldexplainthatKaposi'ssarcomaisnotaninitialsymptom ofHIVinfection,but is linked in category C where the client is to have AIDS. 53. AAnurseisimplementingaplanofcareforaclientwhohasAIDSwithrecurringpneumonia.Whichofthe following actions should the nurse take? A. Encouragefluidintakeof1500mL/day. Rationale:Thenurseshouldencourageafluidintakeof3000mL/day,not1500mL/day,toloosen sputum. B. Positionheadofbedat10degrees. Rationale:Thenurseshouldpositiontheheadofthebedat30to45degrees, not10degrees,toassistin deep breathing exercises. C. Coughanddeepbreatheevery8 hr. Rationale:Thenurseshouldimplementcoughanddeepbreathingevery2to4hr,notevery8hr,for pulmonary hygiene. D. Obtainasputumculture. Rationale:Thenurseshouldobtainasputum culturetodeterminewhichantibioticisneededfor the organism that is causing the pneumonia. Page25 54. Anurseiscaringforaclient whois1daypostoperativefollowingaleftradicalmastectomy.Whichofthefollowing behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? A. Refusingtolookatthedressingorsurgicalincision Rationale: Clients who refuse to look at the surgical incision or surgical dressing are having difficulty adjustingtothelossofabodypartorwithbodydisfigurement.Thisindicatestheclientisnot yet ready to acknowledge the results of the surgery. B. Askingforpainmedicationevery3hr Rationale:Itisanexpectationthatclientswillhavepainpostoperativelyandwillrequestpainmedication regularly. C. Askingquestionsabouttheinformationonherpostoperativecarepamphlet Rationale:Itisanexpectationthatclientswillhavequestionsaboutpostoperativecare. D. Performingarm exercisesonceortwiceaday Rationale:Itisanexpectationthatclientswillhavedifficultyperformingtherecommendedexercisessoon after surgery, but this client is performing them and the frequency should increase with time and healing. 55. AAnurseissettinggoalsforaclientwhohasAIDSandisattheendoflife.Whichofthefollowingare realistic goals? A. Theclientwillverbalizeanunderstandingofthemodeofdiseasetransmission. Rationale:Theclientverbalizinganunderstandingofthemodeofdiseasetransmissionisdoneatthetime of initial diagnosis, so this is not a realistic goal. B. Theclientwillexperienceaweightgainofonetotwopoundsper week. Rationale:Theclientmaynothavethedesiretoeatduringtheendoflifeandmayexperienceaweight loss, so this is not a realistic goal. C. Theclientwillincreaseattendanceatcommunitysocialactivities. Rationale:Theclientmaynothavetheenergyorinterest toattendcommunitysocialactivities,sothisis not a realistic goal. D. Theclientwillreceivemedicationtominimizeepisodesofbreakthroughpain. Rationale:Theclientshouldreceivemedicationtominimizeepisodesofbreakthroughpainasagoalfor the end of life care. 56. AAnurseisassessingaclientwhohassystemiclupuserythematosus(SLE).Whichofthefollowingfindingsisthe Page26 highestpriorityforthenursetoreporttotheprovider? A. Clientreportoffeelingsofdepression. Rationale:TheclientwhohasSLEcommonlyreportsfeelingsofdepression.However,accordingtothe safety and risk reduction priority setting framework, this finding is not the highest priority. B. Dry,raisedrashonthe face. Rationale:TheclientwhohasSLEcommonlyhasaclassic “butterfly”reddishrashontheface.However, according to the safety and risk reduction priority setting framework, this finding is not the highest priority. C. Presenceofperipheraledema. Rationale: TheclientwhohasSLEisatgreatestriskfordeathfromlupusnephritis.Therefore,according tothesafetyandrisk reductionprioritysettingframework,findingsthatindicateanimpairment of renal function are the highest priority to report. D. Jointpaininhandsandknees. Rationale: TheclientwhohasSLEcommonlyreportsjointpain.However,accordingtothesafetyandrisk reduction priority setting framework, this finding is not the highest priority 57. AA nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explainthat, after thelaboratoryhastheenzyme-linkedimmunosorbentassay(ELISA)results,itwillusewhichofthefollowingtests to confirm the diagnosis? A. CD4+T-cellcount Rationale: AfterconfirmationofHIVinfection,theCD4+T-cellcounthelpsprovidersdecidewhento initiateantiretroviralmedicationtherapy.AlowCD4+T-cellcount isassociatedwithmore disease manifestations. B. Westernblotanalysis Rationale:TheWesternblotanalysisisusedtoconfirmseropositivitywhentheELISAtesthasapositive result. ELISA is inexpensiveandaccurate withfewfalse-positives.Westernblot is expensive, so is done only for confirmation. C. QuantitativeRNAassay Rationale:AfterconfirmationofHIVinfection,quantitativeRNAassays(atypeofviralloadtest)usegene amplification to determine the amount of HIV- RNA in the client’s serum. D. Viralloadtest Rationale:AfterconfirmationofHIVinfection,aviralloadtesthelpsdeterminetheamountofviralgenetic material(DNAorRNA)intheclient’sblood,ratherthanthebody’sresponsetoHIVinfection. 58. AAnurseistalkingwithaclientwhosethyroid-stimulatinghormone(TSH)levelwillbemeasured.Whichofthe Page27 followingstatementsbythenurseexplainsthepurposeofthistest? A. "Thistestmeasurestheamountofthyroidhormonethatattachestoaproteininyourblood." Rationale:ThisdescribestheT3resinupdatetest,whichmeasurestheamountofthyroidhormonebound to thyroxine binding globulin. B. "Thistestdetectsantithyroidantibodiesinyourblood." Rationale:Thisdescribesanantithyroidantibodytiter. C. "Thistestmeasurestheabsorptionofiodineandhowitrelatestothethyroidgland." Rationale:Thisdescribestheradioactiveiodineuptaketest. D. "Thistestdetermineswhetheryourthyroidglandisoveractive,appropriatelyactive,orunderactive." Rationale:ThisdescribestheTSHtest,whichhelpsdeterminethyroidstatusandhelpsmonitorthe effectiveness and dosage of thyroid hormone replacement therapy. 59. AA nurse is caring for a client who is scheduled for a bone marrow aspiration. The client asks the nurse about the sitestheprovidermightusefortheprocedure.Whichofthefollowinglocationsshouldthenurseidentifyas oneof the sites used for this procedure? A. Femur Rationale:Theproviderwouldnotusethefemurforbonemarrowaspiration. B. Humerus Rationale:Theproviderwouldnotusethehumerusforbonemarrowaspiration. C. Sternum Rationale:Providersmostoftenextractbonemarrowfromtheiliaccrestofadults,buttheysometimesuse the sternum. D. Ribs Rationale:Theproviderwouldnotusetheribsforbonemarrowaspiration. 60. AAnurseiscaringforaclientwhois8hrpostoperativefollowingasubtotalthyroidectomy.Inwhichofthe following positions should the nurse keep the client? A. HighFowler'swithneckextended Rationale:Neckextensioncouldplaceexcessivetensionontheoperativeareaandthesutures. B. HighFowler'swithneckinaneutralposition. Rationale:HighFowler'sdoesnotsupporttheheadandneckareawellenoughandcouldplaceexcess Page28 pressureontheoperativearea. C. Semi-Fowler'swithneckextended Rationale:Neckextensioncouldplaceexcessivetensionontheoperativeareaandthesutures. D. Semi-Fowler'swithneckinaneutralposition Rationale: Semi-Fowler's is the most comfortable position for a client who has had thyroid surgery. Neck flexioncouldcompromisetheairway,andneckextensioncouldplaceexcessivetensiononthe operative area and the sutures. A neutral position is essential. 61. Anurseiscaringforaclient1hrfollowingasubtotalthyroidectomy.Inwhichofthefollowing positionsshouldthe nurse place the client? A. Semi-Fowler’s Rationale:Positioningtheclientinsemi-Fowler’s,withtheheadsupportedwithapillow,istheappropriate position to decrease pressure on the suture line and prevent edema formation, which could cause respiratory distress. B. Dorsalrecumbent Rationale:Positioningtheclientindorsalrecumbentpositionwouldincreaseedemaformationandmay compromise airway exchange by not having the head of the bed elevated high enough. C. Supine Rationale:Positioningtheclientinsupinepositionwouldincreaseedemaformationandmaycompromise airway exchange by not having the head of the bed elevated. D. Sims’ Rationale:PositioningtheclientinSims’positionwouldincreaseedemaformationandmaycompromise airway exchange by not having the head of the bed elevated. 62. AAnurseisplanningcareforaclientwhohasleukemiaandaplateletcountof130,000/mm3.Whichofthe following interventions should the nurse include in the plan of care? A. ChecktheIVsiteforbleedingevery8hr. Rationale:Thenurseshouldchecktheclient'sIVsiteforbleedingevery4 hr. B. LimitIMinjections. Rationale:ThenurseshouldplantolimitIMinjectionsorvenipuncturestopreventharm totheclient.If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward. C. Obtainarectaltemperatureevery8 hr. Rationale:Thenurseshouldavoidprocedureswhichcouldtraumatizetherectaltissuesandcause Page29 bleeding. D. Checktheclientforproteinuria. Rationale:Thenurseshouldchecktheclient'surineandstoolforblood. 63. Anurseisreviewingtheprovider'shistoryandphysicalformforaclientwhohas advancedmultiplemyeloma. Which of the following findings should the nurse expect? A. Ecchymoses Rationale: A client who has multiple myeloma has an overgrowth of plasma cells in the bone marrow, whichleadstoareductioninothertypesofbloodcells.Astheplateletsareaffected,theclient is prone to bleeding and bruising. B. Hypocalcemia Rationale:Thenurseshouldexpecttheclienttohavehypercalcemia. C. Hypotension Rationale:Thenurseshouldexpecttheclienttohavehypertension. D. Polycythemia Rationale:Thenurseshouldexpecttheclienttohaveanemia. 64. AAnurseisperforminganintegumentaryassessmentforaclient.Whichofthefollowingfindingsshouldthe nurse identify as possible squamous cell carcinoma? A. Painless,raisedpurplenodulesonthehardpalate Rationale:Thenurseshouldidentifypainless,raisedpurplenodulesaspossibleKaposi'ssarcoma. B. Afirm nodulewithahardcrust Rationale: Squamous cell carcinoma appears as a firm nodule, which can either have a crust or a depressedareainthecenter.Themarginsareindurated,andthelesionisfixedtothedeeper tissue of the area. C. Asmallmaculewithayellow-brownscale Rationale:Thenurseshouldidentifyasmallmaculewithayellow-brownscaleasactinickeratosis,which is premalignant, and can progress to squamous cell carcinoma if untreated. D. Yellow-whitepatchesofgrowthonthetongue Rationale:Thenurseshouldidentifyyellow-whitepatchesofgrowthonthetongueaspossibleoral candidiasis. Page30 65. AAnurseiscaringforaclientwhoaskstobescreenedforcervicalcancerbecause arelativehasbeen diagnosed with it. Which of the following tests should the nurse expect the provider to use? A. Aserumprolactin level Rationale:Thenurseshouldrecognizethatprolactinlevelscandetectproblemssuch asbreastdischarge and thyroid problems. B. APapanicolaoutest Rationale: A Papanicolaou test involves sampling cells from the cervix to detect abnormal cells and growth.ThenurseshouldrecommendtheclienthaveanannualPaptestbetweenages21to 29, and every 5 years from ages 30 to 65. C. Avaginalultrasound Rationale:Thenurseshouldrecognizethatavaginalultrasoundisprescribedtodetectendometrial cancer. D. Anendometrialbiopsy Rationale:Thenurseshouldrecognizethatendometrialbiopsyisprescribedtodetectendometrialcancer. 66. AAnurseiscaringforaclientwhoispostoperativefollowingaright-sidedmastectomyandhasadrainconnectedto a portable drainage evacuator. Which of the following actions should the nurse? A. Dangletheoperativelimbfor5mineveryhour. Rationale:Thenurseshouldplantokeeptheoperativelimbelevatedonapillowwhiletheclientisawake, to promote return of lymphatic fluid and prevent edema. B. Placetheheadoftheclient’sbedata15°angle. Rationale:Thenurseshouldelevatetheheadoftheclient’sbedatleast30°topromotebreathing. C. Keepthewounddrainevacuatorfullyexpandedatalltimes. Rationale:Thenurseshouldplantocollapsethedrainevacuatorsandsealittocreateconstant,low pressure suctioning, which will pull drainage from the wound. D. Takebloodpressuresontheclient'snon-affected arm. Rationale: Thenurseshouldplantoonlytakebloodpressures,giveinjections,orperformvenipunctureon theclient'snon-affectedarm toavoidcompromisingcirculation.Thenurseshouldinstruct other staff to follow these precautions as well. 67. AAnursesuspectsanaphylaxiswhencaringforaclientfollowingtheinitialadministrationofanoralantibiotic. Which of the following should be the nurse's priority intervention? Page31 A. InsertanIVline. Rationale:ThenurseshouldinsertanIVlinetoprovidefluidsandmedications.However,itisnotthe priority action when following the nursing process approach to client care. B. Counttherespiratoryrate. Rationale:Checkingtheclient’srespiratorystatusisthepriorityactionwhenfollowingthenursingprocess approachtoclientcare. C. Administeroxygen. Rationale:Thenurseshouldadministeroxygentotheclientusingahigh-flow,non-rebreathermaskto prevent hypoxia. However, it is not the priority action when following the nursing process approach to client care. D. Prepareequipmentforintubation. Rationale:Preparingequipmentforintubationensurestheclientwillmaintainanopenairwayintheevent of respiratory failure. However, it is not the priority action when following the nursing process approach to client care. 68. Anurseiscaringforaclientwhohasright-sidedacoust