Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
1. A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should the nurse make?
iviv iviv iviv iviv
A. "Uric acid levels drop and calcium forms precipitate."
iviv iviv iviv iviv iviv iviv iviv
Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "Tophi form in the kidneys and they impair the excretion of uric acid."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
not part of the primary disease process. iviv iviv iviv iviv iviv iviv iviv
C. "The intra-articular deposition of urate crystals causes inflammation."
iviv iviv iviv iviv iviv iviv iviv
Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
cause inflammation and pain. iviv iviv iviv iviv
D. "Articular cartilage thins, leading to splitting and fragmentation."
iviv iviv iviv iviv iviv iviv iviv
Rationale: Gout does not thin and fragment cartilage. iviv iviv iviv iviv iviv iviv iviv
2. A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should the nurse include in the teaching?
iviv iviv iviv iviv iviv iviv iviv
A. Use Echinacea to manage joint pain.
iviv iviv iviv iviv iviv
Rationale: The nurse may include the use of complementary and alternative therapies in the teaching.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
However, Echinacea is used for the treatment of the common cold, not osteoarthritis. iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Alternative therapies that are used for osteoarthritis include glucosamine, chondroitin, and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
topical capsaicin. iviv iviv
B. Apply ice to the joint before exercising.
iviv iviv iviv iviv iviv iviv
Rationale: The nurse should recommend that the clients begin exercising immediately
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
following the application of heat. This reduces pain and improves mobility,
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
allowing for increased range-of-motion during exercises. Cold application may
iviv iviv iviv iviv iviv iviv iviv iviv iviv
be applied following exercise to decrease discomfort and inflammation.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Maintain a recommended body weight. iviv iviv iviv iviv
Rationale: Obesity is a risk factor for the development of osteoarthritis. Maintenance of an ideal
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
weight is one way a client can prevent added wear and tear on joints and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
promote overall joint health. iviv iviv iviv iviv
D. Reduce the amount of purine in the diet.
iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should recognize that limiting purine in the diet, which is often found in
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
organ meats, is recommended for clients who have gout.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
3. A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
is nothing more to do, as the
iviv iviv iviv iviv iviv iviv iviv
Page iviv1
,Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
damage is done. Which of the following is the correct nursing response?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
your previous level of activity safely."
iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse uses the therapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
presenting reality by indicating her perception of the situation for the client.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
giving reassurance, thus discouraging the client from further communication.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. "Exercise is good for you and good for your heart." iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication techniques of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
disagreeing and giving advice. iviv iviv iviv iviv
D. "Your doctor is the expert here, and I’m sure he would only recommend what is best for you."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
defending. iviv
4. A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should identify which of the following medications as the cause of the client’s low potassium level?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. Furosemide
Rationale: Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and chloride and results in diuresis, which decreases potassium through excretion
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
in the distal nephrons. iviv iviv iviv iviv
Hypokalemia is an adverse effect of furosemide. iviv iviv iviv iviv iviv iviv
B. Nitroglycerin
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of nitroglycerin. Nitroglycerin is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
a vasodilator medication to treat angina. iviv iviv iviv iviv iviv iviv
C. Metoprolol
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of metoprolol.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Metoprolol is a beta-blocker that slows the heart rate and improves
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
contractility of the heart muscle. iviv iviv iviv iviv iviv
D. Spironolactone
Rationale: Spironolactone is a potassium-sparing diuretic medication; therefore, hyperkalemia is an
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
adverse effect of this medication. iviv iviv iviv iviv iviv
5. A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF)
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
neurovascular status of the client's affected extremity? (Select all that apply.)
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Page iviv2
,Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
A. Color
B. Temperature
C. Ecchymosis
D. Skin integrity
iviv
E. Sensation
Rationale: Color is correct. Clients who have sustained trauma to an extremity, such as a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
fracture, are at increased risk for neurovascular compromise. The nurse should
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
check the color of the client's affected extremity as part of this assessment. The
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nurse should identify pallor or cyanosis of the extremity as an indication of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
peripheral neurovascular dysfunction and should notify the provider.Temperature is
iviv iviv iviv iviv iviv iviv iviv iviv iviv
correct. Clients who have sustained trauma to an extremity, such as a fracture, are
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
at increased risk for neurovascular compromise. The nurse should monitor the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
temperature of the extremity as a part of this assessment and identify skin that is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
cool or cold to the touch as having decreased perfusion to the tissues of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
extremity, which is an indication of peripheral neurovascular dysfunction. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should report skin that is cool to the touch to the provider.Ecchymosis is incorrect.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Ecchymosis, or bruising, is an expected finding with leg injuries and is not a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
component of a neurovascular check.Skin integrity is incorrect. While the nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should assess the incision of a client who is postoperative following an open
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
reduction and internal fixation of the femur, it is not a component of a
iviv i v i v iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
neurovascular check.Sensation is correct. Clients who have sustained trauma to an
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
extremity, such as a fracture, are at increased risk for neurovascular compromise.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
The nurse should assess the client's extremity for numbness or tingling. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should recognize diminished pain or paresthesia as an indication of damage to the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nerves or peripheral neurovascular dysfunction and should report it to the provider.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
6. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
following manifestations as a complication and contact the provider immediately?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. Serosanguineous drainage from the puncture site iviv iviv iviv iviv iviv
Rationale: A small amount of serosanguineous drainage at the puncture site is expected after a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
thoracentesis. iviv
B. Discomfort at the puncture siteiviv iviv iviv iviv
Rationale: Mild discomfort at the puncture site is expected after a thoracentesis.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Increased heart rate iviv iviv
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
mediastinal content shift after the aspiration of a large amount of fluid from the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
client's pleural space. iviv iviv iviv
Therefore, the client may experience an increase in heart and respiratory rate,iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
along with coughing with blood-tinged frothy sputum, and tightness in the chest.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
These findings require notification of the provider immediately.
iviv iviv iviv iviv iviv iviv iviv iviv
D. Decreased temperature iviv
Rationale: Infection is possible after any invasive procedure; however, it takes time to develop
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and increases the body temperature.
iviv iviv iviv iviv iviv
Page iviv3
, Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
7. A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and hemoptysis. Which of the following tests should the nurse realize is the most reliable to
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
confirm the diagnosis of active pulmonary TB?
iviv iviv iviv iviv iviv iviv iviv
A. Chest x-ray iviv
Rationale: A chest x-ray may be helpful for detecting old or new lesions that are large enough
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
to be visualized. However, the client who has an HIV infection may have a normal x-
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
ray or show infiltrates which would be expected in the client who has pneumonia.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. Sputum culture for acid-fast bacillus iviv iviv iviv iviv
Rationale: Although the Mantoux (skin test) and the chest x-ray may be useful screening tools
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions,
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
or tissues is the only method that can actually confirm the diagnosis.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Sputum smear iviv
Rationale: A sputum smear is able to detect the presence of mycobacterium, but it does not
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
distinguish between mycobacterium tuberculosis and other strains of mycobacterium.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
D. Mantoux test iviv
Rationale: The Mantoux skin test is an effective screening tool, but it is unable to distinguish
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
between an active case of TB and a client who has been, at some time in the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
past, exposed to TB. The results are also variable, depending upon the skill of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nurse administrating and reading the test.
iviv iviv iviv iviv iviv iviv
8. A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
affecting her knees. Which of the following client statements indicates an understanding of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
teaching?
iviv
A. "I can use either heat or ice to help relieve the discomfort."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should reinforce that different treatment modalities, such as heat or cold
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
therapy, can be tried to determine which one is more effective for the client. Heat
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
application can help with muscle relaxation in the area around the affected joint.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
The application of cold numbs nerve endings and decreases joint inflammation.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should instruct the client that the primary medication of choice for the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
treatment of osteoarthritis is acetaminophen. NSAIDS, such as celecoxib and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
ibuprofen, might be tried if acetaminophen does not control discomfort.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. "I should limit physical activity to prevent further injury."
iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should encourage the client to include aerobic exercise and lower extremity
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
strength training into her daily regimen. These activities have been shown to slow
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
the progression of osteoarthritis and relieve the manifestations of the disorder.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
D. "I will elevate my legs by placing two pillows under my knees when I go to bed."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale:
Page iviv4
Medical Surgical,
iviv iviv
A+
iviv
1. A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should the nurse make?
iviv iviv iviv iviv
A. "Uric acid levels drop and calcium forms precipitate."
iviv iviv iviv iviv iviv iviv iviv
Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "Tophi form in the kidneys and they impair the excretion of uric acid."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
not part of the primary disease process. iviv iviv iviv iviv iviv iviv iviv
C. "The intra-articular deposition of urate crystals causes inflammation."
iviv iviv iviv iviv iviv iviv iviv
Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
cause inflammation and pain. iviv iviv iviv iviv
D. "Articular cartilage thins, leading to splitting and fragmentation."
iviv iviv iviv iviv iviv iviv iviv
Rationale: Gout does not thin and fragment cartilage. iviv iviv iviv iviv iviv iviv iviv
2. A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should the nurse include in the teaching?
iviv iviv iviv iviv iviv iviv iviv
A. Use Echinacea to manage joint pain.
iviv iviv iviv iviv iviv
Rationale: The nurse may include the use of complementary and alternative therapies in the teaching.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
However, Echinacea is used for the treatment of the common cold, not osteoarthritis. iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Alternative therapies that are used for osteoarthritis include glucosamine, chondroitin, and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
topical capsaicin. iviv iviv
B. Apply ice to the joint before exercising.
iviv iviv iviv iviv iviv iviv
Rationale: The nurse should recommend that the clients begin exercising immediately
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
following the application of heat. This reduces pain and improves mobility,
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
allowing for increased range-of-motion during exercises. Cold application may
iviv iviv iviv iviv iviv iviv iviv iviv iviv
be applied following exercise to decrease discomfort and inflammation.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Maintain a recommended body weight. iviv iviv iviv iviv
Rationale: Obesity is a risk factor for the development of osteoarthritis. Maintenance of an ideal
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
weight is one way a client can prevent added wear and tear on joints and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
promote overall joint health. iviv iviv iviv iviv
D. Reduce the amount of purine in the diet.
iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should recognize that limiting purine in the diet, which is often found in
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
organ meats, is recommended for clients who have gout.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
3. A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
is nothing more to do, as the
iviv iviv iviv iviv iviv iviv iviv
Page iviv1
,Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
damage is done. Which of the following is the correct nursing response?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
your previous level of activity safely."
iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse uses the therapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
presenting reality by indicating her perception of the situation for the client.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
giving reassurance, thus discouraging the client from further communication.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. "Exercise is good for you and good for your heart." iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication techniques of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
disagreeing and giving advice. iviv iviv iviv iviv
D. "Your doctor is the expert here, and I’m sure he would only recommend what is best for you."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
defending. iviv
4. A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should identify which of the following medications as the cause of the client’s low potassium level?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. Furosemide
Rationale: Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and chloride and results in diuresis, which decreases potassium through excretion
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
in the distal nephrons. iviv iviv iviv iviv
Hypokalemia is an adverse effect of furosemide. iviv iviv iviv iviv iviv iviv
B. Nitroglycerin
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of nitroglycerin. Nitroglycerin is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
a vasodilator medication to treat angina. iviv iviv iviv iviv iviv iviv
C. Metoprolol
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of metoprolol.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Metoprolol is a beta-blocker that slows the heart rate and improves
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
contractility of the heart muscle. iviv iviv iviv iviv iviv
D. Spironolactone
Rationale: Spironolactone is a potassium-sparing diuretic medication; therefore, hyperkalemia is an
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
adverse effect of this medication. iviv iviv iviv iviv iviv
5. A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF)
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
neurovascular status of the client's affected extremity? (Select all that apply.)
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Page iviv2
,Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
A. Color
B. Temperature
C. Ecchymosis
D. Skin integrity
iviv
E. Sensation
Rationale: Color is correct. Clients who have sustained trauma to an extremity, such as a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
fracture, are at increased risk for neurovascular compromise. The nurse should
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
check the color of the client's affected extremity as part of this assessment. The
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nurse should identify pallor or cyanosis of the extremity as an indication of
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
peripheral neurovascular dysfunction and should notify the provider.Temperature is
iviv iviv iviv iviv iviv iviv iviv iviv iviv
correct. Clients who have sustained trauma to an extremity, such as a fracture, are
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
at increased risk for neurovascular compromise. The nurse should monitor the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
temperature of the extremity as a part of this assessment and identify skin that is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
cool or cold to the touch as having decreased perfusion to the tissues of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
extremity, which is an indication of peripheral neurovascular dysfunction. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should report skin that is cool to the touch to the provider.Ecchymosis is incorrect.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Ecchymosis, or bruising, is an expected finding with leg injuries and is not a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
component of a neurovascular check.Skin integrity is incorrect. While the nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should assess the incision of a client who is postoperative following an open
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
reduction and internal fixation of the femur, it is not a component of a
iviv i v i v iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
neurovascular check.Sensation is correct. Clients who have sustained trauma to an
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
extremity, such as a fracture, are at increased risk for neurovascular compromise.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
The nurse should assess the client's extremity for numbness or tingling. The nurse
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
should recognize diminished pain or paresthesia as an indication of damage to the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nerves or peripheral neurovascular dysfunction and should report it to the provider.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
6. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
following manifestations as a complication and contact the provider immediately?
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
A. Serosanguineous drainage from the puncture site iviv iviv iviv iviv iviv
Rationale: A small amount of serosanguineous drainage at the puncture site is expected after a
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
thoracentesis. iviv
B. Discomfort at the puncture siteiviv iviv iviv iviv
Rationale: Mild discomfort at the puncture site is expected after a thoracentesis.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Increased heart rate iviv iviv
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
mediastinal content shift after the aspiration of a large amount of fluid from the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
client's pleural space. iviv iviv iviv
Therefore, the client may experience an increase in heart and respiratory rate,iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
along with coughing with blood-tinged frothy sputum, and tightness in the chest.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
These findings require notification of the provider immediately.
iviv iviv iviv iviv iviv iviv iviv iviv
D. Decreased temperature iviv
Rationale: Infection is possible after any invasive procedure; however, it takes time to develop
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and increases the body temperature.
iviv iviv iviv iviv iviv
Page iviv3
, Detailed Answer Key iviv iviv
Medical Surgical,
iviv iviv
A+
iviv
7. A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
and hemoptysis. Which of the following tests should the nurse realize is the most reliable to
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
confirm the diagnosis of active pulmonary TB?
iviv iviv iviv iviv iviv iviv iviv
A. Chest x-ray iviv
Rationale: A chest x-ray may be helpful for detecting old or new lesions that are large enough
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
to be visualized. However, the client who has an HIV infection may have a normal x-
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
ray or show infiltrates which would be expected in the client who has pneumonia.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. Sputum culture for acid-fast bacillus iviv iviv iviv iviv
Rationale: Although the Mantoux (skin test) and the chest x-ray may be useful screening tools
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions,
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
or tissues is the only method that can actually confirm the diagnosis.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. Sputum smear iviv
Rationale: A sputum smear is able to detect the presence of mycobacterium, but it does not
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
distinguish between mycobacterium tuberculosis and other strains of mycobacterium.
iviv iviv iviv iviv iviv iviv iviv iviv iviv
D. Mantoux test iviv
Rationale: The Mantoux skin test is an effective screening tool, but it is unable to distinguish
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
between an active case of TB and a client who has been, at some time in the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
past, exposed to TB. The results are also variable, depending upon the skill of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
nurse administrating and reading the test.
iviv iviv iviv iviv iviv iviv
8. A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
affecting her knees. Which of the following client statements indicates an understanding of the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
teaching?
iviv
A. "I can use either heat or ice to help relieve the discomfort."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should reinforce that different treatment modalities, such as heat or cold
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
therapy, can be tried to determine which one is more effective for the client. Heat
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
application can help with muscle relaxation in the area around the affected joint.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
The application of cold numbs nerve endings and decreases joint inflammation.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should instruct the client that the primary medication of choice for the
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
treatment of osteoarthritis is acetaminophen. NSAIDS, such as celecoxib and
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
ibuprofen, might be tried if acetaminophen does not control discomfort.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
C. "I should limit physical activity to prevent further injury."
iviv iviv iviv iviv iviv iviv iviv iviv
Rationale: The nurse should encourage the client to include aerobic exercise and lower extremity
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
strength training into her daily regimen. These activities have been shown to slow
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
the progression of osteoarthritis and relieve the manifestations of the disorder.
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
D. "I will elevate my legs by placing two pillows under my knees when I go to bed."
iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv iviv
Rationale:
Page iviv4
