CACI EXAM WITH VERIFIED 200 +
QUESTIONS AND ANSWERS|| GUARANTEED
PASS|| ALREADY GRADED A+ || LATEST
VERSION!!!
A client is admitted to the Emergency Department with a tension
pneumothorax. Which assessment should the nurse expect to identify?
A) An absence of lung sounds on the affected side.
B) An inability to auscultate tracheal breath sounds.
C) A deviation of the trachea toward the side opposite the pneumothorax.
D) A shift of the point of maximal impulse to the left, with bounding pulses -
ANSWER-Correct Answer(s): C Tension pneumothorax is caused by rapid
accumulation of air in the pleural space, causing severely high intrapleural
pressure. This results in collapse of the lung, and the mediastinum shifts toward
the unaffected side, which is subsequently compressed (C). (A, B, and D) are
not demonstrated with a tension pneumothorax.
A middle-aged male client asks the nurse what findings from his digital rectal
examination (DRE) prompted the healthcare provider to prescribe a repeat
serum prostatic surface antigen (PSA) level. What information should the nurse
provide?
A) A uniformly enlarged prostate is benign prostatic hypertrophy that occurs
with aging.
B) The spongy or elastic texture of the prostate is normal and requires no further
testing.
C) An infection is usually present when the prostate indents when a finger is
pressed on it.
D) Stony, irregular nodules palpated on the prostate should be further evaluated.
- ANSWER-Correct Answer(s): D PSA levels are prescribed to screen for
prostatic cancer which is often detected by DRE and manifested as small, hard,
,or stony, irregularly-shaped nodules on the surface of the prostate (D). Although
PSA levels are prescribed for routine screening, the findings suggestive of BPH
(A), normal texture (B) or infection (C) do not suggest cancer of the prostate,
which requires further evaluation.
What is the primary nursing diagnosis for a client with asymptomatic primary
syphilis?
A) Acute pain.
B) Risk for injury.
C) Sexual dysfunction.
D) Deficient knowledge. - ANSWER-Correct Answer(s): D An asymptomatic
client with primary syphilis is most likely unaware of this disease, so to prevent
transmission to others and recurrence in the client, the priority nursing diagnosis
is deficient knowledge (D). Asymptomatic primary syphilis is not painful, so
(A) is not applicable at this time. Although the client is at risk for injury (B) and
sexual dysfunction (C) related to complications, teaching the client about
transmission and treatment is instrumental in preventing the progression to
systemic secondary or tertiary syphilis.
A client who has just tested positive for human immunodeficiency virus (HIV)
does not appear to hear what the nurse is saying during post-test counseling.
Which information should the nurse offer to facilitate the client's adjustment to
HIV infection?
A) Inform the client how to protect sexual and needlesharing partners.
B) Teach the client about the medications that are available for treatment.
C) Identify the need to test others who have had risky contact with the client.
D) Discuss retesting to verify the results, which will ensure continuing contact. -
ANSWER-D) Discuss retesting to verify the results, which will ensure
continuing contact. Encouraging retesting (D) supports hope and gives the client
time to cope with the diagnosis. Although post-test counseling should include
education about (A, B, and C), retesting encourages the client to maintain
medical follow-up and management.
,The nurse hears short, high-pitched sounds just before the end of inspiration in
the right and left lower lobes when auscultating a client's lungs. How should this
finding be recorded?
A) Inspiratory wheezes in both lungs.
B) Crackles in the right and left lower lobes.
C) Abnormal lung sounds in the bases of both lungs.
D) Pleural friction rub in the right and left lower lobes. - ANSWER-B) Crackles
in the right and left lower lobes. Fine crackles (B) are short, high-pitched
sounds heard just before the end of inspiration that are the result of rapid
equalization of pressure when collapsed alveoli or terminal bronchioles
suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or
musical sound caused by rapid vibration of bronchial walls that are first evident
on expiration and may be audible. Although (C) describes an adventitious lung
sound, this documentation is vague. (D) is a creaking or grating sound from
roughened, inflamed surfaces of the pleura rubbing together heard during
inspiration, expiration, and with no change during coughing.
A client asks the nurse about the purpose of beginning chemotherapy (CT)
because the tumor is still very small. Which information supports the
explanation that the nurse should provide?
A) Side effects are less likely if therapy is started early.
B) Collateral circulation increases as the tumor grows.
C) Sensitivity of cancer cells to CT is based on cell cycle rate.
D) The cell count of the tumor reduces by half with each dose. - ANSWER-D)
The cell count of the tumor reduces by half with each dose. Initiating
chemotherapy while the tumor is small provides a better chance of eradicating
all cancer cells because 50% of cancer cells or tumor cells are killed with each
dose. (A, B, and C) vary based on the type of cancer.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What
action should the nurse implement?
, A) Encourage fluids to 3000 ml/day.
B) Check stools for occult blood.
C) Provide oral hygiene every 2 hours.
D) Check for fever every 4 hours. - ANSWER-B) Check stools for occult blood.
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a
common side effect of chemotherapy. A client with thrombocytopenia should
be assessed frequently for occult bleeding in the emesis, sputum, feces (B),
urine, nasogastric secretions, or wounds. (A) does not minimize the risk for
bleeding associated with thrombocytopenia. (C) may cause increased bleeding
in a client with thromobcytopenia. (D) assesses for infection, not risk for
bleeding.
The nurse is caring for a client with end stage liver disease who is being
assessed for the presence of asterixis. To assess the client for asterixis, what
position should the nurse ask the client to demonstrate?
A) Extend the left arm laterally with the left palm upward.
B) Extend the arm, dorsiflex the wrist, and extend the fingers.
C) Extend the arms and hold this position for 30 seconds.
D) Extend arms with both legs adducted to shoulder width. - ANSWER-B)
Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping
tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and
dorsiflexing the wrist causing rapid, nonrhythmic extension and flexion of the
wrist while attempting to hold position (B). (A, C, and D) do not illicit asterixis.
During the assessment of a client who is 24 hours posthemicolectomy with a
temporary colostomy, the nurse determines that the client's stoma is dry and
dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. - ANSWER-A) Notify the
surgeon. The stoma should appear reddish pink and moist, which indicates
QUESTIONS AND ANSWERS|| GUARANTEED
PASS|| ALREADY GRADED A+ || LATEST
VERSION!!!
A client is admitted to the Emergency Department with a tension
pneumothorax. Which assessment should the nurse expect to identify?
A) An absence of lung sounds on the affected side.
B) An inability to auscultate tracheal breath sounds.
C) A deviation of the trachea toward the side opposite the pneumothorax.
D) A shift of the point of maximal impulse to the left, with bounding pulses -
ANSWER-Correct Answer(s): C Tension pneumothorax is caused by rapid
accumulation of air in the pleural space, causing severely high intrapleural
pressure. This results in collapse of the lung, and the mediastinum shifts toward
the unaffected side, which is subsequently compressed (C). (A, B, and D) are
not demonstrated with a tension pneumothorax.
A middle-aged male client asks the nurse what findings from his digital rectal
examination (DRE) prompted the healthcare provider to prescribe a repeat
serum prostatic surface antigen (PSA) level. What information should the nurse
provide?
A) A uniformly enlarged prostate is benign prostatic hypertrophy that occurs
with aging.
B) The spongy or elastic texture of the prostate is normal and requires no further
testing.
C) An infection is usually present when the prostate indents when a finger is
pressed on it.
D) Stony, irregular nodules palpated on the prostate should be further evaluated.
- ANSWER-Correct Answer(s): D PSA levels are prescribed to screen for
prostatic cancer which is often detected by DRE and manifested as small, hard,
,or stony, irregularly-shaped nodules on the surface of the prostate (D). Although
PSA levels are prescribed for routine screening, the findings suggestive of BPH
(A), normal texture (B) or infection (C) do not suggest cancer of the prostate,
which requires further evaluation.
What is the primary nursing diagnosis for a client with asymptomatic primary
syphilis?
A) Acute pain.
B) Risk for injury.
C) Sexual dysfunction.
D) Deficient knowledge. - ANSWER-Correct Answer(s): D An asymptomatic
client with primary syphilis is most likely unaware of this disease, so to prevent
transmission to others and recurrence in the client, the priority nursing diagnosis
is deficient knowledge (D). Asymptomatic primary syphilis is not painful, so
(A) is not applicable at this time. Although the client is at risk for injury (B) and
sexual dysfunction (C) related to complications, teaching the client about
transmission and treatment is instrumental in preventing the progression to
systemic secondary or tertiary syphilis.
A client who has just tested positive for human immunodeficiency virus (HIV)
does not appear to hear what the nurse is saying during post-test counseling.
Which information should the nurse offer to facilitate the client's adjustment to
HIV infection?
A) Inform the client how to protect sexual and needlesharing partners.
B) Teach the client about the medications that are available for treatment.
C) Identify the need to test others who have had risky contact with the client.
D) Discuss retesting to verify the results, which will ensure continuing contact. -
ANSWER-D) Discuss retesting to verify the results, which will ensure
continuing contact. Encouraging retesting (D) supports hope and gives the client
time to cope with the diagnosis. Although post-test counseling should include
education about (A, B, and C), retesting encourages the client to maintain
medical follow-up and management.
,The nurse hears short, high-pitched sounds just before the end of inspiration in
the right and left lower lobes when auscultating a client's lungs. How should this
finding be recorded?
A) Inspiratory wheezes in both lungs.
B) Crackles in the right and left lower lobes.
C) Abnormal lung sounds in the bases of both lungs.
D) Pleural friction rub in the right and left lower lobes. - ANSWER-B) Crackles
in the right and left lower lobes. Fine crackles (B) are short, high-pitched
sounds heard just before the end of inspiration that are the result of rapid
equalization of pressure when collapsed alveoli or terminal bronchioles
suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or
musical sound caused by rapid vibration of bronchial walls that are first evident
on expiration and may be audible. Although (C) describes an adventitious lung
sound, this documentation is vague. (D) is a creaking or grating sound from
roughened, inflamed surfaces of the pleura rubbing together heard during
inspiration, expiration, and with no change during coughing.
A client asks the nurse about the purpose of beginning chemotherapy (CT)
because the tumor is still very small. Which information supports the
explanation that the nurse should provide?
A) Side effects are less likely if therapy is started early.
B) Collateral circulation increases as the tumor grows.
C) Sensitivity of cancer cells to CT is based on cell cycle rate.
D) The cell count of the tumor reduces by half with each dose. - ANSWER-D)
The cell count of the tumor reduces by half with each dose. Initiating
chemotherapy while the tumor is small provides a better chance of eradicating
all cancer cells because 50% of cancer cells or tumor cells are killed with each
dose. (A, B, and C) vary based on the type of cancer.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What
action should the nurse implement?
, A) Encourage fluids to 3000 ml/day.
B) Check stools for occult blood.
C) Provide oral hygiene every 2 hours.
D) Check for fever every 4 hours. - ANSWER-B) Check stools for occult blood.
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a
common side effect of chemotherapy. A client with thrombocytopenia should
be assessed frequently for occult bleeding in the emesis, sputum, feces (B),
urine, nasogastric secretions, or wounds. (A) does not minimize the risk for
bleeding associated with thrombocytopenia. (C) may cause increased bleeding
in a client with thromobcytopenia. (D) assesses for infection, not risk for
bleeding.
The nurse is caring for a client with end stage liver disease who is being
assessed for the presence of asterixis. To assess the client for asterixis, what
position should the nurse ask the client to demonstrate?
A) Extend the left arm laterally with the left palm upward.
B) Extend the arm, dorsiflex the wrist, and extend the fingers.
C) Extend the arms and hold this position for 30 seconds.
D) Extend arms with both legs adducted to shoulder width. - ANSWER-B)
Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping
tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and
dorsiflexing the wrist causing rapid, nonrhythmic extension and flexion of the
wrist while attempting to hold position (B). (A, C, and D) do not illicit asterixis.
During the assessment of a client who is 24 hours posthemicolectomy with a
temporary colostomy, the nurse determines that the client's stoma is dry and
dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. - ANSWER-A) Notify the
surgeon. The stoma should appear reddish pink and moist, which indicates
