1.
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's
history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect
this client to exhibit?
A) Elevated LDH.
Feedback: INCORRECT
B) Elevated serum amylase.
Feedback: INCORRECT
C) Elevated CK-MB.
Feedback: CORRECT
D) Elevated hematocrit.
Feedback: INCORRECT
Feedback: INCORRECT
The cardiac isoenzyme CK-MB (C) is the most sensitive and most reliable indicator of myocardial damage
of all the cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac
enzyme that peaks around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be
expected in a client with a fluid volume deficit, which is not a typical finding in MI.
Points Earned: 0.0/1.0
Correct Answer(s): C
2.
A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial
HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive
relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse
recommend the client return for repeat blood testing?
A) 6 to 18 months.
Feedback: INCORRECT
B) 1 to 12 months.
Feedback: INCORRECT
C)
D)
,Feedback: INCORRECT
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV
positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to repeat the serum
screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests
positive. (B and C) may provide inaccurate results because the time frame maybe too early to reevaluate the
client.
Points Earned: 0.0/1.0
Correct Answer(s): D
3.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure
without specific instruction from the healthcare provider if the client's
A) serum digoxin level is 1.5.
Feedback: INCORRECT
B)
C) serum potassium level is 3.
Feedback: CORRECT
D) apical pulse is 68/min.
Feedback: INCORRECT
Feedback: INCORRECT
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the
chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for
digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse
withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
Points Earned: 0.0/1.0
Correct Answer(s): C
4.
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse
anticipates which change in prescription for the client?
A)
B)
C)
, D) The dosage of the diuretic will be increased.
Feedback: INCORRECT
Feedback: INCORRECT
This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss
of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level
(C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.
Points Earned: 0.0/1.0
Correct Answer(s): C
5.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
A)
B) Compare the client's blood type with the label on the albumin.
Feedback: INCORRECT
C) Assign a UAP to monitor blood pressure q15 minutes.
Feedback: INCORRECT
D) Administer through a large gauge catheter.
Feedback: CORRECT
E) Monitor hemoglobin and hematocrit levels.
Feedback: CORRECT
F) Assess for increased bleeding after administration.
Feedback: CORRECT
Feedback: INCORRECT
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not
contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin
administration does not require blood typing (B). Vital signs should be monitored periodically to assess for
fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the
first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be
necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood
volume and blood pressure may cause bleeding (F).
Points Earned: 0.0/4.0
Correct Answer(s): A, D, E, F
, 6.
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
A)
B)
C)
D)
Feedback: INCORRECT
Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and
cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such
as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed
to carefully perform monthly BSE (D) and consider changes in any previous "lumpiness." Fibrocystic
disease does not increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual cycle, and
typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen (B),
which is not indicated. Nipple discharge associated with fibrocystic breasts is often milky or watery-milky
and is an expected finding (C).
Points Earned: 0.0/1.0
Correct Answer(s): D
7.
The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the
nurse to respond to first?
A) Potassium 6.0 mEq.
Feedback: CORRECT
B) Daily urine output of 400 ml.
Feedback: INCORRECT
C) Peripheral neuropathy.
Feedback: INCORRECT
D) Uremic fetor.
Feedback: INCORRECT
Feedback: INCORRECT
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal
arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular
destruction. In CRF, an increase in serum nitrogenous waste products, electrolyte imbalances, and
demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's
history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect
this client to exhibit?
A) Elevated LDH.
Feedback: INCORRECT
B) Elevated serum amylase.
Feedback: INCORRECT
C) Elevated CK-MB.
Feedback: CORRECT
D) Elevated hematocrit.
Feedback: INCORRECT
Feedback: INCORRECT
The cardiac isoenzyme CK-MB (C) is the most sensitive and most reliable indicator of myocardial damage
of all the cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac
enzyme that peaks around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be
expected in a client with a fluid volume deficit, which is not a typical finding in MI.
Points Earned: 0.0/1.0
Correct Answer(s): C
2.
A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial
HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive
relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse
recommend the client return for repeat blood testing?
A) 6 to 18 months.
Feedback: INCORRECT
B) 1 to 12 months.
Feedback: INCORRECT
C)
D)
,Feedback: INCORRECT
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV
positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to repeat the serum
screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests
positive. (B and C) may provide inaccurate results because the time frame maybe too early to reevaluate the
client.
Points Earned: 0.0/1.0
Correct Answer(s): D
3.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure
without specific instruction from the healthcare provider if the client's
A) serum digoxin level is 1.5.
Feedback: INCORRECT
B)
C) serum potassium level is 3.
Feedback: CORRECT
D) apical pulse is 68/min.
Feedback: INCORRECT
Feedback: INCORRECT
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the
chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for
digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse
withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
Points Earned: 0.0/1.0
Correct Answer(s): C
4.
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse
anticipates which change in prescription for the client?
A)
B)
C)
, D) The dosage of the diuretic will be increased.
Feedback: INCORRECT
Feedback: INCORRECT
This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss
of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level
(C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.
Points Earned: 0.0/1.0
Correct Answer(s): C
5.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
A)
B) Compare the client's blood type with the label on the albumin.
Feedback: INCORRECT
C) Assign a UAP to monitor blood pressure q15 minutes.
Feedback: INCORRECT
D) Administer through a large gauge catheter.
Feedback: CORRECT
E) Monitor hemoglobin and hematocrit levels.
Feedback: CORRECT
F) Assess for increased bleeding after administration.
Feedback: CORRECT
Feedback: INCORRECT
(A, D, E, and F) are the correct selections. Albumin should be infused within four hours because it does not
contain any preservatives. Any fluid remaining after four hours should be discarded (A). Albumin
administration does not require blood typing (B). Vital signs should be monitored periodically to assess for
fluid volume overload, but every 15 minutes is not necessary (C). This frequency is often used during the
first hour of a blood transfusion. A large gauge catheter (D) allows for fast infusion rate, which may be
necessary. Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood
volume and blood pressure may cause bleeding (F).
Points Earned: 0.0/4.0
Correct Answer(s): A, D, E, F
, 6.
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
A)
B)
C)
D)
Feedback: INCORRECT
Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and
cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such
as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed
to carefully perform monthly BSE (D) and consider changes in any previous "lumpiness." Fibrocystic
disease does not increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual cycle, and
typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen (B),
which is not indicated. Nipple discharge associated with fibrocystic breasts is often milky or watery-milky
and is an expected finding (C).
Points Earned: 0.0/1.0
Correct Answer(s): D
7.
The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the
nurse to respond to first?
A) Potassium 6.0 mEq.
Feedback: CORRECT
B) Daily urine output of 400 ml.
Feedback: INCORRECT
C) Peripheral neuropathy.
Feedback: INCORRECT
D) Uremic fetor.
Feedback: INCORRECT
Feedback: INCORRECT
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal
arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular
destruction. In CRF, an increase in serum nitrogenous waste products, electrolyte imbalances, and
demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath
