A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
<p> <div> <font> <span> <b>A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in
getting pregnant and wants to know if other factors could be contributing to their difficulty. What
information is best for the nurse to provide? (Select all that apply.)</b> </span> </font> </div> </p>
Marijuana cigarettes do not affect sperm count.
Alcohol consumption can cause erectile dysfunction.
Low testosterone levels affect sperm production.
Cessation of smoking improves general health and fertility.
Obesity has no effect on sperm production.
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testerone levels and obesity.
What is the correct procedure for performing an opthalmoscopic examination on a client's right retina?
<p> <b> <b> <b>What is the correct procedure for performing an opthalmoscopic examination on a
client's right retina?<br/> </b> </b> <br/> <br/> </b> </p>
Instruct the client to look at examiner's nose and not move his/her eyes during the exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away
and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against
his/her face and then direct it at the client's pupil.
The nurse is planning care to prevent complication for a client with multiple myeloma. Which
intervention is most important for the nurse to include?
<p> <div> <font> <span> <b>The nurse is planning care to prevent complication for a client with
multiple myeloma. Which intervention is most important for the nurse to include?</b> </span> </font>
</div> </p>
Safety precautions during activity.
Assess for changes in size of lymph nodes.
,Maintain a fluid intake of 3 to 4 L per day.
Administer narcotic analgesic around the clock.
Rationale
Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and
hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to
promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse
osteoporosis, mobilization and weight bearing should be encouraged to promote bone reabsorption of
circulating calcium, which can cause renal complications.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus.
Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?
<p> <div> <font> <span> <b>The nurse is preparing a teaching plan for a client who is newly diagnosed
with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the
client about hypoglycemia?</b> </span> </font> </div> </p>
Sweating, trembling, tachycardia.
Polyuria, polydipsia, polyphagia.
Nausea, vomiting, anorexia.
Fruity breath, tachypnea, chest pain.
Rationale
Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of
epinephrine as a compensatory response to the low blood sugar.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate an increased serum level of which substance?
<p> <div> <font> <span> <b>In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate an increased serum level of which substance?</b> </span>
</font> </div> </p>
Sodium.
Antidiuretic hormone.
Potassium.
Glucose.
Rationale
Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have
profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent
and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by
primary aldosteronism.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and
warmth on the lower left calf. What intervention would be most helpful to this client?
, <p> <div> <font> <span> <b>Two days postoperative, a male client reports aching pain in his left leg. The
nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to
this client?</b> </span> </font> </div> </p>
Apply sequential compression devices (SCDs) bilaterally.
Assess for a positive Homan's sign in each leg.
Pad all bony prominences on the affected leg.
Advise the client to remain in bed with the leg elevated.
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial
care includes bedrest and elevation of the extremity.
Which intervention should the nurse plan to implement when caring for a client who has just undergone
a right above-the-knee amputation?
<p> <div> <font> <span> <b>Which intervention should the nurse plan to implement when caring for a
client who has just undergone a right above-the-knee amputation?</b> </span> </font> </div> </p>
Maintain the residual limb on three pillows at all times.
Place a large tourniquet at the client's bedside.
Apply constant, direct pressure to the residual limb.
Do not allow the client to lie in the prone position.
Rationale
A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding
occurs. The purpose is to have the tourniquet available to applied to the residual limb to control
bleeding if hemorrhaging was to occur. The residual limb should not be placed on a pillow because a
flexion contracture of the hip may result and the client should be encouraged to lie in the prone position
to prevent flexion contracture of the hip.
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client
who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the
last 2 hours. What priority nursing action should be implemented?
<p> <div> <font> <span> <b>After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated
urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?</b>
</span> </font> </div> </p>
Report the findings to the surgeon.
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes.
Rationale
, An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour).
Dark, concentrated, and low volume of urine output should be reported to the surgeon.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is
most important for the nurse to implement?
<p> <div> <font> <span> <b>A client who has heart failure is admitted with a serum potassium level of
2.9 mEq/L. Which action is most important for the nurse to implement?</b> </span> </font> </div>
</p>
Give 20 mEq of potassium chloride.
Initiate continuous cardiac monitoring.
Arrange a consultation with the dietician.
Teach about the side effects of diuretics.
Rationale
Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is
most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or
other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride
should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
<p> <div> <font> <span> <b>In preparing to administer intravenous albumin to a client following
surgery, what is the priority nursing intervention? (Select all that apply.)</b> </span> </font> </div>
</p>
Set the infusion pump to infuse the albumin within four hours.
Compare the client's blood type with the label on the albumin.
Assign a UAP to monitor blood pressure q15 minutes.
Administer through a large gauge catheter.
Monitor hemoglobin and hematocrit levels.
Assess for increased bleeding after administration.
Rationale
Albumin should be infused within four hours because it does not contain any preservatives. Any fluid
remaining after four hours should be discarded. Albumin administration does not require blood typing.
Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter
allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and
hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding
because of the increased blood volume and blood pressure.
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
<p> <div> <font> <span> <b>How should the nurse position the electrodes for modified chest lead one
(MCL I) telemetry monitoring?</b> </span> </font> </div> </p>
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
<p> <div> <font> <span> <b>A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in
getting pregnant and wants to know if other factors could be contributing to their difficulty. What
information is best for the nurse to provide? (Select all that apply.)</b> </span> </font> </div> </p>
Marijuana cigarettes do not affect sperm count.
Alcohol consumption can cause erectile dysfunction.
Low testosterone levels affect sperm production.
Cessation of smoking improves general health and fertility.
Obesity has no effect on sperm production.
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testerone levels and obesity.
What is the correct procedure for performing an opthalmoscopic examination on a client's right retina?
<p> <b> <b> <b>What is the correct procedure for performing an opthalmoscopic examination on a
client's right retina?<br/> </b> </b> <br/> <br/> </b> </p>
Instruct the client to look at examiner's nose and not move his/her eyes during the exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away
and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against
his/her face and then direct it at the client's pupil.
The nurse is planning care to prevent complication for a client with multiple myeloma. Which
intervention is most important for the nurse to include?
<p> <div> <font> <span> <b>The nurse is planning care to prevent complication for a client with
multiple myeloma. Which intervention is most important for the nurse to include?</b> </span> </font>
</div> </p>
Safety precautions during activity.
Assess for changes in size of lymph nodes.
,Maintain a fluid intake of 3 to 4 L per day.
Administer narcotic analgesic around the clock.
Rationale
Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and
hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to
promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse
osteoporosis, mobilization and weight bearing should be encouraged to promote bone reabsorption of
circulating calcium, which can cause renal complications.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus.
Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?
<p> <div> <font> <span> <b>The nurse is preparing a teaching plan for a client who is newly diagnosed
with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the
client about hypoglycemia?</b> </span> </font> </div> </p>
Sweating, trembling, tachycardia.
Polyuria, polydipsia, polyphagia.
Nausea, vomiting, anorexia.
Fruity breath, tachypnea, chest pain.
Rationale
Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of
epinephrine as a compensatory response to the low blood sugar.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate an increased serum level of which substance?
<p> <div> <font> <span> <b>In assessing a client diagnosed with primary hyperaldosteronism, the nurse
expects the laboratory test results to indicate an increased serum level of which substance?</b> </span>
</font> </div> </p>
Sodium.
Antidiuretic hormone.
Potassium.
Glucose.
Rationale
Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have
profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent
and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by
primary aldosteronism.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and
warmth on the lower left calf. What intervention would be most helpful to this client?
, <p> <div> <font> <span> <b>Two days postoperative, a male client reports aching pain in his left leg. The
nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to
this client?</b> </span> </font> </div> </p>
Apply sequential compression devices (SCDs) bilaterally.
Assess for a positive Homan's sign in each leg.
Pad all bony prominences on the affected leg.
Advise the client to remain in bed with the leg elevated.
Rationale
The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial
care includes bedrest and elevation of the extremity.
Which intervention should the nurse plan to implement when caring for a client who has just undergone
a right above-the-knee amputation?
<p> <div> <font> <span> <b>Which intervention should the nurse plan to implement when caring for a
client who has just undergone a right above-the-knee amputation?</b> </span> </font> </div> </p>
Maintain the residual limb on three pillows at all times.
Place a large tourniquet at the client's bedside.
Apply constant, direct pressure to the residual limb.
Do not allow the client to lie in the prone position.
Rationale
A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding
occurs. The purpose is to have the tourniquet available to applied to the residual limb to control
bleeding if hemorrhaging was to occur. The residual limb should not be placed on a pillow because a
flexion contracture of the hip may result and the client should be encouraged to lie in the prone position
to prevent flexion contracture of the hip.
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client
who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the
last 2 hours. What priority nursing action should be implemented?
<p> <div> <font> <span> <b>After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated
urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?</b>
</span> </font> </div> </p>
Report the findings to the surgeon.
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes.
Rationale
, An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour).
Dark, concentrated, and low volume of urine output should be reported to the surgeon.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is
most important for the nurse to implement?
<p> <div> <font> <span> <b>A client who has heart failure is admitted with a serum potassium level of
2.9 mEq/L. Which action is most important for the nurse to implement?</b> </span> </font> </div>
</p>
Give 20 mEq of potassium chloride.
Initiate continuous cardiac monitoring.
Arrange a consultation with the dietician.
Teach about the side effects of diuretics.
Rationale
Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is
most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or
other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride
should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
<p> <div> <font> <span> <b>In preparing to administer intravenous albumin to a client following
surgery, what is the priority nursing intervention? (Select all that apply.)</b> </span> </font> </div>
</p>
Set the infusion pump to infuse the albumin within four hours.
Compare the client's blood type with the label on the albumin.
Assign a UAP to monitor blood pressure q15 minutes.
Administer through a large gauge catheter.
Monitor hemoglobin and hematocrit levels.
Assess for increased bleeding after administration.
Rationale
Albumin should be infused within four hours because it does not contain any preservatives. Any fluid
remaining after four hours should be discarded. Albumin administration does not require blood typing.
Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter
allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and
hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding
because of the increased blood volume and blood pressure.
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
<p> <div> <font> <span> <b>How should the nurse position the electrodes for modified chest lead one
(MCL I) telemetry monitoring?</b> </span> </font> </div> </p>
