ALL QUESTIONS ASSOCIATED WITH ATI

A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER
SULFADIAZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2
WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING
ADVERSE EFFECTS?

LEUKOPENIA
AN ADVERSE EFFECT OF SILVER SULFA. THE
NURSE SHOULD MONITOR THE CLIENTS ALLERGIC REACTION CAUSING A DECREASE
IN THE CLIENTS WBC COUNT

A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN
ADMITTED FOR TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG
WITHOUT METASTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM
WHICH OF THE FOLLOWING PROCEDURES?

SURGICAL EXCISION
THE TREATMENT OF CHOICE FOR SMALL,
SUPERFICIAL LESIONS. DEEPER LESIONS REQUIRE WIDE LOCAL EXCISION,
FOLLOWED BY SKIN GRAFTING

A NURSE IS CARING FOR A CLIENT WHOSE WOUNDS ARE COVERED WITH A
HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENT'S QUESTIONS ABOUT THE
DRESSING, THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE
FOLLOWING SOURCES?

PIG SKIN
HETEROGRAFTS ARE OBTAINED FROM AN
ANIMAL, USUALLY A PIG

A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS
RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF SKIN CANCER IS THE
MOST SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE ?

MELANOMAS.
MALIGNANT NEOPLASMS WITH ATYPICAL
MELANOCYTES IN BOTH THE EPIDERMIS, THE DERMIS, AND SOMETIMES THE SUBQ
CELLS. IT IS THE MOST LETHAL TYPE OF SKIN CANCER. OFTEN CAUSING
METASTASES IN THE BONE, LIVER, LUNGS, SPLEEN , CNS AND THE LYMPH NODES.

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES
TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDROTHERAPY.
WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES AN
UNDERSTANDING OF THE TEACHING?

I WILL BE ON A SPECIAL SHOWER TABLE"
HYDROTHERAPY IS A SPECIAL SHOWER TABLE
THAT FACILITATES THE EXAMINATION AND DEBRIDEMENT OF THE WOUND.
ADVANTAGES: THE WATER CAN BE KEPT AT A
CONSTANT TEMPERATURE AND THERE IS A LOWER RISK OF WOUND INFECTION.

A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN
AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE
EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT
THE CLIENT HAS A PRESSURE ULCER AT WHAT OF THE FOLLOWING STAGES?

STAGE 2
- PARTIAL THICKNESS SKIN LOSS
- VISIBLE AND SUPERFICIAL
- CAN APPEAR AS A BLISTER, ABRASION,
OR SHALLOW CRATER
- EDEMA PERSISTS AND THE ULCER CAN
BECOME INFECTED.
- MIGHT REPORT PAIN AND DRAINAGE

A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE
RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING
LABORATORY FINDINGS SHOULD THE NURSE EXPECT.

SODIUM 132 MEq/L
SHOULD ANTICIPATE CLIENT TO HAVE A LOW
SODIUM LEVEL BECAUSE SODIUM IS TRAPPED IN INTERSTITIAL SPACE

A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL
PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO. WHICH
OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER?

TEMPERATURE OF 39.1 (102.4)
- ELEVATED TEMP INDICATES INFECTION
- SEPSIS IS CRITICAL FINDING FOLLOWING
A MAJOR BURN

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE
CLIENTS ABOUT MEASURES TO REDUCE THE RISK OF SKIN CANCER. WHICH OF THE
FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE.

AVOID EXPOSURE TO THE MIDDAY SUN
- AVOID CONTACT BETWEEN 1100 AND 1500
BECAUSE SUN RAYS ARE THE STRONGEST DURING THAT TIME

A NURSE IN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW
DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION
FOR WHICH OF THE FOLLOWING MEDICATIONS?

ACYCLOVIR
- ANTIVIRAL MEDICATION
- INHIBITS REPLICATION OF THE VIRUS
THAT CAUSES HERPES ZOSTER

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF AN EDUCATION SESSION
ABOUT MALIGNANT MELANOMA FOR A GROUP OF CLIENTS. THE NURSE SHOULD
INCLUDE THAT WHICH OF THE FOLLOWING CLIENTS HAS AN INCREASED RISK FOR
DEVELOPING MALIGNANT MELANOMA

A CLIENT WHO HAS A LIGHT COMPLEXION
- A LIGHT COMPLEXION HAS LESS PIGMENTATION

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH
OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF A
MALIGNANT MELANOMA

IRREGULARLY SHAPED WITH BLUE TONES
- MALIGNANT MELANOMAS ARE IRREGULARLY
SHAPED AND CAN BE BLUE, RED, OR WHITE IN TONE.
- OFTEN OCCUR ON UPPER BACK AND LOWER LEGS

A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS
POSTOPERATIVE FOLLOWING A SURGICAL EXCISION OF A BASAL CELL CARCINOMA.
WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN
INDICATION OF MALIGNANCY OF A MOLE?

ULCERATION
- BLEEDING , EXUDATION ARE INDICATIONS
OF A MOLES POTENTIAL MALIGNANCY
- INCREASING IN SIZE
- FOLLOW UPS AND PROPER TECHNIQUES FOR
SELF EXAMINATION

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND
AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER
FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE?

SHIFT YOUR WEIGHT IN THE WHEELCHAIR EVERY 15 MINUTES
- THIS RESPONSE ADDRESSES THE SAFETY
ISSUE OF PRESSURE ULCER RISK
- MOST LIKELY TO DEVELOP IF THE CLIENT
DOES NOT SHIFT POSITION FREQUENTLY TO RELIEVE PRESSURE

A NURSE ON A SURGICAL UNIT IS CARING FOR FOUR CLIENTS WHO HAVE
HEALING WOUNDS. WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT
TO HEAL BY PRIMARY INTENTION?

SURGICAL INCISION
A WOUND THAT HEALS BY PRIMARY INTENTION

PRIMARY INTENTION

A CLEAN WOUND THAT IS CLOSED MECHANICALLY WITH WELL APPROXIMATED
EDGES AND MINIMAL SCARRING

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND
HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT
THAT WHICH OF THE FOLLOWING NUTRIENTS PROMOTES WOUND HEALING?

VITAMIN C

A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER
FACE AND HANDS. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT
INDICATES THAT SHE HAS ADAPTED TO HER CHANGED BODY IMAGE?

MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE?

A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE
CLIENT HAS A SMALL BLISTER THAT CONTAIN BLOOD AND THE SKIN OF THE
AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY
AS WHICH OF THE FOLLOWING?

3 DEGREE FROSTBITE
AFFECTED SKIN HAS SMALL BLISTERS
THAT ARE BLOOD FILLED AND THE SKIN DOES NOT BLANCH

A NURSE IN A PROVIDERS OFFICE IS COLLECTING DATA FROM A CLIENT WHO
HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5CM (0.20IN)
IN SIZE, ELEVATED, AND SOLID, WITH VERY DISTINCT BORDERS. THE NURSE
SHOULD DOCUMENT THE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS?

PAPULES
SMALL, SOLID, ELEVATED LESION
WITH DISTINCT BORDERS USALLY SMALLER THAN 10MM IN
DIAMETERS WARTS AND ELEVATED MOLES ARE EXAMPLES

A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A
SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?

IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART
LIMIT THE SPREAD OF THE
VENOM ANY CLOTHING OR JEWELRY SHOULD BE REMOVED BEFORE
SWELLING WORSENS

THE HEALTH CARE PROVIDER HAS ORDERED ORAL GRISEOFULVIN OF TINEA
CAPITIS. THE PATIENT'S MOTHER ASKS THE NURSE WHY AN ORAL MEDICATION IS
USED RATHER THAN A CREAM. WHAT INFORMATION SHOULD BE PROVIDED BY THE NURSE?

TOPICAL CREAMS DO NOT REACH THE ROOT OF THE HAIR TO KILL FUNGUS

THE NURSE IS CARING FOR A PATIENT WITH AN OPEN SKIN LESION. WHAT IS
THE PATIENT GOAL WITH HIGH PRIORITY?

THE PATIENT DOES NOT DEVELOP AN INFECTION OF THE LESION

WHAT ASSESSMENT SHOULD THE NURSE REPORT TO THE HEALTH CARE PROVIDER
IMMEDIATELY FOR AN ADULT PATIENT WITH PARTIAL THICKNESS BURNS OVER 25%
OF HIS BODY?

HOURLY URINARY OUTPUT OF 10 TO 15 ML

A PATIENT HAS A RASH ON HER BACK THAT BEGAN ABOUT 10 DAYS AGO WITH A
RAISED, SCALY BORDER AND A PINK CENTER. NOW SHE HAS A SIMILAR ERUPTION
ON BOTH SIDES OF HER BACK. WHAT CONDITION MIGHT SHE HAVE?

PITYRIASIS ROSEA

A PATIENT COMPLAINS OF A BURMNING PAIN ON HIS LOWER THORACIC AREA. ON
INSPECTION, THE AREA IS FOUND TO BE ERYTHEMATOUS AND EDEMATOUS WITH A
CLUSTER OF VESICLES. WHAT CONDITION IS MOST LIKELY TO BE DIAGNOSED?

HERPES ZOSTER

A PATIENT STATES THAT HE HAS BASAL CELL CARCINOMA AND IS GOING TO
DIE. WHEN PLANNING THE BEST RESPONSE TO MAKE, THE NURSE SHOULD INCLUDE
WHAT KNOWLEDGE?

BASAL CELL CARCINOMA IS RARELY TERMINAL

IT IS IMPORTANT TO TEACH A PATIENT THE WARNING SIGNS OF SKIN CANCER.
WHICH CHARACTERITICS OF A NEVUS IS A WARNING SIGN OF SKIN CANCER?

BORDER IRREGULARITY DELAYED OR PROLONGED LESIONAL
HEALING

A PATIENT HAS AN INHALATION BURN INJURY. WHICH IS A MEDICAL EMERGENCY?

RESPIRATORY STRIDOR

WHAT METHOD OF ASSESSING BURN SIZE APPLIES ONLY TO ADULTS?

RULE OF NINES

THE NURSE JUST FINISHED AN ASSESSMENT FOR A PATIENT WITH SYSTEMIC
LUPUS E. WHAT CLINICAL MANIFESTATION WOULD THE NURSE EXPECT TO FIND?

ORAL ULCERS ERYTHEMATOUS RASH OVER THE NOSE AND
CHEEKS

THE HEALTH CARE PROVIDER HAS SCHEDULED A DEBRIDEMENT FOR A PATIENT
WHO HAS PARTIAL THICKNESS BURNS ON HIS CHEST AND RIGHT UPPER LEG.
WHICH NURSING INTERVENTION IS MOST IMPORTANT?

ADMINISTER AN OPIOIOD ANALGESIC INTRAVENOUSLY BEFORE THE DEBRIDEMENT

A PATIENT IS ADMITTED WITH PARTIAL AND FULL THICKNESS BURNS ON HIS
RIGHT LOWER EXTREMITY. WHAT IS LIKELY TO BE INCLUDED IN THE PLAN OF
CARE INITIALLY?

CLOSED DRESSING CHANGE EVERY 3 HOURS

A PATIENT IS ADMITTED WITH PARTIAL THICKNESS BURNS ON HIS UPPER CHEST
AND FACE. WHAT IS THE MOST IMPORTANT THING FOR THE NURSE TO MONITOR IN
THE PATIENT ON ADMISSION?

RESPIRATORY PROBLEMS

WHAT SHOULD BE INCLUDED IN THE ASSESSMENT OF A PATIENT WITH AN
ELECTRICAL BURN?

CARDIAC IRREGULARITIES

A PATIENT IS ADMITTED WITH HERPES ZOSTER. THE HEALTH CARE PROVIDER
ORDERS AN ANTIVIRUL MEDICATION TO SLOW THE PROGRESSION OF THE VIRUS.
WHICH MEDICATION WITH THE NURSE ADMINISTER?

ACYCLOVIR (ZOVIRAX)

A PATIENT HAS BEEN DIAGNOSED WITH SCABIES. WHAT WILL THE NURSE
ANTICIPATE TO ASSESS WITH THIS PATIENT?

WAVY BROWN LINES ON THE SKIN NOCTURNAL PRITUS (ITCHING
THAT IS MORE SEVERE AT NIGHT

AN ADOLESCENT PATIENT IS SEEN IN THE CLINIC WITH A MILD CASE OF ACNE.
WHAT DOES THE NURSE EXPECT TO ASSESS?

THE PATIENT REPORTS A SENSE OF LOW SELF ESTEEM

A PATIENT WITH THERMAL BURNS OVER 30% OF HIS BODY HAS MAINTAINED A
URINARY OUTPUT OF 250 ML FOR THE PAST 8 HOURS. WHAT CAN THE NURSE
INFER FROM THIS INFORMATION?

STAGE OF HYPOVOLEMIC BURN SHOCK IS RESOLVING

A PATIENT TELLS THE NURSE SHE HAS NOT GONE OUT OF THE HOUSE FOR WEEKS
BECAUSE SHE COULD NOT COVER LESIONS ON HER FACE WITH MAKEUP. WHAT
WOULD BE AN APPROPRIATE PATIENT PROBLEM?


DISTORED BODY IMAGE, RELATED TO CHANGE IN PERSONAL APPEARANCE

WHEN TEACHING A PATIENT TO CARE FOR HERPES ZOSTER LESIONS AT HOME,
WHAT IS THE MOST IMPORTANT INSTRUCTION FOR THE NURSE TO PROVIDE?

WHAT HANDS BEFORE AND AFTER APPLYING MEDICATION

THE NURSE IS REVIEWING THE HISTORY FOR A PATIENT WHO HAS BEEN
ADMITTED WITH CELLUITIS. WHAT CONDITIONS WOULD PREDISPOSE THE PATIENT
TO CELLULITIS?

MALNUTRITION TREATMENT WITH CHEMOTHERAPY
VENUS INSUFFICIENCY OF THE LOWER LEGS DIABETES
MELLITUS

A PARENT TELLS THE DERMATOLOGISTS THAT HER DAUGHTER SEEMS TO BE
LOOSING INTEREST IN SCHOOL/ WHICH MEDICATION COULD HAVE CAUSED THE
PATIENTS CHANGE IN BEHAVIOR

ISOTRETINOIN

AN AFRICAN AMERICAN PATIENT IS SEEN WITH IMPENDING SHOCK AFTER AN
ACCIDENT. HOW WOULD THE NURSE EXPECT THE SKIN TO APPEAR DURING THE
ASSESSMENT OF THE PATIENT?

ASHEN, GRAY, OR DULL

THE NURSE PLANNING THE CARE FOR A PATIENT WHO HAS IMPETIGO EXPECTS TO
ADMINISTER WHAT TOPICAL DRUG TO THE PATIENT ?

RETAPAMULIN

WHEN TEACHING HOME CARE TO A PATIENT WITH RECURRENT GENITAL HERPES
INFECTION. IT IS IMPORTANT TO INCLUDE WHAT INFORMATION?

THE PATIENT WILL NEED TO USE PROTECTION EVEN WHEN NO LESIONS
ARE EVIDENT PRECAUTIONS FOR DELIVERY MUST BE MADE IN THE
EVENT OF BECOMING PREGNANT

A NURSE IN A DEMATOLOGY CLINCIC IS USING THE ABCDE METHOD WHILE
SCREENING SEVERAL OF A CLIENTS SKIN LESIONS FOR SKIN CANCER. WHICH OF
THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER

COLOR VARIATION WITHIN A LESION

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE
CLIENTS ABOUT MEASURES TO REDUCE RISK OF SKIN CANCER. WHAT
INSTRUCTIONS SHOULD THE NURSE INCLUDE ?

AVOID EXPOSURE TO THE MIDDAY SUN

A NURSE IN A PROVIDER'S OFFICE IS COLLECTING DATA FROM A CLIENT WHO
HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5 (0.20 IN)
IN SIZE, ELEVATED, AND SOLID WITH DISTINCT BORDERS. THE NURSE SHOULD
DOCUMENT THESE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS ?

PAPULES

A NURSE IS SCREENING A CLIENT FOR SKIN CANCER. WHEN REINFORCING
TEACHING WITH THE CLIENT ABOUT SKIN CANCER RISK, WHICH OF THE
FOLLOWING RISK FACTORS SHOULD THE NURSE INCLUDE ?

EXCESSIVE EXPOSURE TO ULTRAVIOLET LIGHT

A NURSE IS REINFORCING TEACHING WITH A GROUP OF CLIENTS ABOUT SKIN
CANCER. THE NURSE SHOULD EXPLAIN THAT BASAL CELL CARCINOMA ORIGINATES
FROM WHICH OF THE FOLLOWING TISSUES?

EPIDERMIS

A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER
FACE AND HANDS. WHAT STATEMENT BY THE CLIENT INDICATES THAT SHE HAS
ADAPTED TO HER CHANGED BODY IMAGE?

MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE?

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND
HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT
THAT WHICH OF THE FOLOOWING NUTRIENTS PROMOTES WOUND HEALING

VITAMIN C

A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN
AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE
EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT
THE CLIENT HAS A PRESSURE ULCER AT WHICH OF THE FOLLOWING STAGES?

2

A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER
SULFADIZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2
WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING
ADVERSE EFFECTS

LEUKOPENIA

A NURS EIN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW
DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION
FOR WHICH OF THE FOLLOWING MEDICATIONS

ACYCLOVIR

A NURSE IS CARING FOR A CLIENT WHO HAS A DEEP PARTIAL AND FULL
THICKNESS BURN AND REQUIRES A TOPICAL ANTIMICROBIAL DRUG. THE GOAL OF
THIS MEDICATION THERAPY IS TO REDUCE WHICH OF THE FOLLOWING OUTCOMES

BACTERICAL GROWTH

A NURSE IS CARING FOR A CLIENT WHO WOUNDS ARE COVERED WITH A
HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENTS QUESTIONS ABOUT THE
DRESSING THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE
FOLLOWING SOURCES

PIG SKIN

A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN
ADMITTED FOR THE TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG
WITHOUT MESTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM
WHICH OF THE FOLLOWING PROCEDURES ?

SURGICAL EXCISION

A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE
RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING LAB
FINDINGS SHOULD THE NURSE EXPECT

SODIUM 132 MeQ/l

A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 3 DAYS POST OP
FOLLOWING ABDOMINAL SURGERY. THE CLIENTS INCISION I SLIGHTLY
EDEMATOUS, APPEARS PINK WTH CRUSTING ON THE EDGES AND IS DRAINING
SERISANGUINOUS FLUID. WHICH OF THE FOLLOWING STATEMENTS DESCRIBES THIS INCISION?

THE INCISION IS SHOWING SIGNS OF HEALING WITHOUT COMPLICATIONS

A NURSE IS ASSISTING WITH PLANNING CARE FOR A CLIENT WHO HAS DEEP
PARTIAL THICKNESS AND FULL THICKNESS THERMAL BURNS OVER 40 PERCENT OF
HIS TOTAL BODY SURFACE. THE FOLLOWING INTERVENTIONS SHOULD SHOULD THE
NURSE INCLUDE IN THE PLAN

INITIATE RANGE OF MOTION EXERCISES

A NURSE IS CARING FOR A CLIENT WHO HAS SMOKE INHALATION AND FULL
THICKNESS BURNS COVERING 63 PERCENT OF HER BODY. WHICH OF THE
FOLLOWING NURSING ACTIONS IS THE NURSES PRIORITY ?

MONITOR RESPIRATORY STATUS

A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL
PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO WHICH
OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER

TEMP 39.1 (102.4)

A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A
SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?

IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART

A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS
RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF CANCER IS THE MOST
SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE?

MELANOMAS

A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS POST
OP FOLLOWING SURGICAL EXCISION OF A BASAL CELL CARCINOMA. WHICH OF THE
FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN INDICATION OF
MALIGNANCY OF A MOLE

ULCERATION

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH
OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF
MALIGNANT MELANOMA

IRREGULARLY SHAPED BLUE TONES

A NURSE ON A SURGICAL UNIT IS CARING FOR 4 CLIENTS WHO HAVE WOUND
HEALING WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT TO HEAL
BY PRIMARY INTENTION

SURGICAL INCISION

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES
TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDRO THERAPY.
WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES UNDERSTAND
OF THE TEACHING

I WILL BE ON A SPECIAL SHOWER CHAIR

A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE
CLIENT HAS SMALL BLISTERS THAT CONTAIN BLOOD AND THE SKIN OF THE
AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY
AS WHICH OF THE FOLLOWING

THIRD DEGREE FROSTBITE

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND
AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER
FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE
INCLUDE ?

SHIFT YOUR WEIGHT IN THE WC EVERY 15 MINUTES

A NURSE IN AN URGENT CARE CLINIC IS COLLECTING DATA FROM A CLIENT WHO
HAS EXTENSIVE BURNS, INCLUDING ON HER FACE . WHICH OF THE FOLLOWING
DATA SHOULD THE NURSE COLLECT

RESPIRATORY RATE

A NURSE IS CARING FOR A CLIENT WHO HAS REGULAR OCCUPATIONAL EXPOSURE
TO SUN LIGHT AND PRESENTS TO THE CLINIC FOR EVAL OF SEVERAL SKIN
LESIONS WHICH OF THE FOLLOWING FINDINGS SHOULD ALERT THE NURSE TO THE
FOLLOWING FINDINGS SHOULD ALRET THE NURSE TO THE POSSIBILITY OF
MALIGNANT MELANOMA?

AN IRREGULARLY SHAPED BROWN LESION WITH LIGHT BLUE AREAS ON THE NECK

A COMMUNITY HEALTH NURSE IS TEACHING ABOUT MELANOMA WITH A GROUP OF
CLIENTS. WHICH OF THE FOLLOWING CHARACTERISTICS OF LESIONS ASSOCIATED
WITH MELANOMA SHOULD THE NURSE INCLUDE INT HE TEACHING?

IRREGULAR BORDER

A NURSE IS REINFORCING DISCHARGE TEACHING ABOUT FOOT CARE WITH A
CLIENT WHO HAS DIABETES. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD
THE NURSE INCLUDE IN THE TEACHING ?

TEST WATER TEMP WITH THE WRIST

A NURSE IS ASSESSING A PATIENT'S INDWELLING URINARY CATHETER DRAINAGE
AT THE END OF THE SHIFT AND NOTES THE OUTPUT IS CONSIDERABLY LESS THAN
THE FLUID INTAKE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST?

CHECK THE CATHETER FOR KINKS

A NURSE IS LIKELY TO RECIEVE AN ORDER FOR URINARY CATHETERIZATION OF
A NEWLY ADMITTED PATIENT WHO

IS IN THE ICU FOR GASTROINTESTINAL BLEED

A NURSE IS PREPARING TO INSERT AN INDWELLING URINARY CATHETER FOR A
FEMALE PATIENT. WHEN BEGINNNING THE INSERTION PROCEDURE, THE NURSE
SHOULD INSTRUCT THE PATIENT TO

BEAR DOWN

WHEN PROVIDING PERINEAL CARE FOR A FEMALE PATIENT WHO HAS AN
INDWELLING URINARY CATHETER. WHAT AREA SHOULD THE NURSE CLEAN LAST

THE ANUS

A NURSE IS PLANNING ON OBTAINING A URINARY SPECIMEN FROM A PATIENTS
CLOSED URINARY SYSTEM. IDENTIFY THE SEQUENCE OF STEPS THE NURSE SHOULD TAKE

WIPE THE PORT WITH AN ALCOHOL SWAB INSERT A 10 ML
SYRINGE AND NEEDLE INTO THE PORT WITHDRAW 5 ML OF
URINE TRANSFER THE URINE TO A STERILE SPECIMEN CONTAINER
TRANSPORT THE SPECIMEN TO THE LAB

A NURSE IS APPLYING A CONDOM CAT FOR AN OLDER ADULT PATIENT WHO IS
UNCIRCUMCISED. WHAT IS AN APPROPRIATE STEP IN THE PROCEDURE ?

LEAVING A SPACE BETWEEN THE PENIS AND THE CATHETERS TIP

A NURSE WHO IS PREPARING TO INSERT A STRAIGHT URINARY CAT FOR A MALE
PATIENT SHOULD

APPLY LIGHT TRACTION TO THE PENIS

A NURSE IS CARING FOR A PATIENT WHO HAS A TRACH TUBE WITH AN INNER
CANNULA IN PLACE. WHAT SUPPLIES SHOULD THE NURSE USE TO DY THE INNER
CANNULA OF THE PATIENTS TRACH TUB AFTER CLEANING IT

FOLDED PIPE CLEANERS

A NURSE IS PREPARING TO SUCTION SECRETIONS FORM THE MOUTH OF A
PATIENT WHO HAS DYSPHAGIA. WHAT IS THE APPROPRIATE SUCTION DEVICE OR
METHOD FOR THE NURSE TO USE?

YANKAUER CATHETER

A NURSE IS CARING FOR A PATIENT WHO HAS A TRACHEOSTOMY TUBE IN PLACE.
DURING TRACH CARE, WHAT SHOULD THE NURSE PLACE UNDERNEATH THE FLANGES
OF THE OUTER CANNULA

COMMERCIALLY PREPARED FENESTRATED DRESSING
- DOES NOT UNRAVEL AND HAS FENESTRATION
SLITS DESIGNED TO FIT AROUND THE TRACHOSTOMY TUBE UNDER THE FLANGES

A NURSE IS CARING FOR A PATIENT WHO HAS CUFFED ENDOTRACHEAL TUBE IN
PLACE. WHAT IS AN APPROPRIATE COMPONENT OF ET TUBE CARE FOR THIS PATIENT

REPOSITIONING THE ET TUBE IN THE PATIENTS MOUTH EVERY 12 HOURS

A NURSE IS PREPARING TO PERFORM ENDOTRACHEAL TUBE CARE AND PLANS TO
USE TAPE TO SECURE THE TUBE. WHAT IS AN APPROPRIATE PREP ACTION FOR
THIS PROCEDURE ?

HAVE TINCTURE OF BENZOIN READY TO APPLY TO THE PATIENTS FACE

A NURSE IS SUCTIONING A PATIENTS AIRWAY USING IN LINE SUCTIONING.
WHEN USING THIS METHOD IT IS APPROPRIATE FOR THE NURSE TO

REUSE THE CATHETER REPEATEDLY

A NURSE IS PERFORMING CHEST PHYSIOTHERAPY FOR A PATIENT WHO NEEDS
HELP MOBILIZING AND EXPECTORATING THICK PULMONARY SECRETIONS. TO
INCREASE THE TURBULENCE OF THE AIR THE PATIENT EXHALES THE NURSE
SHOULD USE WHICH TECHNIQUE

VIBRATION
USED DURING OR AFTER PERCUSSION TO
INCREASE THE TURBULENCE OF EXHALED AIR AND LOOSEN SECRETIONS

A NURSE IS CARING FOR A PATIENT WHO SUSTAINED TRAUMA TO HIS HEAD AND
NECK AND WILL REQUIRE LONG TERM AIRWAY SUPPORT. WHAT DEVICE WILL BE
REQUIRED FOR HOME HEALTH CARE FOR THIS PATIENT?

TRACHEOSTOMY TUBE

STANDARD PRECAUTIONS MANDATE

DISINFECTING HANDS IMMEDIATELY AFTER REMOVING GLOVES

AFTER COMPLETING A PROCEDURE THAT REQUIRED DONNING PERSONAL
PROTECTIVE EQUIPMENT CONSISTING OF A GOWN, N95, A FACE SHIELD AND
GLOVES. WHAT SHOULD THE NURSE REMOVE FIRST WHEN REMOVING PPE SEPARATELY

GLOVES

YOU ARE ABOUT TO IRRIGATE A PATIENTS OPEN WOUND. BESIDES GLOVES,
WHICH OTHER ITEM OF PPE MUST YOU WEAR?

FACE SHIELD

WHICH PRODUCT CAN AFFECT THE PERMEABILITY OF GLOVES

PETROLEUM BASED HAND LOTION

A CLIENT HAS A HEALTHCARE ASSOCIATED INFECTION (HAI). WHAT BEST
DESCRIBES HAI?

ACQUIRING THE INFECTION WHILE HOSPITALIZED

YOU ARE CARING FOR A PATIENT DIAGNOSED WITH MYCOPLASMAL PNEUMONIA.
DROPLET PRECAUTIONS HAVE BEEN INSTITUTED SO YOU MUST

PROTECT YOUR EYES

CONTACT PRECAUTIONS WOULD BE MANDATED FOR A HOSPITALIZED ADULT
PATIENT DIAGNOSED WITH

INFECTIOUS DIARRHEA

you are washing your hands with non antimicrobial soap and water
prior to repositioning a patient in a bed. during the handwashing
procedure it is important to?

continue for at least 15 seconds

to decontaminate your hands with an alcohol based gel, you rub them
together until all of the gel has evaporated and your hands are dry.
the primary reason you do this is that

drying provides the full antiseptic effect

which of the following is an advantage of using alcohol based gel?

it use takes less time than washing with soap and water does

after assisting a newly admitted patient in removing his shoes and
outerwear you notice what appears to be soil or grime on your hands you

wash your hands with soap and water

WHERE DOES HEMATOPOIESIS TAKE PLACE?

RED BONE MARROW

THE NURSE IS REPOSITIONING A PATIENT. DURING THE MOVEMENT THE
EXTREMITY IS PLACED IN A POSITION AWAY FROM THE MIDLINE OF THE BODY.
TO DOCUMENT THIS POSITION, WHAT TERM IS MOST APPROPRIATE

ABDUCTION

A PATIENT IS SUSPECTED OF HAVING RHEUMATOID ARTHRITIS. WHAT
DIAGNOSTIC TESTS MAY BE USED TO SUPPORT THE DIAGNOSIS?

CBC ESR C REACTIVE PROTEIN

THE NURSE IS REVIEWING THE ASSESSMENT FINDINGS AND MEDICAL HISTORY OF
A PATIENT SUSPECTED OF HAVING GOUTY ARTHRITIS. WHAT FINDINGS SUPPORT
THE DIAGNOSIS?

TOPHI

A 55 YEAR OLD PATIENT MENTIONS THAT SHE IS POSTMENOPAUSAL AND IS NOT
TAKING ESTROGEN SUPPLEMENTS. A REVIEW OF HER NORMAL DIETARY INTAKE
INDICATES HIGH CONSUMPTION OF CAFFINE LIMITED DIETARY INGESTION OF
CALCIUM. BASED ON HER HISTORY, SHE FACES AN INCREASED RISK FOR WHAT CONDITION?

OSTEOPOROSIS

WHAT ARE APPROPRIATE NURSING INTERVENTION FOR A PATIENT SUFFERING
FROM A FRACTURED HIP WITH A BIPOLAR HIP REPAIR?

MAINTAIN ABDUCTION OF THE AFFECTED EXTREMITY ENSURE
THE HEAD OF THE BED IS NOT ELEVATED MORE THAN 45 DEGREES

A PATIENT IS BEING DISCHARGED AFTER A PROSTHETIC HIP IMPLANT. SHE
ASKS WHEN SHE CAN BEGIN TO BEAR WEIGHT ON THE AFFECTED LEG. WHAT WOULD
THE NURSE RESPONSE BE?

YOU WILL MOST LIKELY REQUIRE SOME DEGREE OF NON WEIGHT BEARING
FOR 6 WEEKS TO 3 MONTHS

A PATIENT HAS BEEN SEEING THE HEALTH CARE PROVIDER FOR COMPLAINTS OF
OSTEOARTHRITIS. TODAY THE PATIENT IS DISCUSSING CONCERNS ABOUT THEIR
CONDITION AND ASKS WHAT HAS CAUSE THE OSTEOARTHRITIS. WHAT WOULD BE
THE NURSES RESPONSE?

WEAR AND TEAR OVER THE YEARS HAVE MOST LIKELY CAUSED THE
JOINTS TO BEGIN TO DEGENERATE

WHEN PROVIDING CARE TO A PATIENT IN SKELETAL TRACTION WHAT ACTION
WOULD BE INCLUDED IN THE NURSE'S PLAN OF CARE?

CLEANSE PIN SITES AND OBSERVE FOR SIGNS OF INFECTION

AFTER A FRACTURE OF THE FOREARM OR TIBIA, COMPLAINTS OF SHARP, DEEP,
UNRELENTING PAIN IN THE HAND OR FOOT UNRELIEVED BY ANALGESICS OR
ELEVATION OF THE EXTREMITY INDICATE WHAT TYPE OF INFECTION?

COMPARTMENT SYNDROME

A PATIENT SUFFERED A KNEE INJURY WHILE PLAYING FOOTBALL. THE PATIENT
IS SCHEDULED FOR AN ARTHROSCOPIC EXAM AND ASKS THE NURSE TO EXPLAIN
THE PROCEDURE. WHAT INFORMATION WILL BE GIVEN TO THIS PATIENT ?

YOUR HEALTH CARE PROVIDER WILL INSERT A SMALL SCOPE INTO YOUR
KNEE JOINT TO VISUALIZE THE JOINT FOR DAMAGED TISSUE

A PATIENT WITH RA ASKS IF THERE IS A CURE. WHAT WOULD BE THE MOST
APPROPRIATE RESPONSE BY THE NURSE ?

NO, BUT NEW DRUGS CAN INTERFERE WITH THE BODYS REACTION TO
INFLAMMATION AND BETTER CONTROL THE DISEASE PROCESS

A PATIENT IS SCHEDULED FOR ENDOSCOPIC SPINAL MICRO SURGERY TO CORRECT
A HERNIATED DISK. WHAT IS THE MOST ACCURATE STATEMENT CONCERNING THIS
TYPE OF SURGERY

SPECIAL SCOPES ARE PLACED THROUGH SMALL INCISIONS CAUSEING
MINIMAL DAMAGE TO SURROUNDING TISSUE

A PATIENT HAS OSTEOARTHRITIS OF THE KNNEE AND IS SEEKING INFORMATION
ABOUT GLUCOSAMINE SUPPLEMENTS. WHAT WOULD BE AN APROPRIATE RESPONSE
FROM THE NURSE ?

STUDIES SUGGEST THAT GLUCOSAMINE SUPPLEMENTS MAY HAVE BE
HELPFUL IN MAINTAING HEALTHY JOINT FUNCTION

WHAT IS THE MOST APPROPRIATE NURSING ASSESSMENT FOR THE PATIENT
PROBLEM OF INEFFECTIVE TISSUE PERFUSION, SECONDARY TO FRACTURED HIP?

ASSESS FOR DISTAL PULSES

A PATIENT HAS JUST UNDERGONE TOTAL HIP REPLACEMENT. THE PATIENT ASKS
WHY SHE CANNOT CROSS HER LEGS WHEN SITTING BUT MUST DO STRAIGHT LEG
RAISING EXERCISES. WHAT IS THE MOST CORRECT RESPONSE?

THE EXERCISES HELP STRENGTHEN THE LEG MUSCLES, CROSSING YOUR
LEGS PUTS PRESSURE ON THE JOINTS AND COULD DAMAGE THE HIP PROSTHESIS

WHICH OBJECTIVE SIGNS WILL THE NURSE FIND DURING THE ASSESSMENT OF A
PATIENT WITH COMPARTMENT SYNDROME IN THE LOWER LEG?

ABSENCE OF PULSATION IN THE AFFECTED EXTREMITY PAIN
THAT IS UNRELEASED BY MEDICATION OR ELEVATION OF THE EXTREMITY

A PATIENT HAD A COMPOUND FRACTURE OF HIS RIGHT FEMUR 2 YEARS BEFORE
THE PRESENT ADMISSION. HIS HCP SUSPECTS OSTEOPMYELITIS AND HAS
INFORMED THE PATIENT THAT TESTS ARE NEEDED TO CONFIRM THE DIAGNOSIS.
THE PATIENT WANTS TO KNOW WHAT TESTS CAN BE ORDERED TO DETERMINE
OSTEOMYELITIS. AN APPROPRIATE RESPONSE WOULD BE ?

BONE SCAN BONE BIOPSY ESR

A CONSTRUCTION WORKER SUFFERED A FRACTURE OF THE FEMUR 48 HOURS AGO.
THE NURSE NOTICES THAT HE HAS PETECHIAE ON THE CONJUNCTIVA, CHEST ,
NECK AND AXILLAE. PETECHIAE IN THESE LOCATIONS ARE CONSISTENT WITH
WHICH CONDITION?

FAT EMBOLISM

A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 24 HR POST OP
FOLLOWING AN ABOVE THE ELBOW AMPUTATION. WHAT SHOULD THE NURSE
IDENTIFY AS PRIORITY?

REPORT OF MUSCLE SPASMS

A NURSE IS CARING FOR A CLIENT WHO HAD A BELOW THE KNEE AMPUTATION
FOR GANGRENE OF THE RIGHT FOOT. THE CLIENT REPORTS SENSATIONS OF
BURNING, AND CRUSHING PAIN IN THE TOES OF THE RIGHT FOOT. WHAT
STATEMENT SHOULD THE NURSE MAKE ?

AN ANTICONVULSANT MEDICATION CAN BE HELPFUL IN RELIEVING THIS TYPE OF PAIN.

A nurses is caring for a client who is 4hr post-op following a
laparoscopic cholecystectomy. which of the following findings should
the nurse expect?

right shoulder pain

nurse is assessing client who is experiencing perforation of a peptic
ulcer. which of the following manifestations should the nurse expect?

border like abdomen

A nurse is assessing a client who was admitted with a bowel
obstruction. The client reports severe abdominal pain. Which of the
following findings should indicate to the nurse that a possible bowel
perforation has occurred?

rigid abdomen

A nurse is caring for a client who has celiac disease. Which of the
following foods should the nurse remove from the client's meal tray?

wheat toast

A nurse is caring for a client who is 2 days postoperative following
a gastric bypass. The nurse notes that bowel sounds are present. Which
of the following foods should the nurse provide at the initial feeding?

clear liquids

A nurse is caring for a client who is receiving total parenteral
nutrition (TPN) therapy and has just returned to the room following
physical therapy. The nurse notes that the infusion pump for the
client's TPN is turned off. After restarting the infusion pump, the
nurse should monitor the client for which of the following findings?

Diaphoreisis

A nurse is caring for a client who has a percutaneous endoscopic
gastrostomy (PEG) tube and is receiving intermittent feedings. Prior
to initiating the feeding, which of the following actions should the
nurse take first?

place the client in semi followers position

A nurse is preparing a community education program about hepatitis B.
Which of the following statements should the nurse include in the teaching?

A hepatitis B immunization is given to infants and children.

A nurse is caring for a client who has fulminant hepatic failure.
Which of the following procedures should the nurse anticipate for this client?

liver transplant

a nurse is collecting data from a client who is in the early stages
of hep a. which of the following manifestions should the nurse expect?

anorexia

A nurse is caring for a client who is dehydrated and is receiving
continuous tube feeding through a pump at 75 mL/hr. When the nurse
assesses the client at 0800, which of the following findings requires
intervention by the nurse?

the head of the bed elevated 20 degrees

A nurse is caring for a client who is scheduled to undergo an
esophagogastroduodenoscopy (EGD). The nurse should identify that this
procedure is used to do which of the following?

to detect ulcerations in the stomach

a nurse is reinforcing teaching with a client who has diverticulitis
about preventing acute attacks. what type foods should the nurse recommend?

foods high in fiber

a nurse is assisting a client who has esophageal varices. the nurse
might anticipate a prescription for what medication?

vasopressin

A nurse is teaching a client who has Barrett's esophagus and is
scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the
following statements should the nurse include in the teaching?

This procedure can determine how well the lower part of your
esophagus works.

A nurse in a provider's office is assessing a client who states he
was recently exposed to tuberculosis. Which of the following findings
is a clinical manifestation of pulmonary tuberculosis?

night sweats

A nurse is caring for an older client who has chronic obstructive
pulmonary disease with pneumonia. The nurse should monitor the client
for Which of the following acid-base imbalances?

respiratory acidosis

A nurse is caring for a client who has a tracheostomy with an
inflated cuff in place. Which of the following findings indicates that
the nurse should suction the client's airway secretions?

the nurse ascultates coarse crackles in the lung field

A nurse is providing teaching to a client about pulmonary function
tests. Which of the following tests measures the volume of air the
lungs can hold at the end of maximum inhalation?

total lung capacity

A nurse is planning care for a client following placement of a chest
tube 1 hr ago. Which of the following actions should the nurse include
in the plan of care?

tape all connections between the chest tube and drainage system.

A nurse in an urgent care clinic is collecting data from a client who
reports exposure to anthrax. Which of the following findings is an
indication of the prodromal stage of inhalation anthrax?

dry cough

A nurse on a medical unit is assisting with the care of a client who
has a possible closed pneumothorax and significant bruising of the
left chest following a motor vehicle crash. The client reports severe
left chest pain on inspiration. The nurse should hear which of the
following findings when auscultating the clients lung sounds?

absence of breath sounds

A nurse in a clinic is reinforcing teaching with a client who is to
have a tuberculin skin test. Which of the following information should
the nurse include?

You must return to the clinic to have the test read in 2 or 3 days

A nurse is assisting with discharge teaching for a client who is
postoperative following a rhinoplasty. Which of the following
instructions should the nurse include?

Lie on you back with you head elevated 30 degrees when resting

A nurse is reinforcing teaching with a client who has cystic fibrosis
and a prescription for daily chest physiotherapy. The nurse should
instruct the client that which of the following is the purpose of
these treatments?

To mobilize secretions in the airways

A nurse is reinforcing preoperative teaching with a client who is to
undergo a pneumonectomy. The client states I am afraid it will hurt to
cough after the surgery. Which of the following statements should the
nurse make?

I will show you how to splint your incision while coughing

A nurse is collecting data from a client who has a prescription for
cisplatin IV to treat lung cancer. Which of the following client
findings is an adverse effect of this medication?

tinnitus

A nurse is reinforcing teaching about pursed lip breathing for a
client who has COPD and emphysema. The nurse should explain that this
breathing does which of the following?

Keeps the airways open on exhalation

A nurse is assisting the provider to prepare a client for a
thoracentesis. The nurse should instruct the client that which of the
following positions will be used for this procedure?

Sitting while leaning forward over the bedside table

A nurse is assisting with the development of a teaching plan about
how to prevent an acute asthma attack for a young adult client. Which
of the following points should the nurse plan to discuss first?

Determine the clients perception of the disease process and what
might have triggered the current attack

A nurse on a medical unit is assisting with the care of a client who
aspirated gastric contents prior to admission. The provider prescribed
100% oxygen by nonrebreather mask after the client reported severe
dyspnea. Which of the following findings is a clinical manifestation
of acute respiratory distress syndrome?

PaO2 50 mmHg

A nurse is assisting with the plan of care for a client who has COPD
and is malnourished. Which of the following recommendations to promote
nutritional intake should the nurse include in the plan?

eat high calorie food first

A nurse on a medical surgical unit is caring for a client who is
postoperative following a hip replacement surgery. The client reports
feeling apprehensive and restless. The nurse collects additional data
from the client. Which of the following findings is an indication of
pulmonary embolism?

sudden onset of dyspnea

a nurse is caring for a client who smokes cigarettes and has a new
diagnosis of emphysema. what actions should the nurse take to assist
the client with smoking cessation?

Discuss ways the client can reduce the number of cigaretters smoked
per day

A nurse is caring for a client who has pneumonia and is experiencing
thick oral secretions. what actions should the nurse take first?

encourage deep breathing and coughing

a nurse is reinforcing preop teaching with a client who will undergo
a total laryngectomy. what statements should the nurse identify as an
indication that the client understands the impact of the surgery?

I understand that I will have a permanent tracheostomy after
the surgery

A nurse on a medical surgical unit is caring for 4 clients. what
client should then urse monitor for crepitus?

a client who has a chest tube following a pneumothorax

a nurse is caring for a client for whom the respiratory therapist has
just removed the endotracheal tube. what actions should the nurse take first?

evaluate the client for stridor

a nurse is reinforcing teaching about pursed lip breathing with a
client who has COPD and emphysema. The nurse should explain that this
breathing technique does which of the following

keeps the airways open on exhalation

a nurse is caring for an older adult client who has COPD and
pneumonia. the nurse should monitor the client for which of the
following acid base imbalances?

respiratory acidosis

a nurse is assisting with the plan of care for a client who is post
op following a hip arthroplasty/ in the clients medical record, the
nurse notes a history of COPD. What oxygen delivery methods should the
nurse recommend to use for this client

nasal cannula

a nurse is caring for a client is scheduled to have his chest tube
removed. what action should the nurse take ?

auscultate the lungs after removal

a nurse is reinforcing teaching with a client who has cystic fibrosis
and a prescription for daily chest physiotherapy. what is the purpose
of this treatment.

to mobile secretions in the airways

a nurse is reinforcing discharge teaching with a client who had a
pulmonary embolism. what statement should the nurse identify as an
indication that the client understands the information?

I'll call the doctor if I see any blood in my urine or stool

A nurse is reinforcing discharge teaching about improving gas
exchange with a client who has emphysema. what information should the
nurse include in the teaching.

use pursed- lip breathing during periods of dyspnea (shortness of breath)

a nurse is collecting data about the respiratory status of a client
who has COPD. what manifestations should the nurse identify as an
indication of the early onset of respiratory failure.

Tachycardia

a nurse is collecting data from a client who has a positive TB skin
test. which of the following findings should the nurse identify as an
indication the the client has active TB ?

night sweats

a nurse is helping the provider prepare a client for thoracentesis.
the nurse should instruct the client that which of the following
positions will be used for this procedure.

sitting while leaning forward over the bedside table

a nurse is assisting with the care of a client who had a chest tube
inserted 12 hours ago. the nurse notes a crackling sensation upon
palpation of the skin on the right side of the clients chest. the
nurse should notify the charge nurse that the client is demonstrating
a clinical manifestation of which of the following complications?

Crepitus

a nurse is preparing to assist a provider in withdrawing arterial
blood from a clients radial artery for ABG measurement. what actions
should the nurse plan to take?

check the circulation in the clients ulnar artery prior to obtaining
the specimen

a nurse is assisting with planning postop education for a client who
will undergo radial neck dissection for cancer of the larynx. the
nurse should suggest which of the following topics?

npo status alternative methods of communication
changes in body image swallowing exercises

a nurse is caring for a client who is post op following a
rhinoplasty. what findings should be reported to the surgeon

frequent swallowing
- can indicate posterior nasal bleeding and
possibly hemorrhage

a nurse is reinforcing teaching about breathing techniques with a
client who has emphysema. which of the following statements should the
nurse identify as an indication that the client understands the
mechanics behind pursed lip breathing?

when I breathe out through pursed lips, my airways don't
collapse between breaths"
- slows exhalation
- maintains inflation of the distal airways
- enhances respirations

a nurse is reinforcing discharge instructions with a client who has a
new laryngectomy. the nurse should tell the client to be careful while
bathing to prevent what complication?

aspiration of water

a nurse is reinforcing preop teaching with a client who has lung
cancer and will undergo a pneumonectomy. which of the following pieces
of information should the nurse include?

you will have a chest tube placed after surgery we'll
help you turn, cough, and breathe deeply after surgery
we'll give you oxygen to support your breathing if you need
it

a nurse on a med surg unit is caring for a client who is post op
following a hip replacement. the client reports feeling apprehensive
and restless. the nurse collects additional data from the client. what
finding is an indication of pulmonary embolism.

sudden onset of dyspnea
- rapid onset
- dyspnea due to reduced blood flow to the lungs

a nurse is caring for a client who has a chest tube. the nurse notes
that the chest tube has become disconnected from the chest drainage
system. what actions should the nurse take?

immerse the end of the chest tube in a bottle of sterile water

a nurse in a providers office is collecting data from a client who
reports recent exposure to TB. which of the following findings is a
clinical manifestation of pulmonary TB ?

night sweats
- fevers also clinical manifestation

a nurse is caring for a client who had a left lowerr lobectomy to
treat lung cancer. what factor has a significant impact on the plan of
care for this client?

Lung cancer usually has metastasized before the client has symptoms

a nurse in an urgent care clinic is collecting data from a client who
reports exposure to anthrax. which of the following findings is an
indication of the prodromal stage of inhalation anthrax?

dry cough

a nurse on a medical unit is assisting with the care of a client who
has a possible closed pneumothorax and significant bruising of the
left chest following a motor vehicle crash. the client reports sever
left chest pain on inspiration. the nurse should hear what findings
when auscultating the client's lung sounds

absence of breath sounds

a nurse is reviewing the lab results of a client who has metabolic
alkalosis. which of the following labs values should the nurse expect?

pH 7.49
HCO3 32 mEq/L
PACO2 40 mmHG

a nurse is reinforcing teaching with a client about pulmonary
function tests. which of the following tests measures the volume of
air the lungs can hold a the end of max inhalation ?

total lung capacity

a nurse in a clinic is reinforcing teaching with a client who is
scheduled to have a TB skin test. which of the following pieces of
info should the nurse include?

you must return to the clinic to have the test read in 2 or 3 days

a nurse is reinforcing discharge teaching with a client who has
emphysema. which of the following instructions should the nurse take?

try to drink at least 2-3 liters of fluid per day .........
.....

a nurse is caring for a client who is experiencing acute opioid
toxicity. which of the following actions should the nurse identify as priorty.

ensure an adequate airway

a nurse is caring for a client following a right pleural
thoracentesis. the nurse measures a total of 35 mL of purulent
drainage. what findings indicate a tension pneumothorax?

- tracheal deviation to the left
- absent breath sounds on the right side
- neck vein distention

a nurse on a med surg unit is collecting data from a client who
recently transferred from the ICU following endotracheal extubation.
which of the following findings should the nurse identify as a
possible manifestation of tracheal stenosis and report to the charge nurse

increased coughing

a nurse is collecting data from a client who has pharyngitis. what
finding is the nurses priority to report to the provider

inspiratory stridor

a nurse is caring for a client who is extremely anxious and is
hyperventilating. the clients ABG results are pH 7.50, PaCO2 27 mmHg
and HCO3 - 25 mEq/L. the nurse should identify that the client has
which of the following acid base imbalances.

respiratory alkalosis

a nurse is reinforcing teaching with a client who has a chronic cough
and is scheduled for a bronchoscopy. what statement indicates an
understanding of the teaching?

a tissue sample might be obtained during the procedure

a nurse is assisting with the plan of care for a client who has COPD
and is malnourished. which of the following recommendations to promote
nutritional intake should the nurse include in the plan of care.

Eat high calorie foods first

a nurse is assisting a provider with a comprehensive physcial
examination of a client. when the provider uses transillumination the
nurse should explain to the client that this technique helps evaluate
which of the following structures?

maxillary sinuses

a nurse is collecting data from a client who has a precription for
cisplatin IV to treat lung cancer. what is an adverse effect of this medication?

tinnitus

a nurse is contributing to the plan of care for a client who is
recieving mechanical ventaliation. which of the following
recommendations should the nurse make?

maintain the head of the bed at 30 degrees

a nurse on a medical unit is assisting with the care of a client who
aspirated gastric contents prior to admission. the provider prescribed
100 percent oxygen by norebreather mask after the client reported
severe dyspnea. what findings is a clinical manifestation of acute
respiratory distress syndrome?

PaO2 50 mmHg

a nurse is caring for a client who has a 20 year history of COPD and
is recieving oxygen at 2 L/min via nasal cannula/ the client is
shortness of breath and has O2 sat via pulse ox of 85%. what actions
should the nurse take.

Increase the oxygen flow and request and ABG

a nurse in a medical surgical unit is assessing a client . the nurse
should identify that which of the following findings is a
manifestation of pulmonary embolism.

stabbing chest pain

a nurse is reinforcing preop teaching with a client who is scheduled
to undergo pneumonectomy. the client states " I am afraid that
coughing will hurt after the surgery" what response should the
nurse make

i will show you how to splint your incision while coughing

a nurse is assisting with the plan of care for a client following
placement of a chest tube 1 hour ago/ what action should the nurse
include in the plan of care.

tape all connections between the chest tube and draingage system

a nurse is assisting with discharge teaching for a client who is post
op following a rhinoplasty. which of the following instructions should
the nurse include?

lie on your back with your head elevated 30 degrees when resting

a nurse is assisting with the care of a client who has a chest tube
in place following a thoractomy. which of the following actions should
the nurse take?

- place the drainage unit below the clients chest level

a nurse is preparing a client for discharge following a bronchoscopy.
what assesment is the nurses priority.

- confirming the gag reflex

a nurse is caring for a client who has a tracheostomy with an
inflated cuff in place. which of the following findings indicates that
the nurse should suction the clients airway secretions?

the client has coarse crackles in the lung fields

a nurse is assiting with preparing a client for a bronchoscopy. which
actions should the nurse take?

- explain the client will recieve sedation and will not remember the procedure
- verify that the client understands the
purpose and nature of the procdure

a nurse is caring for a client who is post op following a thoracic
lobectomy. the client has 2 chest tubes in place. 1 in the lower
portion of the thorax and the other higher up on the chest wall. when
the family asks the nurse why the client has 2 chest tubes, which of
the following responses should the nurse make?

the lower tube will drain blood, an the higher tube will remove air

a nurse in the PACU is collecting data from a newly admitted client
and observes intercoastal retractions and high pitched inspiratory
sound. the nurse should identify that these findings are
manifestations of which of the following complications?

respiratory obstruction

a nurse is auscultating the lungs of a client who is having an acute
asthma attack. which of the following sounds should the nurse expect
to hear.

noisy wheezing

a charge nurse recieves notification of the admission of a client who
is coughing frequenly and whose sputum is pink, frothy, and copious .
the client has a history of night sweats, anorexia, and weight loss.
which of the following actions should the nurse take?

- assign the client to a private room with negative - pressure airflow
- wear an respirator when entering the clients room

a nurse is caring for a client who has COPD and is experiencing
shortness of breath. what action should the nurse take first?

place the client in an upright position

the nurse notes blanching, coolness, and edema at the peripheral IV
site. on the basis of these findings, the nurse should implement which actin?
1. remove the iv
2. apply a warm compress
3. check for a blood return
4. measure the area for infiltration

remove the iv
rationale: because infiltration can be damaging
to the surrounding tissue, the appropriate action would be to remove
the iv to prevent any further damage.

the nurse has recieved the client assignment for the day. which
client should the nurse attend to first?
1. the client who has a nasogastric tube attached
to intermitten suction
2. the client who needs to receive subq insulin
before breakfast
3. the client who is 2 days post op and is
complaining of incisional pain
4. the client who has a blood glucose level of 50
mg/dL (2.85 mmol/L and complains of blurred vision

the client who has a blood glucose level of 50 mg/dL (2.85 mmol/L)
and complains of blurred vision
rationale: client is showing symptoms of
hypoglycemia, treatment should be implemented first.

the nurse preps to care for a client on contact precautions who has a
hospital acquired infection caused by methicillin resistant
staphylococcus aurues. the client has an abdominal wound that requires
irrigation and has a tracheostomy attached to a mechanical ventilator,
which requires frequent suctioning. the nurse should assemble which
neccessary protective items before entering the clients room?
1. gloves and gown
2. gloves mask goggles
3. gloves mask gown goggles
4. gloves gown and shoe protectors

gloves mask gown goggles

a nurse at an opthalmology clinic is collecting data from a client
referred by the provider for a potential cataract. which of the
following client reports should the nurse recognize is consistent with cataracts?
halos when looking at lights loss
of peripheral vision bright flashes of light and
floaters eyestrain and headache with close work

halos when looking at lights

a nurse is collecting data from an older client who states he is
homeless. which of the following findings should the nurse document as
comorbidities for the client ?
inadequate shelter clothing for the
weather malnutrition and poverty dementia and
tuberculosis lack of preventive health care and
immunizations

dementia and tuberculosis

a nurse is reinforcing teaching about calcium supplements with an
older adult female client who has osteoporosis and a recent pair of a
fracture in her right hip. what should the nurse include in the instructions?

you should take your calcium supplements with a large glass of water

a nurse is reinforcing teaching with a group of healthy older adult
clients about health screenings after age 50 years. what health
screening should the nurse recommend that the clients complete annually?

visual acuity

a nurse is participating on a committee that is developing age
appropriate care standards for older adult clients. which of the
following of erikson's developmental tasks should the nurse recommend
as the focus?

integrity

a nurse is reinforcing dietary teaching with an older adult who is on
bedrest following development of DVT about methods to increase
peristalsis. which of the following high fiber food choices should the
nurse recommend?
navy bean soup canned fruit
juice white rice pudding soy milk

navy bean soup

a nurs eat an assisted living center is conducting an orientation
session for a group of newly hired AP. what instruction should the
nurse include regarding clients who are hearing impaired?

maintain eye contact with the clients

a nurse is assisting with planning care for an older adult client
following abdominal surgery for a bowel obstruction. what information
about pain management should the nurse include in the plan of care?

older adult clients are sensitive to the analgesic effect of opiates

a nurse at a long term care facilitiy is assisting with planning care
for a group of older adults. when planning care, the nurse should
consider that older adult clients are most likely to exhibit a
decrease in which of the following?
short term memory creative
ability decision making skills cognitive
capacity

short term memory

a nurse in a long term care facility is promoting reminiscence among
older adult clients. which of the following actions should the nurse take?

institute a daily storytelling hour

a nurse is reinforcing teaching with a newly hired assistive
personnel about her role in helping older clients witch adls. the
nurse should explain that which of the following is the most common
factor that affects a clients ability to perform ADLS?
social withdrawal chronic physcial
disability emotional impairment cognitive
dysfunction

chronic physical disability

a nurse is assisting with the admission of an older adult client who
fell at home 3 days ago. the client has fractured hip, malnutrition,
and dehydration. which of the following laboratory values, noted n
admission, should indicate to the nurse prolonged manlnutrition?
increased sodium decreased
albumin increased BUN decreased blood
glucose

decreased albumin

a nurse is caring for an older adult client who has a new onset of
type 2 diabetes mellitus. which of the following physciologic changes
contribute to the development of type 2 diabetes?
increased production of insulin by the
pancreas decreased sensitivity to the circulating
insulin increased rate of glucose metabolism
decreased release of gylcogen by the liver

decrease sensitivity to the circulating insulin

a nurse is caring for an older adult client who has pneumonia. which
of the following physiologic changes associated with aging places the
client at a greater risk for pneumonia?
decreased anterior posterior diameter
increased diameter of the small airways decreased
number of cilia increased alveolar surface

decreased number of cilia

a nurse is caring fora client who has alzheimers disease and refuses
to take her morning antihypertensive med. the client is oriented to
name and place and is able to perform adls' with minimal supervision.
which of the following actions should the nurse take?
crush the pills and feed them to the client
in applesauce insist the client comply by informing
her of the possible implications of a missing dose notify
the provider of the need for further evaluation of the clients
level of competence ask the client to express her
reasons for refusing the medications and document the event

ask the client to express her reasons for refusing the medication and
document the event

a nurse is collecting data from an older adult client for signs of
dehydration. which of the following findings should the nurse consider
an expected pat of the aging process?
elevation of urine specific gravity
decreased creatinine clearance dry oral mucous
membranes poor skin turgor over the sternum

decreased creatinine clearance

an older adult client tells a nurse at a health fair " I am
always forgetting things. I cannot even remember where I parked my car
! Do you think I have alzheimer's disease?" what would be the
therapeutic response by the nurse ?

that must be very upsetting. can you tell me about your forgetfulness?

a nurse is reinforcing teaching with a group of older adult female
clients who are postmenopausal about dietary requirments. what
statement should the nurse make about folic acid?

adequate folic acid intake is associated with a reduced risk
for heart disease

a nurse is reinforcing teaching with an older adult client who has
osteoarthritis of the right hip and lower lumber vertebrae. which of
the following statements by the client indicates an understanding of
the teaching?
" I should avoid the use of a heating
pad on my back" " to relieve the pressure on my
hip, I can use a cane while ambulating" " I have
steriod injections to my joints as the first medication of choice
to treat my pain" I will exercise if it causes
pain"

to relieve the pressure on my hip I can use a cane while ambulating

a nurse is collecting data from an older adult client during an
annual physical. which of the following findings should the nurse
report to the provider ?
BP 118/76 mm Hg fasting blood
glucose level of 160mg/dL report of waking to void two to
three times per night report of a bowel movement every
other day

fasting blood glucose level 160 mg/dL

a nurse is reviewing the medical record of a client who is
postmenopausal and has osteoporosis. the client has a new prescription
for alendronate sodium. which of the following findings in the clients
history should the nurse recognize is a contraindication to this medication?
glaucoma pagets disease
esophageal stricture long term corticosteriod use

esophageal stricture

a nurse is collecting data from an older adult client. which of the
following actions should the nurse take to collect subjective data?
leave the client a writen questionaire to
fill out in private allow sufficient time for the client
to respond to the questions talk to family members to
obtain the clients health history obtain the health
history from the clients medical record

allow sufficient time for the client to respond to the questions

a nurse in the clinic is assessing an older adult client for the
second time this week. the client reports a decreased energy level,
insomnia, and anorexia. Diagnositic tests are withing the expected
reference ranges. For which of the following conditions should the
nurse screen the client?
sarcopenia dementia
depression diabetes

depression

a nurse is contributing to the plan of care for a client who had a
stroke. which of the following goals should the nruse identify as the
priority for this client?
the clients skin will remain intact during
hospitalization the client will verbalize one new word each
week the client will begin to help turn himself in bed,
indicating improved mobilitiy the clients aireway will
remain clear, as evidenced by clear breath sounds.

the client's airway will remain clear, as evidenced by clear breath sounds.

a nurse is planning to administer diphenydramine hydrochloride to an
older adult client. which of the following actions should the nurse
plan to take prior to administration
review the medical record for a client
history of glaucoma plan to administer med 30 min prior to
a meal explain to the client that he will need to
restrict fluid intake once he takes the medicaiton. remind
the client that his appetite might increase when starting this
medication

review the medical record for a client history of glaucoma

a nurse is assisting with the care of an older adult client who has
dementia. the client becomes agitated and confused at night and
wanders into the hallway. what action should the nurse take?

place the clients mattress on the floor

a nurse is contributing to the plan of care for a client who had a
recent stroke and a history of GERD. for which of the following
disorders should the nurse plan to monitor this client.
duodenal ulcer disease aspiration
pneumonia viral pneumonia esophageal
varices

aspiration pneumonia

a nurse is caring for an older adult client who has gout and refuses
to eat. the client's provider has approved the family to bring food
from home. what foods should the nurse recommend that the client not eat?

lentil soup

a nurse is caring for an older adult client. which of the following
physiologic changes associated with aging can affect medication dosage
in this client?
increased glomerular filtration rate
decreased body fat decreased gastric motility
decreased gastric pH

decreased gastric motility

a nurse is reinforcing teaching with an older adult client who has
anemia. which of the following foods should the nurse recommend to
increase the clients iron intake?
greek yogur bran muffin
peanut butter sandwhich dried fruit

dried fruit

a nurse is reviewing the medication list of an older adult client
upon admission and notes that he is taking fluoxetine for depression.
the nurse should identify that fluoxetine can increase the effects of
which of the following medications that is also on the clients list
levothyroxine gabapentin
warfarin nadolol

warfarin

a nurse is assisting with the admission of an older adult client who
is scheduled for surgery. the nurse is completing a medication
reconciliation with the clients new admission medication
prescriptions. for which of the following situations should the nurse
plan to repeat the medication reconcililation process?
the provider obtains informed consent from
the client for surgery they client returns to the unit
from the surgical suite the pharmacy delivers the clients
medications to the unit the nurse is preparing to provide
change of shift report

the client returns to the unit from the surgical suite

a nurse is reviewing the medication list of an older adult client and
notes that the client is taking simvastatin for hypercholesterolemia
as we as multiple herbal supplements. which of the following
supplements indicated on the clients medication list can decrease the
effect of this medication?
garlic ginkgo biloba
glucosamine st johns wort

st. johns wort

a nurse is reinforcing discharge teaching with an older adult client
who is taking multiple medications. which of the following information
should the nurse include in the teaching?
" you should keep a medication list that
includes only your prescribed medications" " you
should compare your medication dose with others taking the same
medications " " you should not experience
adverse effects unless you begin taking a new medication
" "you should consult your provider before taking
an herbal supplement "

you should consult with your doctor before taking any herbal supplements

A nurse is reviewing the laboratory results of an older adult client
who is taking multiple medications. which of the following findings
could impact the clients ability to distribute medication throughout
his system ?
hgb 15 g/dL albumin 3.0 g/dL
potassium 3.7 mEq/L total cholesterol 188 mg/dL

albumin 3.0

a nurse is caring for a client who is using a continuous passive
motion device following a right total knee replacement. which of the
actions should the nurse take when using the CPM device?

line up the frame joints of the COM device with the clients knee.
rationale: to avoid damage to the operative knee

a nurse is reinforcing teaching with an older adult client who is
healthy and has chronic constipation about establishing bowel
retraining program. which of the following statements should the nurse
include in the teaching?

increase the fiber content of your diet
rationale: purpose is to manipulate factors within
the clients control to produce the elimination of a soft formed stool
at regular intervals.

a nurse is reviewing the medical record of an older adult client. for
which of the following medications should the nurse request a hearing
assessment of the client?

furosemide
rationale: can cause ototoxicity. decrease
medication metabolism in the kidneys. teach client s/s of
ototoxicity: tinitus and difficulty hearing

A nurse is reinforcing teaching with an older adult client who is to
start taking warfarin. which of the following statements indicates the
client understands the teaching?

I can continue to eat green salads

a nurse is collecting data from an 85 year old client. which of the
following findings should the nurse report to the provider?

difference in pulse strength between lower extremities
rationale: difference can indicate vascular
complication, assessment of the peripheral vascular system should
also include temp, color, sensation, edema, skin integrity of bother
the upper and lower extremities. identify any differences in symmetry
of the findings and report them.

a nurse at a long term care facility is reinforcing teaching with an
older adult client about ambulating with a quad cane. which of the
following statements should the nurse include in the teaching?

hold the cane in the hand on the stronger side of your body
rationale: this actions allows for a more normal
gait, with the ipsliateral arm and weaker leg moving at the same time

a nurse is collecting data from an older adult female client. which
of the following findings should the nurse identify as a priority ?

rales heard in the bases of the lungs

a nurse is collecting data from an older adult client who reports
feeling anxious about financial concerns and having difficulty
sleeping for several months. which of the following actions should the
nurse take?

determine the clients usual sleep habits

a nurse is assisting in the care of a client who is in hypovolemic
shock. while waiting for a unit of blood, the nurse should plan to
administer which of the following IV solutions?

0.9% sodium chloride

a nurse is caring for a client who has advanced heart failure. which
of the following actions should the nurse take?

enforce fluid restrictions
rationale: helps reduce fluid retention in the lungs
and lower extremities

a nurse is collecting data from a client who has an abdominal aortic aneurysm
what manifestations should the nurse expect?

lower back discomfort
rationale : back and abdominal pain indicate that the
aneurysm is extending downward and pressing on lumbar spinal nerve
roots causing pain

a nurse is contributing to the plan of care for a client who has
pernicious anemia. which of the following interventions should the
nurse recommend?

initiate weekly injections of vitamin B12
rationale: lack of intrinsic factor needed to absorb
vitamin B12 from the gastrointestinal tract

a nurse is reiforcing discharge teaching with a client who has a new
permanent pace maker. which of the following information should the
nurse include in the teaching?

avoid lifting both arms above your head when dressing
rationale : dislodgement of the pacer leads can occur

a nurse is reinforcing teaching with a client who has anemia and a
new prescription for epoetin alfa. what information should the nurse
include in the teaching.

hypertension is a common adverse effect to this medication
rationale: rise in the prodction of erythrocytes

a nurse is caring for a client who is post op following a vein
ligation and stripping for varicose veins. which of the following
actions should the nurse take ?

position the client supine with his legs elevated when in bed?
rationale: promotes venous return to the heart

a nurse is assisting in the care of a client who has abdominal aortic
aneurysm and is scheduled for surgery. the clients vital signs are BP
160/98, HR 102/min, RR 22/min and SPO2 95% which of the following
actions should the nurse take?

administer antihypertensive medication for blood pressure

a nurse is collecting data from a client who has a history of
peripheral arterial disease. which of the following findings on the
clients lower extremities should the nurse expect?

cool, pale skin with minimal body hair

a nurse is collecting data from a client who has a manifestation of
aplastic anemia. what findings should the nurse expect?

petechiae and eccymosiss

a nurse is administering a loop diuretic to a client who has a 3+
pitting edema in the lower extremities. what action should the nurse take?

monitor the client for ototoxicity

a nurse is assiting the plan of care for an older adult client who is
to recieve a unit of packed RBC. what action should the nurse recommend?

verify the information on the packed RBC? with another nurse

a nurse is caring for a client who has a late stage heart failure and
is experiencing fluid volume overload. what findings should the nurse expect?

weight gain of 1 kg (2.2 lbs) in 1 day

a nurse is assisting in the preparation of a unit of packed red blood
cells for a client who has anemia. which of the following actions
should the nurse take first?

witness the informed consent

a nurse is collecting data from a client who has a fluid volume
overload resulting from a cardiovascular disorder. which of the
following manifestations should the nurse expect?

jugular vein distension
moist crackles
postural hypotension

a nurse is evaluating a clients repeat laborartory results 4 hours
after administering fresh frozen plasma. what labs should the nurse review?

prothrombin time

a nurse is caring for a client who has hemophilia. the client reports
pain and swelling in a joint following an injury,

prepare for replacement of the missing clotting factor

a nurse is assisting in collecting data from a client who has a
history of unstable angina. what should the nurse expect?

the client reports chest pain when at rest

a nurse is reinforcing teaching about lifestyle changes with a client
who had a myocardial infarction and has a new prescription for a beta
blocker. what statement indicates the client understand the teaching?

before taking my medication, i will check my blood pressure and
radial pulse rate

a nurse is collecting data from a client who has RS HF. what finding
should the nurse expect?

dependent edema

a nurse is caring for a client who has heart failure and is lethargic
with muscle weakness. the clients telemetry displays dyrhythmias.
which of the following lab results should the nurse anticipate?

potassium 2.8 mEq/L

a nurse is checking lab values for an adult who has sickle cell
anemia and is in crisis. which complication should the nurse monitor?

elevated bilirubin
rationale: hemolysis of the abnormal red blood cells occurs

a nurse is assisting in the plan of care for a client who is
percutaneous transluminal coronary angioplasty with stent placement.
what actions should the nurse anticipate in the postop plan of care?

initiate an aspirin regimen

a nurse is collecting data from a client who reports using fish oil
as a dietary supp. which of the following substances in fish oil
should the nurse recognize as a health benefit to the client?

omega 3 fatty acids

a nurse is monitoring a client who is recieving a unit of packed red
blood cells following surgery. the client reports itching and has
hives 30 minutes after the infusin begins. what action should the
nurse take first ?

stop the infusion of blood

a nurse is assisting in monitoring a client who had a myocardial
infarction. what complication should the nurse monitor the first 24 ?

ventricular dysrhythmias

a nurse is checking for cardiac tamponade on a client who has
pericarditis. which of the following actions should the nurse take?

auscultate bp for pulsus paradoxus

a nurse is collecting data from a client who has pericaditis. what
should the nurse expect?

dyspnea

a nurse caring for a patient who has gastric cancer is initiating an
infusion of parenteral nutrition via the patients implanted port.
which of the following is an appropriate action for the nurse ?

cover the device and the needle with a sterile tranparent dressing

A nurse is caring for a patient who has a central venous catheter.
when flushing the catheter, the nurse uses a 10 mL syringe to prevent
what complication is associated with central vascular access devices

catheter rupture

a nurse is caring for a patient who has a central venous access
device in place. what routine measure should the nurse use
specifically to prevent lumen occlusion?

clamping the extension tubing while removing a syringe from the
injection cap

an older adult patient who adheres to a regular cardio rehab schedule
that includes water aerobics and swimming requires long term central
venous access. what cva device is the best choice for allowing him to
continue his aquatic program?

an implanted port

a nurse is preparing to obtain a blood sample from a patient who has
a triple lumen central catheter in place for multiple therapies. what
would be an appropriate action for the nurse to take?

turn off the distal infusions for 1 to 5 minutes before obtaining the
blood sample

a nurse is caring for a patient who has a central venous catheter and
suddenly develops dyspnea, tachycardia and dizziness. the nurse
suspects air embolism and clamps the catheter immediately. what
position should the patient be placed in?

on his left side in trendelenburg position

a patient who sustained trauma from a motor vehicle crash is
transported to an emergency department. the provider determines the
need for immediate central venous access for fluid and blood
replacement and prophyactic antibiotic therapy. what is the
appropriate cva device for this patient?

nontunneled percutaneous central catheter

a nurse is preparing to flush a patients peripherally inserted
central catheter (PICC) because the patients catheter has a valved
tip, the nurse . . .

use non heparinized saline solution for the flush

a nurse finds a patients iv inserting site red, wam and slightly
edamtous, which of the following actions should the nurse perform first

discontinue the IV line

a nurse has just initiated a new peripheral IV infusion with 5%
dextrose in water continuous infusion. how often should the nurse plan
to replace the primary tubing?

every 96 hours

a nurse who has just initiated an IV infusion explains to the patient
that complications are possible and that she will monitor the infusion
regularly. the nurse should teach the patient that which of the
following findings is an indication of early infiltration?

coolness

a nurse is initiating a peripheral iv infusion punctures the skin and
selected vein and observes blood return in the flashback chamber of
the IV catheter. what action should the nurse perform next?

lower the catheter until it is almost flush with the skin

which of the following is an important nursing action when converting
an IV infusion to a saline lock?

flush the IV cat to confirm patency

a nurse has just inserted a peripheral IV catheter for a continuous
infusion. To secure the cat. the nurse should ?

leave the connection between the hub and the tubing uncovered

a patient in early stage renal failure is prescribed an infusion of
0.45% sodium chloride. This type of solution is appropriate because it
. . .

dilutes extracellular fluid and rehydrates the cells

a nurse is removing an IV cat from a patient who IV infusion has been
discontinued. what action is appropriate?

pull the cat straight back from the insertion site

a nurse is discontinuing an iv infusion. for which of the following
reasons is it important to verify and document the integrity and
condition of the IV cat?

a broken off cath. tip indicates the risk for an embolus.

a nurse is caring for a client who has a new prescription for
verapamil to treat atrial fibrillation. the nurse should instruct the
client to avoid drinking grapefruit juice while taking verapamil
because it can cause the client to experience which of the following conditions?

hypotension

a nurse is providing teaching to a client who has a new prescription
for losartan to treat hypertension. the nurse should instruct the
client that which of the following findings could indicate an adverse
to the drug and needs to be reported

facial edema

a nurse is caring for a client who is taking a diuretic. the nurse
should instruct the client to include which of the following foods in
their diet to increase potassium intake?

raisins

a nurse is teaching a client who has a new prescription for
nitroglycerin. the nurse should instruct the client that which of the
manifestations is a potential adverse effect of this drug?

headache

a nurse is caring for a client who has a new prescription for
dobutamine. the nurse should clarify the prescription with the
provider if the client receiving which of the following types of drugs ?

MAOI
general anesthetic
tricyclic antidepressant
beta blocker

a nurse is caring for a client who has a new prescription for
propranolol to treat tachydysrhthmia. the nurse should instruct the
client to avoid taking which of the following types of OTC drugs while
taking propranolol

NSAIDS

a nurse is teaching a client who has a new prescription for
quinidine. which of the following statements should the nurse include.

monitor your pulse rate and report changes

a nurse is assessing a client who is taking a loop diuretic and is
experiencing a thready, irregular pulse, orthostatic hypotension and
confusion. the nurse should identify that these manifestations
indicate which of the following adverse effects ?

hypokalemia

a nurse is caring for a client who will begin using transdermal NTG
to treat angina pectoris. when speaking to the client about the drug,
which of the following instructions should the nurse include?

apply the patch to a hairless area and rotate sites
apply a new patch when you start your day remove
patches for 10 to 12 hours each day

a nurse should recognice that milrinone is contraindicated for a
client who has which of the following conditions?

acute myocardial infarction

a nurse is teaching a client who has a new prescription for
gemfibrozil. which of the following instructions should the nurse include?

report any new intolerance to fired foods report
muscle tenderness expect periodic liver function
testing

a nurse is caring for a client who has glomerular filtration rate of
10 mL/min and a reduced urine output. the nurse should clarify a
prescription for hydrocholorthiazide for this client because of which
of the following characteristics of the drug?

the drug does not promote diuresis for clients who have renal insufficiency

a nurse is caring for a client who is taking atorvastatin and has a
new prescription for gemfibrozil. the nurse should recognize that this
drug combo places the client at an increased risk for which of the
following adverse effects.

myopathy

a nurse is reviewing new prescriptions with a client who has heart
disease . the nurse should instruct the client that which of the
following drug is prescribed to treat hypercholesterolemia?

simvastatin

a nurse is caring for a client who is taking amiodarone to treat a
fib. which of the following should the nurse instruct the client to
avoid while taking this drug?

grape fruit juice

a nurse is caring for a client who is about to begin captopril
therapy. which of the following adverse effects should the nurse
instruct the client to report because it can indicate a need to
discontinue drug therapy?

rash distorted taste swelling of the
tongue dry cough

a nurs eis caring for a client who is taking spironolactone to treat
hypertension. the nurse should recognize that which of the following
client lab values requires immediate intervention

potassium 5.2 mEq/L

a nurse is administering hydrochlorothiazide to a client who has
gouty arthritis. the nurse should monitor the client for which of the
following findings that indicates an adverse effect of this drug?

hyperuricemia

a nurse is caring for a client who has a new prescripition for
aliskiren to treat hypertension. the nurse should monitor the client
for which of the following findings as an adverse effect of the drug

hyperkalemia throat swelling cough

a nurse is caring for a client who is taking carvedilol and has a
prescription for an oral antidiabetic drug to manage their new
diagnosis of type 2 diabetes mellitus. By taking both drugs
concurrently, the nurse should identify that the client is at an
increased risk for which of the following conditions ?

hypoglycemia

a nurse is caring for a client who has a new prescription for
verapamil. the nurse should clarify the prescription with the provider
if the client has a history of which of the following conditions?

second degree av block

a nurse should identify that which of the following drugs is used
only for the short term treatment of cardiac dysrhthmia because of the
serious adverse effects associated with long term use?

procainamide

a nurse is caring for a client who is taking digoxin and develops
changes on their ECG tracing and other manifestations that indicate
the client has severe digoxin toxcity. which of the following drugs
should the nurse expect to administer to treat this complication

antigen binding fragments

a nurse is providing teaching to a client who is taking simvastatin.
the nurse should instruct the client to report which of the following
manifestations as an indication of a serious adverse reaction that
could require discontinuing drug therapy?

muscle pain

the provider talks with the client about clomiphene therapy. what
instruction should the provider include?

begin 5 days after menstruation begins and take it every day for next
5 days

what adverse effects does clomiphene cause ?

- blurred vision
- hot flashes
breast engorgement
- nausea

recognizing the adverse effects of terbutaline, the nurse should
monitor the client for what?

tachycardia

what drug should the nurse have available to reverse the adverse
effects of terbutaline?

propanolol

the health care provider instructs the client to monitor for what
when a taking conjugated estrogen and medroxyprogesterone acetate to
treat postmenopausal vasomotor symptoms?

- swelling or pain in calf

combination oral contraceptives such as ethinyl estradiol and
drospirenone, should be used with caution when a patient has what disorder?

diabetes

a client is prescribed testosterone to treat testicular failure. the
nurse instructs the client to monitor and report what symptom?

weight gain

a client is prescribed finasteride to treat bph. when providing
instruction about finasteride, the nurse should include which of the
following information?

allow 6 to 12 months to see improvement

what medication should a health care provider question the use of
when using sildenafil to treat erectile dysfunction?

nitroglycerin as needed for chest pain

a client is prescribed clomiphen for infertility. the hcp instructs
the client to monitor for what?

pelvic pain

for rapid relief of urinary obstruction due to prostatic enlargment,
the hcp should choose what drug?

tamsulosin

the hcp administers oxytocin for induction of labor. the hcp should
monitor what order to assess for an adverse effect to oxytocin

- urine output
- bp
duration of contractions
- fetal heart rate

a nurse is caring for a male client who has hyperthyroidism and is
not responding to treatment. the nurse should identify that
hyperthyroidism is a contraindication of what drug?

Bethanechol

a nurse is caring for a client who missed a dose for her oral
contraceptive. what instruction should the nurse give?

take missed dose as soon as possible

a nurse is caring for a client who is taking a combo oral
contaceptive ehtinyl estradiol and drospirenone and is about to begin
taking rifampin to treat TB . what instruction should the nurse give
the client do to possible drug interactions ?

use additional birth control methods

a provider has prescribed a dinoprostone vaginal insert to promote
cervical ripening in a client who is 40 weeks gestation. when
administering dinoprostone, what actions should the nurse take

- urinate prior to insertion
- remove the pouch when active labor begins
- moniter for uterine hyperstimulation
- monitor the patients temperature

after administering terbutaline to a client to inhibit preterm labor,
the nurse should asses what?

Heart Rate

a nurse is providing teaching to a client about using leuprolide to
treat endometriosis. what instruction should the nurse include?

perform weight bearing activities

a nurse is assessing a client who has a new prescription for the
combo oral contraceptive ethinyl estradiol and drospirenone. what
findings should the nurse identify as a contraindication to use of
this medication?

client smokes half a pack of cigarettes a day

a nurse is caring for a client who is about to begin taking
cabergoline to treat infertility. the nurse should explain that the
client needs to monitor which of the following labs ?

prolactin level

a nurse is caring for a client who received human menopausal
gonadotropin what should the nurse expect to find?

follicular maturation

a nurse is providing safety education to a client who is scheduled to
begin treatment for BPH. what instructions should the nurse include in
the teaching?

change positions slowly

a nurse is providing teaching to a client about sildenafil to treat
erectile dysfunction. what instruction should the nurse include?

do not take the drug with high fat foods

a nurse is caring for a client who has a new prescripition for
transdermal conjugated estrogen and medroxyprogesterone to treat
postmenopausal symptoms. what therapeutic effects should the nurse
explain to the client

- reduces the risk of ovarian cancer
- relieves hot flashes
- prevents osteoporosis

a nurse is caring for aclient who has a new prescription for
conjugated equine estrogen. the nurse should instruct the client to
report which indication of a serious adverse reaction?

vaginal bleeding

a nurse is preparing to administer finasteride to a client who has
bph. what precaution should the nurse plan to take when administering
this drug?

wear gloves when handling the table

a nurse is assessing a client who has a new prescription to
oxybutynin to treat neurogenic bladd. what assessment finding should
the nurse identify as an adverset effect?

- dilated pupils
- dizziness
- distended bladder
- fever

a nurse is caring for a client who is about to begin cloiphene
therapy to treat infertility. the nurse should monitor the client for
which of the following adverse effects ?

ovarian hyperstimulation syndrome

a nurse should question the use of conjugated equine estrogen by a
client who has a history of what?

blood clots

a nurse is providing teaching to a client who is taking bethanechol
for urinary retention. what instructions should the nurse include

- avoid driving and activities that require alertness
- increase fluid intake
- stay close to a bathroom after taking the drug

a nurse is teaching a client about conjugated estrogen and
medroxyprogesterone. what instructions should the nurse include?

have blood pressure checked regularly

a nurse is teaching a client who has a prescription for a
testosterone transdermal patch. what statement indicates the client
understand the teaching ?

i should apply the medications to a different site each time

the nurs eis caring for a client who is about to begin taking
finasteride to treat BPH the nurse should explain to the client that
monitoring which lab is important?

prostate specific angtigen

a nurse is teaching a client about receiving leuprolide to treat
endometriosis. the nurse should instruct the client to expect what
side effect?

vaginal dryness

a nurse is caring for a client who has BPH and is taking tamsulosin.
the nurse should question the use of the drug if the client also has

erectile dysfunction for which he takes sildenafil

a nurse should question the use of estadiol and drospirenone by a
client who has a renal disease due to increased risk of what?

hyperkalemia

a nurse is reinforcing teaching for a client who has angina pectoris
and a new prescription to apply a nitroglycerin transdermal patch
daily at home. what instruction should the nurse give the client?

fold used patch with medication area to the inside and discard in a
closed receptacle

a nurse is talking with a client who is about to start taking NTG
oral, sustained release capsuls. what should the instructions include?

swallow the capsules whole

a nurse is caring for a client who has a prescription for metoprolol.
the nurse measures the clients vital signs and notes that the apical
hr is 49/min the nurse should prepare to administer which of the
following ?

atropine

a nurse is caring for a client who has heart failure notices that the
client did not receive his scheduled dose of furosemide. when filling
out an incident report about the occurrence, which oft he followig
information should the nurse include?

- clients breath sounds clear bilaterally
- the nurse documents the clients status as a result of the occurrence
- the clients statement about the occurrence

a nurse is reinforcing teaching a client who has a new prescription
for transfermal NTG to treat angina. the nurse should include what instructions?

apply patch to a hairless area
apply a new patch each morning
remove patch for 10 to 12 hours daily

a nurse is reinforcing discharge teaching with a client prescribed
verapamil to treat angina what should be the nursing instructions

monitor for increased heart rate while taking this medication

a nurse at a providers office is assessing a client who has been
taking hydrocortisone for adrenal insufficiency. the client reports
fatigue and feeling overwhelmed by personal responsibilities. which of
the following findings should the nurse identify as an indication the
provider might need to increase the clients dosage?

hypotension

a nurse is providing teaching to a client who is about to begin
exenatide therapy to treat type 2 diabetes mellitus. which of the
following instructions should the nurse include?

inject the drug subq expect the peak effect in 2
hours use the drug as a supplement to an oral
hypoglycemic

a nurse caring for a client who is about to begin taking pioglitazone
to treat type 2 diabetes mellitus. the nurse should explain to the
client about the need to monitor which of the follow laboratory values

ALT
LDL

a nurse is caring for a client who is about to begin taking
Propulthiouracil PTU to treat hyperthyroidism. the nurse should
instruct the instruct the client to report which of the following
adverse effects

sore throat
joint pain
bradycardia
rash

a nurse is teaching a client about self administering regular
insulin. the nurse should instruct the client to rotate injection
sites to prevent which of the following

lipohypertrophy

a nurse is caring for a client who is taking metformin and is
scheduled to undergo angiography using iodine containing contrast dye.
the nurse should identify that an interaction between metformin and
the IV contrast dye increases the clients risk for which of the
following conditions?

acute renal failure

a nurse is providing teaching to a client about taking
fludrocoritsone to treat adrenocortical insufficiency. which of the
following instructions should the nurse include?

obtain weight measurements daily report weakness or
palpitations have blood pressure checked regularly

a nurse should recognize that a provider will prescribe a lower dose
of sitagliptin for a client who has type 2 diabetes and who also has what?

renal impairment

a nurse is teaching a client who is about to begin levothyroxine
therapy to treat hypothyroidism. which of the following instructions
should the nurse include?

expect life long therapy with the drug

a nurse is caring for a client taking PTU and reports weight gain,
drowsiness and depression. the nurse should identify that the client
is experiencing which of the following adverse reactions

hypothyroidism

a nurse is speaking with a client who is taking glipizide to treat
type 2 diabetes mellitus and has called to report feeling shaky,
hungry, and fatigued. which of the actions should the nurse instruct
the client to take?

perform a fingerstick blood glucose check

a nurse is assessing a client who has a new prescription for
levothyroxine the nurse should identify which of the following
findings as a contraindication

recent MI

a nurse is educaton the parent of a child who has Prader willi
syndrome and has been prescribed somatropin. which of the following
statements by a parent indicates understanding of the teaching?

we will use a different spot for injection each time we give the medication

a nurse is teaching a client who has a prescription for glipizide
what instruction should the nurse include

avoid alcohol

a nurse is teaching a client about acarbose to treat 2 diabetes.
which of the following instructions should the nurse include?

eat more iron rich foods

a nurse is caring for a client who is about to begin insulin glargine
therapy. the nurse should identify the need for additional precautions
because the client also takes which drugs ?

beta blockers

a nurse is caring for a client who is begin taking somatropin. the
nurse should explain the need to monitor which of the following lab values?


urine calcium

blood glucose

a nurse is caring for a client who takes repaglinide 15 to 30 minutes
before each meal to treat type 2 DM. the client asks if i skip a meal
what should i do? which of the following responsese should the nurse make?

skip the dose

a nurse is teaching a client who has a prescripiton for pramlinitide
therapy to treat type 1 DM. which of the following instructions should
the nurse include?

administer before meals

which of the following drugs should a nurse have available for a
client who is experiencing insulin toxicity?

glucagon

a nurse is caring for a client who is taking metformin to treat type
2 dm and reports muscle pain. which of the following adverse reactions
should the nurse suspect?

lactic acidosis

a nurse is caring for a client who is taking desmopressin. the nurse
should make whihc of the following assessments to evaluate the drugs effectiveness?

urine output

when considering replacement therapy options for a client who has
chronic adrenocoritcal insufficiency, a nurse should recognize the
provider will choose which drug?

hydrocortisone

a nurse administers pramlintide at 0800 to a client who has type 1
DM. at which of the following times should nurse expect the drug to
exert its peak ?

0820

a nurse is caring for a client who is taking pioglitazone to treat
type 2 dm. the nurse should monitor for which of the following
findiings ?

weight gain

a nurse is caring for a male client who has an upper urinary tract
infection. the nurse should identify that the infection is in which of
the following portions of the urinary tract

kidney

a nurse is reinforcing teaching with a client who has a urinary tract
infection and a prescription for cipro. which of the following
instructions should the nurse include?

� you should not take an antacid within 2 hours of taking cipro

a nurse is assisting with the development of plan of care for a
client who has cystitis. which of the following interventions should
the nurse include in the plan of care?

provide the client with a warm sitz baths

a nurse is reviewing the medical record of an older adult male
client. the nurse should identify that which of the following findings
place the client at risk for developing a uti?

the client has prostate disease

a nurse is collecting data from a client who has urosepsis. which of
the following findings should the nurse expect?

decreased urinary output

a nurse is caring for a client who has a new prescription for
maraviroc therapy. the nurse should instruct the client to report
which of the following adverse effects?

ParesthesiaCoughJaundiceFever

a nurse should recognize that realtegravir is used to treat clients
who have which of the following conditions?

Resistant HIV disease

a nurse is caring for a client who has a prescription for cisplatin
to treat testicular cancer. the nurse should instruct the client to
report which of the following adverse effects?

ParesthesiasSore throatFlank painTinnitus

a nurse is teaching a client about recommended immunizations. which
of the following immunizations should the nurse recommend the client
receive starting 50 years of age?

herpes zoster

a nurse is assessing a client following a trastuzumab infusion to
treat metastatic breast cancer. which of the following findings should
the nurse recognize as an indication that the client is experiencing
an adverse reaction to the drug?

wheezing
dysrhythmias
hypotension
fever

a nurse is teaching a client about maraviroc. which of the following
instructions should the nurse include?

it is important to report any noticeable rash immediately as it
might indicate an issue with your liver

a nurse is teaching a guardian of a child about the recommended age
range to recieve the hpv vaccine which of the following age ranges
should the nurse include?

11 to 12

A nurse is teaching a client who has a new prescription for
mercaptopurine to treat leukemia. Which of the following instructions
should the nurse include?

Use contraception if pregnancy is a riskPerform oral hygiene
frequentlyPerform hand hygiene frequentlyAvoid activities
that can cause injury

A nurse is instructing a client how to self- administer enfuvirtide.
Which of the following instructions should the nurse include?

Allow the vial to sit until the solution is completely clear and
without particulates

a nurse is teaching about immunizations . which of the following
information should the nurse include in the teaching?

you should receive a tetanus booster every 10 years

a nurse is teaching a client who has a new prescription imatinib to
treat chronic myeloid leukemia. which of the following instructions
should the nurse include?

clean fruits and veggies thoroughly
weigh yourself daily
perform hand hygiene
avoid grapefruit and grapefruit juice

a nurse should recognize that enfuvirtide can be prescribed to
clients who have which of the following conditons?

advanced HIV

a nurse is caring for a client who has a new prescription for
ritonavir and zidovudine is prescribed with ritonavir for which of the
following reasons?

to prevent drug resistance

a nurse is preparing to administer enfuvirtide to a client. which of
the following actions should the nurse plan to perform?

-Administer the drug subcutaneously.-Roll the vial gently to
reconstitute the solution.-Inject the solution at room temperature.

a nurse is caring for a client who has a new prescription for
delavirdine therapy to treat HIV 1. the nurse should instruct the
client to report which oft he following adverse reactions to the drug?

rash

A nurse is preparing to administer paclitaxel IV to a client who has
ovarian cancer. Which of the following actions should the nurse take.
(Select all that apply).

-Give the patient an antihistamine.-Administer the drug through
non-PVC tubing.-Use an in-line filter.

A nurse is teaching the guardian of a 4- month- old infant about
recommended immunizations for the infant. Which of the following
immunizations should the nurse include?

Haemophilus influenza type B vaccine (Hib)

A nurse is caring for a client who has a new prescription for
intrathecal cytarabine therapy to treat meningeal leukemia. The nurse
should inform the client that they will also receive which of the
following drugs to reduce the risk of neurotoxicity?

Dexamethasone

A nurse is caring for a client who is receiving vincristine to treat
lung cancer. The nurse should monitor the client and recognize which
of the following manifestations as an indication that the client is
experiencing an adverse reaction to the drug.

Weak hand grasps.

A nurse is caring for a client who is prescribed zidovudine. Which of
the following laboratory values should the nurse report to the provider?

hemoglobin 7.1

A nurse is preparing to administer the measles, mumps, and rubella
(MMR) vaccine to a child. The nurse should recognize that the MMR
vaccine provides which of the following types of immunity?

Artificial active immunity

A nurse is teaching a client who has a new diagnosis of breast cancer
about the drug tamoxifen. The nurse should tell the client that which
of the following conditions is a contraindication for taking tamoxifen?

Deep-vein thrombosis

A nurse is caring for a client who has a new prescription for
topotecan therapy to treat resistant, small-cell lung cancer. The
nurse should advise the client against taking which of the following
types of over-the-counter drugs while receiving the therapy?

ibuprofen

A nurse should recognize that maraviroc is used in the treatment of
which of the following conditions?

Chemokine receptor 5 (CCR5)-tropic HIV-1

A nurse is considering drug therapy options for a client who has
metastatic breast cancer that is positive for human epidermal growth
factor receptor 2 (HER2). Which of the following drugs should the
nurse expect the provider to prescribe?

Trastuzumab

THE LPN IS OBSERVING THE CLIENTS CARDIAC RHYTHM ON THE MONITOR SCREEN
AND NOTES THAT THERE IS AN ADDITIONAL PROMINENT WAVE FOLLOWING EACH T
WAVE AND SUSPECTS THE PRESCENCE OF U WAVES. WHAT ACTIONS SHOULD THE
LPN TAKE?

...

what are some causes of Fluid Volume Deficit ?

Vomiting
Diarrhea Gi irritation Gi suctioning
Ileostomy or colostomy grainage Draining wounds, burns,
or fistulas Increased urine output from the use of
diuretics

suspected data for a client with fluid volume deficit?

thirst poor skin turgor dry mucous
membranes increased hr thready pulse
dyspnea postural HYPOtension weight loss
flat neck or hand veins dizziness
weakness increased specific gravity of the urine
confusion increased hematocrit decrease in urine
volume and dark concentrated urine

interventions for fluid volume deficit?

Cause is treated Replace fluids IV
solutions Oral rehydration Monitor
vitals, respiratory and neurological status Administer
O2 Check mucous membranes and skin turgor Monitor
weight daily Monitor hematocrit &
electrolytes Prepare to treat electrolytes

a client with kidney damage or failure is at high risk for what?

fluid volume excess

possible causes of fluid volume excess ?

Overhydration with IV fluids Kidney damage
Hf Long term use of corticosteroids Excessive
sodium ingestion Syndrome of inappropriate antidiuretic
hormone secretion Irrigation of wounds or body cavities
with hypotonic fluids

Objective and Subjective data collection for a client who is
experiencing fluid volume excess?

Cough Dyspnea Lung crackles
Increased respirations and heart rate Increased blood
pressure Bounding pulse Pitting edema
Weight gain Neck and hand vein distention
Increased urine output Confusion Decreased
hematocrit

interventions for a client who is experiencing fluid volume excess?

Monitor vitals, respiratory, neurological status
Position in semi-fowlers Administer
diuretics as prescribed Monitor hematocrit and
electrolyte levels Restrict fluids
Low sodium diet
`

what type of diet should a person experiencing fluid volume excess be on?

low sodium

HYPOkalemia

potassium values less than 3.5mEq/L
life threatening

food sources for potassium

Avocados Bananas Cantaloupe
Oranges Strawberries Tomatoes
Carrots Mushrooms Spinach Fish
Pork Beef Veal Potatoes
Raisins

causes of hypokalemia

Potassium losing diuretics
Diarrhea
Vomiting
Gastric suction
Corticosteroids or laxative Kidney disease
Parenteral nutrition Uncontrolled diabetes
Alkalosis

s/s of HYPOkalemia

Leg cramps Abdominal cramps
Lethargy Weakness Shallow respirations
Thready pulse Confusion Decreased
reflexes HYPOactive bowel sounds and ileus
Postural hypotension
Peaked P waves
Flat T waves
Depressed ST segment and U waves

a nurse is caring for a group of clients who have mobility issues.
which of the following clients is at the greatest risk for a complication?

a 3 year old client who has a burned foot
an 80 year old client who has a fractured hip
a 30 year old client who has a cast applied for a fractured
ankle
a 42 year old client who has an indwelling urinary
catheter

an 80 year old client who has a fractured hip

a nurse manager has established staff nurse committees to address
unit issues, instituted an open door policy for talking about
concerns, and supported the professional development of all staff
members. which of the following leadership is this nurse manager?

Laissez- faire
autocratic
democratic
transformational

democratic

an experienced nurse is serving as a mentor to a newly licensed
nurse. which of the following actions should the mentor perform?

establish a set of goals for the newly licensed nurse to
achieve
establish a set timeframe with the newly licensed nurse for
the mentorship
serve as a guide and teacher for the newly licensed nurse in
an established relationship
develop a program of study for for the newly licensed nurse
to follow

serve as a guide and teacher for the newly licensed nurse in an
established relationship

a nurse on a medical surgical unit is planning for a group of
clients. which of the following clients should the nurse attend to first?

a newly admitted client who is scheduled to have an
indwelling urinary catheter inserted
a client who has kidney stones and reports flank pain of 6
on a scale of 0 to 10
a client diagnosed with early stage chronic kidney disease
who has a serum creatinine level of 2.0 mg/dl
a client who has a cast newly applied on the forearm and
reports tingling of the fingers

a client who has a cast newly applied on the forearm and reports
tingling of the fingers

rationale : use ABC's to collect data

a nurse is a member of a quality improvement committee seeking to
reduce the risk of adverse events in a health care facility. when
reviewing recently submitted incident reports, which of the following
incidents should the nurse identify as a sentinel event? \

paralysis of a clients lower extremeties occurred following
epidural anesthesia
a client fall during ambulation did not result in client
injury
a complaint that a nurse was culturally insensitive was made
by a client's family member
surgery to the wrong site was stopped prior to a procedure.

paralysis of the clients lower extremeties occurred following
epidural anesthesia

a nurse in an urgent care facility is preparing to administer a stat
dose of medication to a toddler who is accompanied by their parent.
the child is not wearing an identification band. How should the nurse
identify the client?

ask the child to say their name
say the childs name and ask them if that is correct

ask the parent to identify the child by name
hold the medication until the child receives an id band

ask the parent to identify the child by name

a nurse is reviewing a new prescription by a provider. the nurse
should verify that which of the following components of a prescription
are present? Select all that apply

dat and time of prescription
client's diagnosis
dosage of medication
route of administration
generic name of medication
providers signature

Date and time
dosage of medication
route of administration
generic name of medication
providers signature

A nurse receives a telephone prescription from a provider. The
provider states " administer three-tenths of a milligram of
nitroglycerin orally to the client." How should the nurse
trasncribe "three-tenths of a milligram" on the MAR?

.3 mg
3/10's mg
0.30 mg
0.3 mg

0.3

a nurse is preparing to administer medication to the client. which of
the following should the nurse use to identify the client? select all
that apply

client's telephone number
client's place of birth
client's hospital room number
client's photograph
client's assigned id number

telephone number
name
photograph
assigned id number

a nurse is asked to administer a medication to a client because a
coworker must help with an emergency. the coworker gives the nurse a
syringe labeled furosemide 20 mg. the label also includes the client's
name and hospital id number. which of the following responses by the
nurse is appropriate?

"I'll go and give the medication to the client right
away"
"go with me to identify the client properly, and then
i'll give the medication for you"
"you should ask the charge nurse to administer the
medication"
I'll go help with the emergency situation while you
administer the medication"

I'll go help with the emergency situation while you administer the medication

a nurse is administering medications to a client. which of the
following actions should the nurse perform during the planning step of
the nursing process?

identify client allergies
calculate the dose
explain the purpose of the medication to the client

observe the adverse effects of the medication
verify the dose

calculate the dose
verify the dose

a charge nurse is explaining her understanding of quality improvement
to a newly hired LVN. which of the following statements by the newly
hired nurse requires further teaching?
" the joint commission mandates that accredited
agencies have quality improvement programs quality
improvement measures the degree to which an agency has met a
criterion nurses who provide direct care are an integral
component of the quality process

quality improvement measures the degree to which an agency has met a criterion

rationale: quality improvement promotes quality care and
focuses on prevention. quality assurance measures the degree to
which an agency has met a criterion

magnet recognition program

healthcare organizations that participate in this program must
collect data about nursing sensitive outcomes

which of the following is an iatrogenic risk factor that can increase
a client's risk for falls ?
decreased visual acuity urinary urgency or
nocturia type and number of medications prescribed for the
client

type and number of medications prescribed for the client

rational: prescription medications are iatrogenic risk
factors, which are related to the treatment regimen

a charge nurse receives notification of the admission of a client who
is coughing frequently and whose sputum is pink, frothy, and copious.
the client has a history of night sweats, anorexia, and weight loss.
which ofthe following actions should the nurse take?

assign the client to a private room with negative pressure
airflow
add contact precautions to the clients plan of care

wear n95 respirator when entering the client's room

ensure the clients enviornment provides 4 exchanges of fresh
air per minute
institute protective environment precautions as soon as the
client arrives?

assign the client to a private room with negative pressure airflow
wear an n95 when entering the clients room

rationale: history and status suggests TB. communicable
infection, airborne precautions

a nurse is assisting with the plan of care for a client who has
cushings syndrome due to chronic corticosterioid use. which of the
folllowing actions should the nurse include in the plan of care?
check the clien'ts blood glucose for hypoglycemia
check for hypertension weight the client weekly
insert an indwelling catheter

check for hypertension

rationale: the nurse should check for hypertension which can
indicate fluid volume overload

a nurse is collecting data from a client who has pericarditis. which
of the following manifestations should the nurse expect?
bradycardia relief of chest pain with deep
inspiration dyspnea chest pain that increases when
sitting upright

dyspnea

rationales: pericarditis clients will experience dyspnea,
hiccups and nonproductive cough which may indicate heart failure

a nurse collecting data from a client who has a closed head injury
and is receiving mannitol for manifestations of increase intracranial
pressure. which of the following findings indicates the medication is
having a therapeutic effect?
the clients urine output is 250mL the clients
pupils are dilated the clients heart rate is 56/min
the client is restless

the clients urine output is 250 mL/hour

rationale: mannitol is an osmotic diuretic used to reduce
cerebral edema by drawing water from the brain tissue.

a nurse is reinforcing discharge teaching with a client who is
postoperative following a right mastectomy for breast cancer. the
client will be going home with 2 jackson pratt drains. which of the
following peices of information should the nurse include in the teaching?
cloudy drainage is normal showering is permitted
before the drainage tubes are removed avoid wearing
deodorant until the drains are removed and incision heals
do not begin exercising the arm until the provider removes the
drainage tubes.

avoid wearing deodorant until the drains are removed and the incision heals

rationale: avoid deodorant and talcum powder until healed

a nurse is caring for a client who has just returned from the
surgical suite following a right nephrectomy. which of the following
indicates that the client is meeting successful short term goal
following this procedure ?

the client requests pain medication upon arrival from
surgery
a chest x-ray shows consolidation in the right lower lobe

urinary output is 35 to 50mL hr consistently
the client has slight abdominal distention

urinary output is 35 to 50 mL/hr

rationale: less than 30 mL indicates inadequate blood flow to
the remaining kidney

a nurse is collecting data from a client who is postop following
ESWL. the nurse should identify that which of the following findings
is the priority?
report of palpitations pink-tinged urine
bruising on the flank area stone fragements in the
urine

report palpations

rationale: think of ABC's

a nurse is collecting data from a client who is admitted to the
facility for observation following a closed head injury. which of the
following data is the priority for the nurse to collect to detect a
change in the client's neurological status?
vital signs body posture level of
consciousness examination of pupils

Level of consciousness

rationale : change in LOC can be first indication of a change
in neurologic status

A nurse is reinforcing teaching about hypoglycemia with a client who
has DM. which of the following manifestations should the nurse include?
bradycardia diaphoresis deep, rapid
respirations palpitations shakiness

diaphoresis, shakiness, palpitations

a nurse is caring for a client who has lung cancer that has
metastasized. which of the following findings indicates the client is
developing superior vena cava syndrome?
irregular cardiac rhythm numbness in the hands
muscle cramps facial edema

facial edema

rationale: svc is partial occlusion of the superior vena cava
leading to decreased blood flow through the vein the earliest
manifestation is facial and upper extremity edema

a nurse is caring for a client who has 20 year history of COPD and is
receiving oxygen at 2 L/min via nasal cannula. the client is dyspneic
and has an oxygen sat via pulse ox of 85% which of the following
actions should the nurse take ?
place a nonrebreather mask on the client and increase the
oxygen flow to 3L/min prep the client for possibility of
endo intubation and mechanical ventilation increase the
oxygen flow and request an arterial blood gas determination
position the client supine and administer an antianxiety
medication

increase the oxygen flow and request an arterial blood gas determination

rationale: increase the flow and evaluate its effectivness
with ABG results

a nurse is preparing an automated external defib. for a client
receiving CPR after a cardiac arrest. which of the following actions
should the nurse perform first?
press the analyze button on the machine stop CPR
and move away from the client push the charge button to
prepare to shock apply the defib pads to the clients
chest

apply the defib pads to the clients chest

a nurse is reinforcing discharge teaching with a client who has
aplastic anemia. which of the following statements should the nurse
identify as an indication that the client understands instructions?
I need to stay active to prevent blood clots in my legs
if i have a bad headache I can take aspirin to get rid of
it i should eliminate uncooked foods from my diet for
now i should eat more iron fortified cereal to stregthen my
blood

I should eliminate uncooked foods from my diet for now

rationale: eating thoroughly cooked foods can help prevent
infections avoid raw fruits and veggies

a nurse names 3 objects for the client to remember, asks the client
to repeat them, and tells the client he will have to repeat them again
in a few minutes. after 5 minutes, the nurse asks the client to name
the objects. the nurse is using this strategy to test which type of memory?

immediate

rationale: 3 object protocol involved

a nurse is reinforcing discharge teaching with the partner of a
client who has AIDS. which of the following statements by the clients
partner indicates further teaching?
i will dispose of soiled tissues in a separate plastic
bags I'll clean blood spills immediately with hot water
I know that handwashing is an important preventive measure
i will wash soiled clothes in hot water

I'll clean blood spills immediately with hot water

rationale: clean with bleach and wear gloves

during a neurological eval. a nurse asks how the client arrived at
the appointment and with whom. which of the following types of memory
is the nurse testing?

recall/ recent

a nurse is reinforcing teaching about dietary modifications for a
client with newly diagnosed with cirrhosis. which of the following
foods should the nurse recommend ?
grilled chicken potato soup fish
sticks baked ham

grilled chicken

A NURSE IS REINFORCING DISCHARGE TEACHING TO A CLIENT FOLLOWING OPEN
RADICAL PROSTATECTOMY. THE CLIENT IS GOING HOME WITH AN INDWELLING
URINARY CAT. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES
UNDERSTANDING OF THE TEACHING ?
1. I WILL BE ABLE TO TAKE A TUB BATH IN 1 WEEK
2. i WILL TAKE ACETAMINOPHEN IF i HAVE ANY PAIN
3. i WILL USE SUPPOSITORIES TO PREVENT CONSTIPATION
4. i WILL REGAIN MY BLADDER CONTROL ONCE THE CATHETER IS REMOVED

TAKE ACETAMINOPHEN IF PAIN

A NURSE IS COLLECTING A HEALTH HISTORY FROM A CLIENT WHO HAS SKIN
CANCER. WHICH OF THE FOLLOWING CLIENTS HISTORY AT THE HIGHEST RISK
FACTOR FOR DEVELOPING SKIN CANCER
1. AGE OVER 60
2. GENETIC PREDISPOSITION
3. LIGHT SKINNED RACE
4. OVER EXPOSURE TO SUNLIGHT

OVER EXPOSURE TO SUNLIGHT

A NURSE IS CARING FOR A CLIENT WHO IS RECEIVING CHEMO TO TREAT
CANCER. WHICH OF THE FOLLOWING EFFECTS SHOULD THE NURSE ANTICIPATE
FROM THE CHEMO>
1. GINGIVAL HYPERPLASIA
2. HIRSUTISM
3. PANCYTOPENIA
4. WEIGHT GAIN

PANCYTOPENIA
- BONE MARROW SUPPRESSION
- DEFICIENCY OF WBCS, RBCS AND PLATELT COUNTS
- ADVERSE EFFECT OF CHEMO

A NURSE IS CARING FOR A CLIENT WHO HAS LUNG CANCER THAT HAS
METASTASIZED. WHICH OF THE FOLLOWING INDICATES THE CLIENT IS
DEVELOPING SUPERIOR VENA CAVA SYNDROME?
1. IRREGULAR CARDIAC RHYTHM
2. NUMBNESS IN THE HANDS
3. MUSCLE CRAMPS
4. FACIAL EDEMA

FACIAL EDEMA

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS CANCER AND IS
RECEIVING CHEMOTHERAPY BY PERIPHERAL IV INFUSION. THE CLIENT REPORTS
PAIN AT THE INSERTION SITE AND THE NURSE NOTES FLUID LEAKING AROUND
THE CATHETER. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST?
1. TAKE A PHOTOGRAPH OF THE PERIPHERAL IV SITE
2. OBTAIN AN RECORD THE CLIENTS VITAL SIGNS
3. STOP THE INFUSION
IDENTIFY ALL MEDICATIONS ADMINISTERED THROUGH THE IV SITE FOR THE
PAST 24 HRS

STOP THE INFUSION

A NURSE IS CARING FOR A CLIENT WHO HAS TESTICULAR CANCER AND IS
EXPERIENCING PERIPHERAL NEUORPATHY AS AN ADVERSE EFFECT OF CHEMO.
WHICH OF THE FOLLOWING CLIENT MANIFESTATIOS IS AN EXPECTED FINDING OF
PERIPHERAL NEUROPATHY?
1. THINNING OF THE SCALP HAIR
2. TINGLING OF THE HANDS AND FEET
3. REDUCED ABILITY TO CONCENTRATE
4. SORES IN THE MUCOUS MEMBRANES

TINGLING IN THE HANDS AND FEET

A NURSE IS COLLECTING DATA FROM A CLIENT. WHICH OF THE FOLLOWING
FINDINGS IS THE HIGHEST RISK FACTOR FOR DEVELOPING BLADDER CANCER
1. THE CLIENT IS A HAIRDRESSER
2. THE CLIENT USES TOBACCO
3. THE CLIENT IS OVER 60 YEARS
4. THE CLIENT HAS FREQUENT UTIS

THE CLIENT USES TOBACCO

A nurse is planning care for client who has cancer and has developed
thrombocytopenia following chemotherapy. Which of the following
precautions should the nurse offer to minimize the adverse effects of thrombocytopenia?
1. MONITOR VISITORS FOR MANIFESTATIONS OF INFECTION
2. REMIND THE CLIENT TO USE AN ELECTRIC RAZOR
3. ENCOURAGE FREQUENT REST PERIODS
4. INSTRUCT THE CLIENT TO RINSE MOUTH DAILY WITH NORMAL SALINE

REMIND THE CLIENT TO USE AN ELECTRIC RAZOR
NEUTROPENIA PROHIBIT VISITORS, THROMBOCYTOPENIA DO NOT

A nurse is collecting a health history from a female client who is
undergoing screening for breast cancer. Which of the following factors
should the nurse identify for placing the client at the greatest risk
for developing breast cancer?
1. OBESITY
2. ORAL CONTRACEPTIVE USE
3. ALCOHOL USE
4. OVER 50 YEARS OF AGE

OVER 50 YEARS OF AGE

A nurse is providing teaching to a client who has cancer and is
receiving external radiation therapy. Which of the following
statements by the client indicates an understanding of the teaching?
1. I NEED TO PROTECT THE AREA FROM SUNLIGHT
2. IM GOING TO APPLY SKIN LOTION TO THE AREA EVERY DAY
3. ILL MASSAGE THE AREA ONCE PER DAY
4. ILL WASH THE MARKINGS OFF AFTER EACH THERAPY TREATMENT

I NEED TO PROTECT THE AREA FROM SUNLIGHT

A nurse is providing postoperative discharge teaching to a client
following a pan hysterectomy for uterine cancer. Which of the
following information should the nurse include in the teaching?
1. YOU WILL NEED TO CONTINUE TO USE SOME FORM OF BIRTH CONTROL FOR
6 MONTHS
2. YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE
3. DO NOT LIFT ANYTHING HEAVIER THAN 15 POUNTS
4. PAIN OR BURNING ON URINATION IS AN EXPECTED OUTCOME OF THIS SURGERY

YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE

A nurse is admitting a client who has multiple myeloma and a white
blood cell count of 2,200/mm3. Which of the following foods should the
nurse prohibit the family members from bringing to the client?
1. FRIED CHICKEN FROM A FAST FOOD RESTURAUNT
2. A CASE OF CANNED NUTRITIONAL SUPPLEMENTS
3. A FACTORY SEALED BOX OF CHOCOLATES
4. A FRESH FRUIT BASKET

A FRESH FRUIT BASKET

A nurse is obtaining a health history from a client who has cancer of
the cervix. Which of the following manifestations should the nurse expect?

VAGINAL BLEEDING

A nurse in an oncology clinic is assessing a client who has early
stage Hodgkin's lymphoma. Which of the following findings should the
nurse expect?
1. BONE AND JOINT PAIN
2. ENLARGED LYMPH NODES
3. INTERMITTENT HEMATURIA
4. PRODUCTIVE COUGH

ENLARGED LYMPH NODES