MED SURG FINAL EXAM NEWEST 2024 ACTUAL EXAM TEST BANK 250 QUESTIONS AND CORRECT DETAILED A, Exams of Nursing

Download MED SURG FINAL EXAM NEWEST 2024 ACTUAL EXAM TEST BANK 250 QUESTIONS AND CORRECT DETAILED A and more Exams Nursing in PDF only on Docsity! 1 MED SURG FINAL EXAM NEWEST 2024 ACTUAL EXAM TEST BANK 250 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A nurse is completing a preoperative teaching plan for a client who is to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? Select all that apply Select one or more: a. Having the patient roll onto the operative hip b. Possible use of an abductor device or pillow between the legs when turning c. Sitting in a low reclining chair d. Performing isometric exercises - ...ANSWER...B - possible use of an abductor device or pillow between the legs when turning, D - performing isometric exercises A nurse is presenting g information to clients at a health fair on measures to reduce the risk of amputation. Which of the following information should the nurse provide Select one or more: a. Unplug electrical equipment when having repairs b. encourage clients who have diabetes mellitus to maintain blood glucose within the reference ranges c. Encourage clients who smoke to consider smoking cessation programs. d. Advise clients to wait 2 hrs after taking pin medication before driving - ...ANSWER...B - encourage clients who have 2 diabetes mellitus to maintain blood glucose within the reference ranges, C - encourage clients who smoke to consider smoking cessation programs A client who had an above the knee amputation reports having sharp, stabbing type of phantom pain. Which of the following is an appropriate action by the nurse. ? Select one: a. Facilitate counseling services b. Administer an antiepileptic medication c. Question rather the pain is real d. Encourage cold therapy treatments - ...ANSWER...B - administer antiepileptic medication A nurse is assessing a client who has a casted compound fracture of the right forearm Which of the following finds is an early indication of neurovascular compromise? Select one: a. Pallor b. Pulselessness c. Paralysis d. Paresthesia - ...ANSWER...D - paresthesia A nurse is caring for a client who has a laboratory finding of serum potassium of 5.4 mEq/L, The nurse should assess for which of the following clinical manifestations? Select one: a. Constipation b. EKG changes c. Hypotension d. Polyuria - ...ANSWER...B - EKG changes 5 d. Constipation - ...ANSWER...B - increasing muscle strength The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurses priority when monitoring for GI bleeding? Select one: a. The 40 yr old client who is positive for H. Pylori b. The 45 yr old client who drinks 4 ounces of alcohol a day c. The 70 year old client who takes daily baby aspirin of 81 mg d. The 30 year old client taking acetaminophen prn - ...ANSWER...C - the 70 year old client who takes daily baby aspirin of 81 mg The nurse is instructing the new nurse on her floor. She explains that the definitive diagnosis of PUD involves which test? Select one: a. A urea breath test b. Upper GI endoscopy c. Barium contrast studies d. The string test - ...ANSWER...B - Upper GI endoscopy While performing a home visit, the nurse observes that the clients head of the bed is raised on 6 inch blocks. The nurse should question the client for history of which conditions? Select all that apply. Select one or more: a. Hiatal Hernia b. Dumping syndrome c. Crohns disease d. Gastritis 6 e. GERD - ...ANSWER...A - Hiatial Hernia, D - Gastritis, E - GERD Which clinical manifestations would be present in a patient with DI? Select all that apply Select one or more: a. Polydipsia b. Polyuria c. Decreased urine output d. Increased hemoglobin - ...ANSWER...A - Polydipsia, B - polyuria What breakfast would you encourage the client to order to help relieve constipation? Select one: a. Bran cereal and fresh fruit b. Bran cereal and yogurtBran cereal and yogurt c. Yogurt and fresh fruit d. Fresh fruit and white toast - ...ANSWER...A - bran cereal and fresh fruit Ninety minutes after the subcutaneous insulin apart( Novolog) is administered, The client rings his call light. The nurse enters the room and finds the client is awake and oriented but anxious and diaphoretic. The client has a headache and feeling of fatigue. Capillary blood glucose is 51mg/dL. What action should the nurse take first? Select one: a. Contact the health care provider b. Administer intravenous dextrose 50%. c. Have the patient drink orange juice 4 oz d. Administer intramuscular glucagon. - ...ANSWER...C - have the patient drink orange juice 4 oz 7 A nurse is teaching clients in an outpatient facility about the use of insulin to treat type 1 diabetes mellitus. For which of the following type of insulin should the nurse tell the clients to expect a peak effect 1 to 5 hours after administration? Select one: a. Insulin glargine (Lantus) b. NPH insulin ( Humulin N) c. Regular Insulin ( Humulin R) d. Insulin Lispro ( Humalog) - ...ANSWER...C - regular insulin (Humulin R) A nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting Metformin ( Glucophage). The nurse should monitor the client for which of the following adverse effects? Select one: a. Lactic acidosis b. Hypoglycemia c. Hyperlipidemia d. Respiratory alkalosis - ...ANSWER...A - Lactic acidosis A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes melllitus. Which of the following should the nurse include in the information? Select all that apply. Select one or more: a. Eat less meat and processed foods. b. Decrease intake of saturated fats c. Increase daily fiber intake d. Limit saturated fat intake to 15% of daily caloric intake e. Include omega -3 fatty acids in the diet. - ...ANSWER...A - eat less meat and processed foods, B - decrease intake of 10 For which of the following blood glucose results would the nurse administer a fast sugar? Select one: a. 48 b. 82 c. 126 d. 223 - ...ANSWER...A - 48 Which breakfast menu is most appropriate for a patient with diabetes? Select one: a. Two eggs, bacon,orange juice, coffee b. Oatmeal with artificial sweetner, whole grain toast, tea c. One half grapefruit, cranberry juice, bagel wiht sugar-free jelly d. One slice whole-grain toast with peanut butter, skim milk, orange juice - ...ANSWER...D - one slice whole - grain toast with peanut butter, skim milk. orange juice Which of the following symtoms is most commonly associated with hyperglycemia? Select one: a. Tremor b. Flank pain c. Sweating d. Polyuria - ...ANSWER...D - polyuria The nurse is caring for a client diagnosed with GERD. Which nursing intervention should be implemented? Select one: a. Place the client prone in bed and administernonsteroidal anti infllammatory medications 11 b. Hae the client remain upright at all times and walk for 30 minutes three times a week c. Instruct the client to maintain a right lateral side lying position and take antacids before meals d. Elevate the head of the bed 30 degrees and discuss lifestyle modification - ...ANSWER...D - elevate the head of the bed 30 degrees and discuss lifestyle modifications The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? Select one: a. Tachycardia b. Cool, clammy skin c. Acute flank pain d. Diminished deep tendon reflexes - ...ANSWER...D- diminished deep tendon reflexes A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Select one: a. Osmosis and osmolality b. Hydrostatic pressure c. Active transport d. Diffusion - ...ANSWER...A - osmosis and osmolality 12 The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect? Select one: a. Hypermagnesemia b. Hypophosphatemia c. Hypocalcemia d. Hyperkalemia - ...ANSWER...C - hypocalcemia One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal? Select one: a. Help evaluate pituitary gland function b. Help provide an effective treatment for hypertension- induced oliguria c. Help distinguish hyponatremia from hypernatremia d. Help distinguish reduced renal blood flow from decreased renal function - ...ANSWER...D - help distinguish reduced renal blood flow from decreased renal function The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response? 15 a. Green Vegetables b. Liver c. Beef d. Poultry e. Milk - ...ANSWER...B - liver, D - poultry, E - milk The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Select one: a. Hypertension b. Increased DTRs c. Shallow respirations d. Kussmaul respirations - ...ANSWER...C - shallow respirations A client's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? Select one: a. Apples b. Rice c. Fish d. Bananas - ...ANSWER...D - bananas The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? Select one: a. Hyponatremia b. Hypocalcemia c. Hyperkalemia 16 d. Hypermagnesemia - ...ANSWER...B - hypocalcemia A nurse is caring for a client who has a NG tube attached to low intermittent suction. The nurse should monitor for which of the following electrolyte imbalances? Select one: a. Hyponatrimia b. Hyperphosthatemia c. Hypercalcemia d. Hypomagnesemia - ...ANSWER...A - hyponatrimia The nurse should assess which of the following symptom in an adult patient admitted with diarrhea and dehydration Select one: a. Disorientation, poor skin turgor b. Pale color urine, bradycardia c. Hct d. Lung congestion - ...ANSWER...A - disorientation, poor skin turgor Which of the following is the most reliable way to monitor a patient's fluid status? Select one: a. Lung sounds b. I & O c. Skin Turgor d. Daily weights - ...ANSWER...D - daily weights Which patient at at most risk for fluid excess? Select one: a. An elderly man receiving IV therapy b. A middle aged man following surgery 17 c. A teen with multiple injuries following an accident d. The patient with pneumonia - ...ANSWER...A - an elderly man receiving IV therapy A patient is being discharged from an admission for a fluid imbalance. Which instruction should take priority? Select one: a. "Drink 8 glasses of water per day." b. "Call your doctor if you weak or tired" c. "Weigh yourself at the same time everyday and report any changes." d. "Measure everything you drink and how much you urinate a day." - ...ANSWER...C - Weigh yourself at the same time everyday and report any changes A patient is being placed on a diuretic which foods are high in potassium and should be recommended by the nurse. Select all that apply Select one or more: a. Bread b. banana c. tomato Juice d. Potato - ...ANSWER...B - banana, C - tomato juice, D - potato A nurse caring for a patient receiving D5W at 250 mL/hr. Which of the following finding are an indication of fluid overload? Select one or more: a. Hypotension b. Distended neck veins c. Shortness of breath d. Crackles in lungs 20 c. muscles d. blood vessels - ...ANSWER...A - nerves, C - muscles, D - blood vessels A nurse is providing information to a client newly diagnosed with RA. Which of the following statements by the nurse is appropriate? Select one: a. You will have morning stiffness b. You may have abdominal pain with joint pain c. You will have increased pain at night d. You may gain weight - ...ANSWER...A - you will have morning stiffness The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply Select one or more: a. rotation b. elevation c. Ice d. rest e. compression - ...ANSWER...C - ice, D - rest, E - compression Which nursing assessment finding would indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier? Select one: a. chills b. extreme pain with no relief c. confusion 21 d. cardiac arrest - ...ANSWER...B - extreme pain with no relief The nurse is caring for a client who has had a fracture reduction using a cast. What is most important the nurse to assess? Select one: a. pain level b. neurovascular status c. renal function d. cardiac status - ...ANSWER...B - neurovascular status A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client? Select one: a. encourage deep breathing b. high protein diet c. signs of sepsis d. reduce urine output - ...ANSWER...C - signs of sepsis The nurse is planning an education program for women of childbearing years. What does the nurse recognizes as the primary prevention of osteoporosis? Select all that apply. Select one or more: a. a CT scan should be done yearly b. encourage weight bearing exercises. c. ensure adequate calcium and vitamin D intake d. assess calcium serum levels every six months - ...ANSWER...B - encourage weight bearing exercises, C - ensure adequate calcium and vitamin D intake 22 Michelle, age 66, is a regular at the outpatient orthopedic clinic; she has osteoarthritis of the hands and spinal osteoporosis What is the leading cause of osteoporosis? Select one: a. Folic acid deficiency b. Estrogen deficiency c. Progesterone deficiency d. Vitamin D deficiency - ...ANSWER...B - estrogen deficiency Which of the following is not a symptom of hypokalemia? Select one: a. Weak and slow heart rate b. Muscle twitches/cramps c. Decrease blood pressure d. Positive Chvostek sign - ...ANSWER...A - weak and slow heart rate The client is admitted with a serum sodium level of 110mEq/L. Which nursing intervention should be implemented? Select one: a. encourage fluids b. educate patient in foods rich in calcium c. initiate seizure precautions d. start an intravenous fluid - ...ANSWER...C - initiate seizure precautions A client is taken to the emergency department with an injury to the arm. Which intervention should the nurse implement first? Select one: a. Assess the nailbeds for capillary refill time 25 Select one or more: a. "Insulin permits entry of glucose into the cells of the body." b. Insulin promotes the storage of fat in adipose tissue c. Insulin promotes synthesis of proteins in various body tissues d. Insulin interferes with gluagon from the pancreas - ...ANSWER...A - insulin permits entry of glucose into the cells of the body, B - insulin promotes the storage of fat in adipose tissue, C - insulin promotes synthesis of proteins in various body tissues A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply Select one or more: a. Ketosis prone b. Obesity at diagnosis c. Little endogenous insulin d. Younger than 30 years of age - ...ANSWER...A - ketosis prone, C - little endogenous insulin, D - younger than 30 years of age A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply Select one or more: a. Hypernatremia b. Leukocytosis c. Dehydration 26 d. Hyperglycemia - ...ANSWER...A - hypernatremia, C - dehydration, D - hyperglycemia A client taking sucralfate ( Carafate) PO for PUD has been started on Dilantin to control seizures. Which of the following should be included in the client's teaching? Select one: a. Take both of these medications at the same time b. Take sucralfate with a glass of milk c. Allow a 2 hour interval between these medications d. Chew the pill before swallowing - ...ANSWER...C - allow a 2 hour interval between these medications A nurse is caring for a client who is starting omeprazole(Prilosic) PO for management of GERD. The nurse should recognize that this medication works by Select one: a. improving gastric motility b. decreasing the production of gastric acid c. neutralizing gastric acid d. antagonizing serotonin receptors - ...ANSWER...B - decreasing the production of gastric acid A nurse is providing instructions to a client who has a prescription for metronidazole ( Flagyl) to treat peptic ulcer. The client asks the nurse why this medication has been prscribed. Which of the following responses by the nurse is correct? Select one: a. " The purpose of this medication is to get rid of the infection giardiasis." b. " The purpose of this medication is to get rid of the infection from H. pylori" 27 c. " I dont know" d."The purpose of this medication is to increase the gastric acid in the stomach" - ...ANSWER...B - the purpose of this medication is to get rid of the infection from H. pylori A nurse is caring for a client who has a prescription for metformin. The nurse should inform the client for which of the following medication /food interaction? Select one: a. Concurrent use of iodine containing contrast media may result in acute kidney failure b. Do not eat high fiber foods c. Avoid Vitamin B 12 supplements d. Eat only three meals a day - ...ANSWER...A - concurrent use of iodine containing contrast media may result in acute kidney failure A client with type 2 diabetes is being started on NPH Humulin N insulin. The client asks when this medication will reach its peak? Select one: a. Thirty minutes b. Six to Fourteen hours c. Two to Four hours d. None - ...ANSWER...B - six to fourteen hours Which of the following is the best definition of diabetes mellitus? Select one: a. It is a disease in which high blood glucose results from defective insulin secretion or action b. It is a disease that causes polyuria and polydipsia 30 A nurse is admitting a client to an acute care facility for a total hip arthroplasty. The client takes hydrocortisone for Addison's disease. Which of the following actions is the nurse priority? a. Administering a supplemental dose of hydrocortisone b. Collecting additional info from the client about his history of Addison's disease c. Inserting an indwelling catheter d. Instructing the client about coughing and deep breathing - ...ANSWER...A - administering a supplemental dose of hydrocortisone A nurse is planning to create dietary guidelines for a client who has type 2 DM. Which of the following information should the nurse incorporate in the dietary plan? a. Exchange of carbohydrates is allowed b. Use hydrogenated oils for cooking c. Always have glucose tablets or lifesavers on you d. Drink orange juice everyday e. Carbohydrates should be 45-65% of total daily calorie intake f. Fresh fruit and vegetables should be incorporated in every meal - ...ANSWER...A - exchange of carbohydrates is allowed, C - always have glucose tablets or lifesavers on you, E - carbohydrates should be 45 - 65% of total daily calorie intake, F - fresh fruit and vegetables should be incorporated in every meal A male client, age 42, is diagnosed with DM. he visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client? a. History of radiographic contrast studies that used iodine b. The clients exercise routine 31 c. The clients consumption of carbs d. The clients mental and emotional status - ...ANSWER...C - the clients consumption of carbs The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care? a. Diarrhea due to GI hypermobility b. Anxiety due to forgetfulness and slowed speech c. Imbalanced nutrition due to insufficient calorie intake d. Activity intolerance due to increased metabolic rate - ...ANSWER...B - anxiety due to forgetfulness and slowed speech In the medical surgical unit that a patient has been admitted with hyperglycemia. The patient has confirmed the following symptoms in the past month during her admission that indicates hyperglycemia as a diagnosis. a. Oliguria b. Polyuria c. Tachycardia d. Polydipsia - ...ANSWER...B - polyuria, D – polydipsia RN MEDSURG FINAL EXAM VERSION 2 a nurse is planning dietary teaching for a client who has diabetes mellitus. which of the following actions should the 32 nurse plan to take first? - ...ANSWER...ask client to identify the types of foods she prefers caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL - ...ANSWER...diaphoresis caring for a client who is 72 hr postoperative following an above the knee amputation which actions should the nurse take? - ...ANSWER...assist the client to a prone position every 4 hr. client who has gout and urolithiasis. client asks how to prevent future uric acid stones. - ...ANSWER...take allopurinol as prescribed exercise several times a week limit intake of foods high in purine which of the following findings should the nurse identify as an indication of a basilar skull fracture - ...ANSWER...clear fluid coming form the nares nurse should identify which of the following findings as an indication of breast cancer? - ...ANSWER...a nontender, hard lump that is palpated in one breast nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. which of the following instructions should the nurse include in the teaching? - ...ANSWER...use pursed-lip breathing during periods of dyspnea 35 (3 lb) in the past week. Which of the following statements should the nurse make? - ...ANSWER..."where there any issues last week that kept you from focusing on your diet?" A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? - ...ANSWER...turn the client form side to side A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? - ...ANSWER..."you should take this medication on an empty stomach" A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? - ...ANSWER...viscous urinary output with clots A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching? - ...ANSWER..."i will notify my doctor before I have dental procedures" A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? - ...ANSWER..."you should take aniretroviral medications on a routine schedule" 36 A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? - ...ANSWER...encourage increased fluid intake A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? - ...ANSWER..."I need to lie still in bed during my brachytherapy treatment" A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? - ...ANSWER...thoroughly shampoo hair prior to the EEG A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? - ...ANSWER...chest petechiae A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? - ...ANSWER...instruct the client to perform the valsalva maneuver during removal A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? - ...ANSWER...ask the client about first aid performed at the scene 37 A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? - ...ANSWER..."I will need to take methotrexate even if I'm in remission" A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? - ...ANSWER...characteristics of the cough and sputum A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? - ...ANSWER...fecal-oral contamination A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? - ...ANSWER...offer the client a bedpan every 2 hr. A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? - ...ANSWER...infuse the heparin using an electronic IV pump A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? - ...ANSWER...place the syringe in a puncture-proof disposal container 40 effect of these medications that the client should report to the provider? - ...ANSWER...decreased visual acuity A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? - ...ANSWER...apply pressure to the punch after instilling the medication A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? - ...ANSWER...ask the client to identify the specific food allergies A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment? 1 Increased urinary output 2 Tender mass in the left upper abdomen 3 Elevated erythrocytes, platelets, and granulocytes 4 Polydipsia, increased appetite, and urinary frequency - ...ANSWER...2 Tender mass in the left upper abdomen The client who has a history of allergy to bee stings is brought to the emergency department following a bee sting. What are the interventions to be followed in correct order? 1. Inject epinephrine through the intramuscular route in the mid-portion of the outer thigh. 2. Remove the stinger gently by scraping with a needle. 41 3. Administer oral liquid diphenhydramine. 4. Establish an intravenous infusion with normal saline. - ...ANSWER... The nurse is caring for four clients with hypersensitivity reactions. Which client should the nurse suspect to have a type IV hypersensitive reaction? 1 Client A 2 Client B 3 Client C 4 Client D - ...ANSWER...4 Client D A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide and digoxin. What does the nurse determine is the cause of the depletion? 1 Diuretic therapy 2 Sodium restriction 3 Continuous dyspnea 4 Inadequate oral intake - ...ANSWER...1 Diuretic therapy Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1 Serum sodium of 139 mEq/L (139 mmol/L) 2 Serum chloride of 100 mEq/L (100 mmol/L) 3 Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4 Serum potassium of 7.2 mEq/L (7.2 mmol/L) - ...ANSWER...4 Serum potassium of 7.2 mEq/L (7.2 mmol/L) 42 A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? 1 Nervousness and tachycardia 2 Erythema toxicum rash and pruritus 3 Diaphoresis and altered mental state 4 Deep respirations and fruity odor to the breath - ...ANSWER...4 Deep respirations and fruity odor to the breath The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? 1 Intravenous administration of regular insulin 2 Administer insulin glargine subcutaneously at hour of sleep 3 Maintain nothing prescribed orally (NPO) status 4 Intravenous administration of 10% dextrose - ...ANSWER...1 Intravenous administration of regular insulin A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Tomato juice, raisin bran cereal, and tea 3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee - ...ANSWER...3 Applesauce, cream of wheat, and apple juice The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition? 45 3 Hold the next dose and then resume administration as prescribed. 4 Call the healthcare provider to obtain a prescription with an increased dose. - ...ANSWER...2 Administer the next dose of the medication as prescribed. Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. 1 Impaired memory 2 Intolerance to cold 3 Difficulty breathing 4 Decreased blood pressure 5 Decreased body temperature - ...ANSWER...2 Intolerance to cold 5 Decreased body temperature The healthcare team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse? 1 Placing a Foley catheter 2 Assessing the respirations 3 Placing an intravenous (IV) catheter 4 Administering patient-controlled analgesia - ...ANSWER...2 Assessing the respirations A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 46 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products - ...ANSWER...1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate An older client who was found unconscious at home was admitted to the hospital with a fractured hip, renal failure, and dehydration. In the 24 hours since admission, the client has received 3 L of intravenous fluid. The client has also developed hyponatremia. Which element would the nurse conclude is the most likely to have contributed to the client developing hyponatremia? 1 Reduced dietary salt intake 2 Intravenous fluid infusion 3 Potassium reabsorption rate 4 Increased glomerular filtration - ...ANSWER...2 Intravenous fluid infusion A client with a parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the client's clinical manifestations? 1 Hypercalcemia 2 Hypernatremia 47 3 Hypermagnesemia 4 Hyperphosphatemia - ...ANSWER...1 Hypercalcemia A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? 1 Preventing falls 2 Monitoring electrolytes 3 Administering antiemetics 4 Adjusting the diuretic therapy - ...ANSWER...1 Preventing falls A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness - ...ANSWER...3 Leg cramps 5 Muscle weakness A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply. 1 Nausea 50 A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply. 1 High fat 2 Low sodium 3 High vitamins 4 Moderate protein 5 Low carbohydrates - ...ANSWER...2 Low sodium 3 High vitamins 4 Moderate protein Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? 1 Delayed reaction 2 Cytotoxic reaction 3 Immediate reaction 4 Immune complex-mediated reaction - ...ANSWER...4 Immune complex-mediated reaction A client is seen in the clinic with sickle cell crisis. Which hemoglobin range will the nurse expect to find? 1 6-8 g/100 mL (60-80 mmol/L) 2 10-12 g/100 mL (100-120 mmol/L) 3 12-14 g/100 mL (120-140 mmol/L) 4 16-18 g/100 mL (160-180 mmol/L) - ...ANSWER...1 6-8 g/100 mL (60-80 mmol/L) 51 The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition? 1 Potassium 8 mEq/L 2 Hemoglobin 10 g/dL 3 Phosphorous 7 mg/dL 4 Bicarbonate 15 mEq/L - ...ANSWER...4 Bicarbonate 15 mEq/L Which joint surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)? 1 Osteotomy 2 Arthrodesis 3 Synovectomy 4 Debridement - ...ANSWER...3 Synovectomy A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. 1 Fever 2 Diarrhea 3 Headache 4 Hematuria 5 Ecchymosis - ...ANSWER...3 Headache 4 Hematuria 5 Ecchymosis 52 Which neurologic manifestation in a client is associated with hyperthyroidism? 1 Confusion 2 Hearing loss 3 Tremors 4 Slowness of speech - ...ANSWER...3 Tremors A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question? 1 Malignant growth 2 Pocket of undigested food particles 3 Sac filled with pus from necrotic pancreatic tissue 4 Walled-off space of pancreatic enzymes and exudate - ...ANSWER...4 Walled-off space of pancreatic enzymes and exudate Which electrolyte deficiency triggers the secretion of renin? 1 Sodium 2 Calcium 3 Chloride 4 Potassium - ...ANSWER...1 Sodium A client is diagnosed as having kidney failure. During the oliguric phase, what should the nurse assess for in this client? 1 Hypothermia 2 Hyperphosphatemia 3 55 4 Bending the knees and lowering the body to pick up objects - ...ANSWER...2 Blowing the nose and sneezing A client is admitted to the hospital for acute pancreatitis. The nurse obtains the client's vital signs, performs a physical assessment, and reviews the client's health history. What is the priority intervention by the nurse? 1 Reduce environmental stimuli. 2 Continue to monitor the client's vital signs. 3 Institute constant observation of the client. 4 Assess the client for alcohol withdrawal symptoms. - ...ANSWER...4 Assess the client for alcohol withdrawal symptoms. Place the steps in the process of arthrocentesis in the correct sequence, as performed in a client with rheumatoid arthritis. 1. Cleanse the client's skin 2. Apply local anesthesia 3. Insert an 18-gauge or larger needle into the joint 4. Withdraw fluid from the joint 5. Inject corticosteroids by way of the intraarticular route - ...ANSWER... A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? 1 The injury results in loss of the reflex arc. 2 The injury is above the sixth thoracic vertebra. 3 There has been a partial transection of the cord. 56 4 There is a flaccid paralysis of the lower extremities. - ...ANSWER...2 The injury is above the sixth thoracic vertebra. The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? 1 Positive Kernig sign 2 Glasgow coma score: 10 3 Absence of nuchal rigidity 4 Negative Brudzinski sign - ...ANSWER...1 Positive Kernig sign After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain. - ...ANSWER...4 Determine the characteristics of the pain. A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? 1 Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques 57 2 Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion 3 Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture 4 Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes - ...ANSWER...1 Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular - ...ANSWER...2 Wheezes A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is prescribed by the healthcare provider. Which response does the nurse expect when using a room temperature irrigating solution? 1 Coagulation of blood 2 Neutralization of acids 3 Constriction of blood vessels 4 Stimulation of the vagus nerve - ...ANSWER...3 Constriction of blood vessels 60 3 Young adults 4 Middle-aged persons - ...ANSWER...2 Older adults A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? 1 Increased respiratory rate 2 Decreased workload of the heart 3 Reduced size of the clot blocking the coronary artery 4 Diminished metabolites within the ischemic heart muscle - ...ANSWER...2 Decreased workload of the heart The nurse is assessing four clients in a healthcare setting who have respiratory disorders. Which client's findings indicate possible metabolic acidosis? 1 Client 1 2 Client 2 3 Client 3 4 Client 4 - ...ANSWER...3 Client 3 For two months a client has been taking nonprescription medications and has made dietary changes for symptoms of gastritis. Following assessment by a primary healthcare provider, a diagnosis of extensive carcinoma of the stomach is made. The client asks how the disease got so advanced. On which information about carcinoma of the stomach should the nurse base a response? 1 Presents symptoms of severe pain for the client when in the early stages of the disease process 61 2 Is a risk factor for clients who have an absence of pylori in the stomach 3 Usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4 Often is diagnosed late because symptoms are nonspecific during the early stages - ...ANSWER...4 Often is diagnosed late because symptoms are nonspecific during the early stages The nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction? 1 Client A 2 Client B 3 Client C 4 Client D - ...ANSWER...1 Client A Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1 Flaccid paralysis and numbness 2 Absence of sweating and pyrexia 3 Escalating tachycardia and shock 4 Paroxysmal hypertension and bradycardia - ...ANSWER...4 Paroxysmal hypertension and bradycardia A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1 Mental confusion 2 Increased cholesterol 62 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor - ...ANSWER...1 Mental confusion 4 Flapping hand tremors 5 Musty, sweet breath odor Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease? 1 Incisional pain 2 Popliteal pulse rate 3 Degree of hair growth 4 Lower extremity color - ...ANSWER...4 Lower extremity color A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? 1 Constriction of the superficial vessels dilates the deep vessels. 2 Constriction of the peripheral vessels increases the force of flow. 3 Dilation of the superficial vessels causes constriction of collateral circulation. 4 Dilation of the peripheral vessels causes reflex constriction of visceral vessels. - ...ANSWER...2 Constriction of the peripheral vessels increases the force of flow 65 A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia - ...ANSWER...2 Lethargy A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? 1 Atropine 2 Epinephrine 3 Amiodarone 4 Sodium bicarbonate - ...ANSWER...3 Amiodarone A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order? 1. Check primary healthcare provider's prescription. 2. Obtain vital signs and history of transfusions. 3. Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Change main line solution to normal saline. 5. Check client identification before hanging unit of blood. - ...ANSWER... 66 A client with hypertension is scheduled for a scan and electrolyte studies. During an interview with the nurse, the client exclaims, "I don't know why I just can't get a prescription for high blood pressure pills; that probably is all it is. I'm missing work by being here." Which is the best response by the nurse? 1 "It might not be high blood pressure. We have to be sure." 2 "It's frustrating to miss work and not know for sure what's wrong." 3 "I know it's frustrating, but you need to have a diagnostic workup." 4 "Maybe you could ask your primary healthcare provider if the tests could be done on separate days." - ...ANSWER...2 "It's frustrating to miss work and not know for sure what's wrong." On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to? 1 Lymphadenopathy 2 Thrombocytopenia 3 Hypermetabolic status 4Hepatic encephalopathy - ...ANSWER...3 Hypermetabolic status A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis? 1 Client A 67 2 Client B 3 Client C 4 Client D - ...ANSWER...3 Client C Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply. 1 Turgor of tissue 2 Edema of the ankles 3 Specific gravity of urine 4 Amount of urinary output 5 Texture of mucous membranes - ...ANSWER...1 Turgor of tissue 5 Texture of mucous membranes A client climbing a mountain experiences symptoms of acute mountain sickness. What is the priority nursing action performed by the nurse as prehospital care? 1 Administering acetazolamide 2 Administering dexamethasone 3 Providing oxygen mask to the client 4 Having the client descend to lower altitude - ...ANSWER...4 Having the client descend to lower altitude During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. 70 4 Because of long-term use of insulin, the client's body became sensitive to the insulin dose, causing blood glucose levels to drop erratically. - ...ANSWER...3 Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly. The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. 1 Vomiting 2 Irritability 3 Hypotension 4 Increased respirations 5 Decreased level of consciousness - ...ANSWER...1 Vomiting 2 Irritability 5 Decreased level of consciousness The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority? 1 Client A 2 Client B 3 Client C 4 Client D - ...ANSWER...1 Client A A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory 71 results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? 1 Chronic pain 2 Risk for injury 3 Electrolyte imbalance 4 Inadequate gas exchange - ...ANSWER...3 Electrolyte imbalance A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? 1 Encourage the client to slow the breathing rate. 2 Auscultate the client's lungs and suction if indicated. 3Advise the healthcare provider that the client needs supplemental oxygen. 4 Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure. - ...ANSWER...4 Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure. A client's body mass index (BMI) is 31. This client has a history of hyperinsulinemia caused by an intracranial tumor. Which treatment strategies would be beneficial? Select all that apply. 1 Leptin 2 Orlistat 3 Octreotide 4 Metformin 72 5 Sibutramine - ...ANSWER...3 Octreotide 4 Metformin After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. What will the urine specimen be tested for? 1 Specific gravity 2 Free hemoglobin 3 Carboxyhemoglobin 4 Disseminated intravascular coagulation (DIC) - ...ANSWER...2 Free hemoglobin A client with C8 tetraplegia is admitted to the emergency room. The client develops a blood pressure of 80/40 mm Hg, pulse 48 beats/min, and respiratory rate (RR) of 18 breaths/min. The nurse suspects which condition? 1 Autonomic dysreflexia 2 Hemorrhagic shock 3 Neurogenic shock 4 Pulmonary embolism - ...ANSWER...3 Neurogenic shock A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority? 1 Stop administration of meperidine. 2 Administer transdermal scopolamine. 3 Administer oxygen through facial mask. 75 4 D - ...ANSWER...1 A Which client is observed for hemorrhage and infection as a nursing safety priority? 1 Client A 2 Client B 3 Client C 4 Client D - ...ANSWER...1 Client A A nurse is preparing to assess the client's thyroid gland. Arrange the procedure for posterior palpation of the thyroid gland in sequence. 1. Stand behind the client. 2. Place both thumbs on the nape of the client's neck. 3. Use the index and middle fingers of both hands to feel the thyroid isthmus. 4. Ask the client to flex the neck slightly forward and to the right. 5. Palpate the sternocleidomastoid muscle with the index and middle fingers. 6. Ask the client to swallow water so that the thyroid will move up. - ...ANSWER... The nurse is caring for a client who is diagnosed with diabetes insipidus and is on intranasal desmopressin acetate (DDAVP). The client develops an upper respiratory tract infection during a hospital stay. Which alteration does the nurse anticipate in the client's prescription? 1 Cessation of DDAVP administration 2 Reduced DDAVP dose via oral route 76 3 Reduced DDAVP dose via subcutaneous route 4 Continuation of DDAVP administration via nasal route - ...ANSWER...3 Reduced DDAVP dose via subcutaneous route A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. 1 Polyuria 2 Lethargy 3 Hypotension 4 Muscle twitching 5 Respiratory acidosis - ...ANSWER...2 Lethargy 4 Muscle twitching The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. 1 Pruritus 2 Sedation 3 Constipation 4 Respiratory rate 5 Nausea and vomiting - ...ANSWER...2 Sedation 4 Respiratory rate What are the mediators of injury in IgE-mediated hypersensitivity reactions? Select all that apply. 77 1 Cytokines 2 Mast cells 3 Histamines 4 Neutrophils 5 Leukotrienes - ...ANSWER...2 Mast cells 3 Histamines 5 Leukotrienes What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. 1 The test involves the administration of a contrast medium. 2 Clients should have their hydration levels assessed. 3 Clients are instructed to lie still on a hard table. 4 Clients are served shellfish before the test. 5 A client's serum creatinine level is evaluated after the test. - ...ANSWER...1 The test involves the administration of a contrast medium. 2 Clients should have their hydration levels assessed. 3 Clients are instructed to lie still on a hard table. A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition? 1 Everolimus 2 Azathioprine 3 Mycophenolate acid 4 Methylprednisolone - ...ANSWER...4 Methylprednisolone 80 A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? 1 "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2 "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3 "It decreases the need for immobility because it clears toxins in short and intermittent periods." 4 "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." - ...ANSWER...4 "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply. 1 "I should assess for low blood pressure." 2 "I should assess for increased digitalis toxicity." 3 "I should assess for a decreased rate of ventilation in respiratory alkalosis." 4 "I should assess for an increased depth of ventilation in respiratory alkalosis." 5 "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis." - ...ANSWER...1 "I should assess for low blood pressure." 2 "I should assess for increased digitalis toxicity." 81 3 "I should assess for a decreased rate of ventilation in respiratory alkalosis." A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate? 1 Nasotracheal suction 2 Mechanical ventilation 3 Naloxone administration 4 Cardiopulmonary resuscitation - ...ANSWER...3 Naloxone administration After assessing a client with rheumatoid arthritis, the nurse suspects Sjögren's syndrome. Which manifestations are consistent with Sjögren's syndrome? Select all that apply. 1 Iritis 2 Scleritis 3 Xerostomia 4 Baker's cyst 5 Keratoconjunctivitis sicca - ...ANSWER...3 Xerostomia 5 Keratoconjunctivitis sicca The registered nurse (RN) is caring for four different post- surgical clients. Which activity delegated to the licensed practical nurse (LPN) would be appropriate to achieve a suitable care outcome? Select all that apply. 1 Client 1 82 2 Client 2 3 Client 3 4 Client 4 5 Client 5 - ...ANSWER...1 Client 1 2 Client 2 5 Client 5 The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply. 1 Chills 2 Urticaria 3 Hypotension 4 Tachycardia 5 Bronchospasm 6 Sense of impending doom - ...ANSWER...1 Chills 3 Hypotension 4 Tachycardia One week after being hospitalized for an acute myocardial infarction, a client reports loss of appetite and feeling nauseated. Which of the client's prescribed medications should be withheld and the healthcare provider notified? 1 Digoxin 2 Propranolol 3Furosemide 4 Spironolactone - ...ANSWER...1 Digoxin