PERIOPERATIVE NURSING MS QUIZ WITH QUESTIONS AND ANSWERS VERIFIED BY EXPERTS 2023-2024, Exams of Nursing

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PERIOPERATIVE NURSING MS QUIZ WITH QUESTIONS AND ANSWERS

VERIFIED BY EXPERTS 2023-

1. A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first?
2. Complete the preoperative checklist.
3. Assess the client’s preoperative vital signs.
4. Remove the client’s rings, gold chain, and wristwatch.
5. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L
6. Which client statement made during a presurgical admission assessment needs the most immediate follow-up?
7. “I haven’t eaten foods or had any fluids for the past 12 hours.”
8. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago.”
9. “I took my usual dose of warfarin (Coumadin®) and other cardiac meds this morning with a sip of water.”
10. “I brought a copy of my Health Care Directives so others will know my wishes should my heart stop during surgery.”
11. A nurse is to witness the signature of a surgical con?sent for multiple clients scheduled for surgery the following day. In evaluating the health history of each client, the nurse should plan to obtain a signature from the next of kin for:
12. a 75-year-old client who is blind.
13. a 60-year-old client who does not understand English.
14. a 50-year-old client who is forgetful, but fully oriented.
15. a 16-year-old educated client who fully understands the surgery
16. A nurse receives the written laboratory results of a positive pregnancy test for a client scheduled for an emergency appendectomy. The nurse should first:
17. call the lab to verify the results of the test.
18. inform the client of the positive results.
19. report the results immediately to the surgeon.
20. notify the client’s primary physician of the results
21. During a presurgical admission assessment, a client states, “I’ve told my surgeon that I am a Jehovah’s Witness and I won’t accept a blood transfusion.” Which statement by the nurse would be most appropriate?
22. “Tell me about your fear of receiving a blood transfusion.”

2. “Your request to not receive a transfusion would be honored. Your consent is needed to administer blood or blood products.”
3. “You don’t need to worry about getting a blood transfusion. We have newer equipment that causes less blood loss during surgery.”
4. “Are you sure you wouldn’t want a blood transfusion if one is needed during surgery? You can always change your mind after surgery.”
5. A nurse is analyzing serum laboratory results for a 73-year-old female client scheduled for surgery in 2 hours. The nurse concludes that which result would warrant the most immediate notification of the physician?
6. Hemoglobin 10 g/dL
7. Creatinine 1.0 mg/dL
8. Potassium 4.5 mEq/dL
9. Prothrombin time 22 seconds
10. A nurse is reviewing preoperative orders for a client who is to have surgery on the large intestine the next day. Which written orders should the nurse question? SELECT ALL THAT APPLY.
11. NPO after midnight
12. Erythromycin 500 mg bid
13. Tap water enemas until hard stool passed
14. Clear liquid diet the day before surgery
15. Begin incentive spirometer (IS) use prior to surgery
16. A physician writes an order to hold all medications the morning of surgery for a client with a history of type 1 diabetes mellitus and hypertension. A nurse should call the physician to clarify the hold order for what medication?
17. Acetylsalicylic acid (aspirin)
18. Ducosate sodium (Colace®)
19. Regular and NPH insulin (Humulin®)
20. Clonidine (Catapres®
21. Which client statement indicates that a client who is scheduled for a 3-hour surgery under general anesthesia needs further teaching?
22. “A breathing tube will be placed when I am in the operating room.”
23. “I should shave the skin in the surgical area the evening prior to surgery.”
24. “I should splint my incision with a pillow when coughing and deep breathing after surgery.”

4. “Because herbs, medications, and recreational drugs such as marijuana and cocaine affect the type
5. “I might need a urinary catheter inserted before surgery so my urine output can be monitored.”
6. Which nursing action would be best when a preoperative client verbalizes fear of postoperative pain?
7. Providing diversional activities when client reports fear of pain
8. Encouraging the client to verbalize concerns regarding the fear of pain
9. Informing the client of experiences and the likelihood of pain pre- and postoperatively
10. Explaining the medications ordered for pain control, availability, and treatment goals
11. Which statement by a nurse is most effective when collecting data about a preoperative client’s recreational drug use?
12. “Describe the drugs you use and the frequency that you use these drugs.”
13. “Do you use any over-the-counter medications or illegal substances?”
14. “Tell me about all medications and substances you take because complications can occur if you are taking something we do not know about.” and amount of anesthesia you need, list any of these you take and how often you use them.
15. A nurse evaluates that a preoperative client can properly use a volume incentive spirometer when which client action is noted?
16. Sits upright, inserts the mouthpiece, and blows until the lungs are emptied of air
17. Sits upright, exhales, seals lips around the mouthpiece, inhales, and holds breath for 5 seconds
18. Sits at the edge of the bed, coughs, inserts the mouthpiece, and blows slowly for 10 seconds
19. Sits at the edge of the bed, breathes deeply five times, inserts the mouthpiece, and inhales quickly
20. A client in an operating room holding area, who is to receive general anesthesia, reports having a dry mouth because food and fluids have been withheld for 8 hours. Which action by a nurse is most appropriate?
21. Teach the client that the primary reason food and fluids have been withheld is to prevent vomiting and potential complications
22. Clarify that food and fluids should have been withheld only for 4 hours and offer a small sip of water
23. Explain to the client that a full stomach puts pressure on the diaphragm and prevents full lung expansion during surgery
24. Tell the client that the general anesthetic will soon make the client sleepy and unaware of the mouth dryness
25. A nurse is caring for a client who received conscious sedation during a surgical procedure. Which assessment of this client is most important for a nurse to make postoperatively?

1. Lung sounds
2. Amount of urine output
3. Ability to swallow liquids
4. Rate and depth of breathing
5. Upon arrival to an operating room holding area, a client who is scheduled for abdominal surgery is noted to have replaced a tongue ring that was removed when the operative checklist was completed. Which is the most appropriate initial action by a nurse?
6. Document the findings on the client’s medical record
7. Request that the client once again remove the tongue ring
8. Complete a variance report, noting that the client has replaced the tongue ring
9. Notify the surgeon and the anesthesiologist of the replacement of the tongue ring
10. A nurse is orienting a new nurse to a postanesthesia care unit (PACU). Which statement by the new nurse indicates further orientation is needed?
11. “Lactated Ringer’s (LR) and 5% dextrose with LR are typical IV solutions administered in the PACU.”
12. “If a client has an opioid overdose, I should expect to administer naloxone hydrochloride (Narcan®).”
13. “I should monitor vital signs and perform a pain assessment every 15 minutes or more often if necessary.”
14. “Once a client responds verbally after a spinal anesthetic, the client can be transferred to the nursing unit.”
15. Which information is most important for a postanesthesia care unit nurse to include in a report on a post?operative client to a surgical unit nurse?
16. Location of the relatives
17. Review of the surgical consent
18. Placement of client belongings
19. Last dose and type of pain medication
20. nurse evaluates that a client has achieved an expected outcome for the second postoperative day following abdominal surgery under general anesthesia. Which finding supports the nurse’s conclusion?
21. Passing flatus
22. Urine output 680 mL in 24 hours
23. Crackles in bilateral lung bases
24. Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after analgesic given

19. A nurse is planning the discharge of a client following recovery from an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client states:
20. “I can leave my elastic antiembolic (TEDS®) stockings off once I get home.”
21. “I should be eating a diet high in protein, calories, and vitamin C now and when I get home.”
22. “An alternative method to control pain and reduce swelling is applying ice to my incision.”
23. “I use my incentive spirometer every 2 hours so I can reach my volume goal before discharge.”
24. A nurse is reviewing a plan of care for a postoperative client with a history of sickle cell disease. Which nursing diagnosis, documented on the client’s care plan, should the nurse address first?
25. Anxiety
26. Impaired skin integrity
27. Deficient fluid volume
28. Ineffective airway clearance
29. A nurse is caring for a postoperative client who reports an inability to void. Which initial action by the nurse is most appropriate?
30. Turning on running water
31. Inserting a urinary catheter
32. Palpating the client’s bladder
33. Reviewing the client’s chart for the time of the last voiding
34. A postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. A nurse’s initial intervention should be to:
35. immediately notify the surgeon.
36. position the client flat in bed.
37. limit the client’s fluid intake.
38. administer steroid medications.
39. A physician documents in a client’s postoperative progress notes that the client is experiencing a respiratory infection with a shift to the left in the white blood cell (WBC) differential count. Which finding by a nurse reviewing the client’s laboratory report would support the physician’s documentation?
40. Decreased WBC count
41. Increased band cells
42. Decreased hemoglobin

4. Increased C-reactive protein
5. In reviewing a physician’s orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism?
6. Have the client dangle the legs the evening of surgery
7. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily
8. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn)
9. Encourage coughing and deep breathing (C&DB) every hour while awake
10. A nurse assesses that a client on the second postoperative day following abdominal surgery has diminished breath sounds in both lung bases, is taking shallow breaths, is able to achieve only 500 mL on an incentive spirometer, and has been smoking one pack of cigarettes per day prior to surgery. The nurse’s best interpretation of these findings is that the client is experiencing:
11. atelectasis.
12. pneumonia.
13. a normal postoperative course.
14. chronic obstructive pulmonary disease (COPD)
15. A nurse notes redness, swelling, and warmth of and around the incision when assessing a client’s leg incision 48 hours after femoral popliteal bypass surgery. The nurse’s best analysis should be that the incision is:
16. healing normally for the second postoperative day.
17. showing signs of rejection of the suture materials.
18. inflamed and could indicate the presence of an infection.
19. infected and showing signs of wound dehiscence.
20. Which outcome should indicate to a nurse that a postsurgical client’s coughing and deep breathing (C&DB) is most effective?
21. Respirations are 16 per minute and unlabored.
22. Lung sounds are audible and clear on auscultation.
23. Coughs include small amount of clear secretions.
24. Cough effort is strong and productive.
25. A client is to receive a second dose of oxycodone/ acetaminophen (Percocet®) for postoperative incisional pain. When a nurse brings the medication to the client, the client says, “Why bring this medication again? It makes me feel sick.” Which statement is the most appropriate initial nurse response?

1. “I can call the doctor to see what else can be ordered for your pain.”
2. “Describe what you feel when you say that the medication makes you feel sick.”
3. “The doctor has ordered an antacid. I can give you this along with the medication.”
4. “Many people say the same thing. The aspirin in the medication is hard on your stomach.”
5. A nurse evaluates that the drainage from a client’s nasogastric (NG) tube, inserted for gastric decompression during emergency surgery, would be normal if it:
6. returns brown-liquid in color.
7. returns greenish-yellow in color.
8. has an alkalotic hydrogen level (pH).
9. measures less than 25 mL in volume.
10. A nurse notifies a physician after assessing a client 5 days after an exploratory laparotomy and noting a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. Which typical complication of abdominal surgery should the nurse conclude may be occurring?
11. Paralytic ileus
12. Silent peritonitis
13. Fluid volume excess
14. Malabsorption syndrome
15. Which statement should a nurse include when teaching a client prior to discharge following abdominal surgery?
16. “Return to work in about 4 weeks because working increases your physical activity gradually.”
17. “The ordered iron and vitamins tablets will promote wound healing and red blood cell growth.”
18. “Daily walking carrying 10-pound weights will help to strengthen your incision.”
19. “Home-care nursing service is usually paid by insurance if you need help around the house.
20. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
21. Urinary output of 20 mL/hr
22. Temperature of 37.6° C (99.6° F)
23. Blood pressure of 100/70 mm Hg
24. Serous drainage on the surgical dressing

33. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?
34. “Use of an incentive spirometer will help prevent pneumonia.”
35. “Close monitoring of your oxygen saturation will detect hypoxemia.”
36. “Administration of intravenous fluids will prevent or treat fluid imbalance.”
37. “Early ambulation and administration of blood thinners will prevent pulmonary embolism.”
38. The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?
39. Avoid oral hygiene and rinsing with mouthwash.
40. Verify that the client has not eaten for the last 24 hours.
41. Have the client void immediately before going into surgery.
42. Report immediately any slight increase in blood pressure or pulse.
43. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client?
44. Obtain a court order for the surgery.
45. Have the charge nurse sign the informed consent immediately.
46. Send the client to surgery without the consent form being signed.
47. Obtain a telephone consent from a family member, following agency policy.
48. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
49. “If it’s any help, everyone is nervous before surgery.”
50. “I will be happy to explain the entire surgical procedure to you.”
51. “Can you share with me what you’ve been told about your surgery?”
52. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.”
53. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client?
54. Inhale as rapidly as possible.
55. Keep a loose seal between the lips and the mouthpiece.
56. After maximum inspiration, hold the breath for 15 seconds and exhale.

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
5. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?
6. “Aspirin can cause bleeding after surgery.”
7. “Aspirin can cause my ability to clot blood to be abnormal.”
8. “I need to continue to take the aspirin until the day of surgery.”
9. “I need to check with my doctor about the need to stop the aspirin before the scheduled surgery.”
10. The nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
11. Hard reddened skin
12. Serous drainage
13. Purulent drainage
14. Warm, tender skin
15. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?
    1. Increasing restlessness
16. A pulse of 86 beats per minute
17. Blood pressure of 110/70 mm Hg
18. Hypoactive bowel sounds in all four quadrants
19. A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.
20. Contact the surgeon.
21. Instruct the client to remain quiet.
22. Prepare the client for wound closure.
23. Document the findings and actions taken.
24. Place a sterile saline dressing and ice packs over the wound.
25. Place the client in a supine position without a pillow under the head.
26. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which

laboratory result would be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed?

1. Hemoglobin, 8.0 g/dL (80 mmol/L)
2. Sodium, 145 mEq/L (145 mmol/L)
3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L)
4. Platelets, 210,000 cells/mm3 (210 × 109 /L)
5. The nurse receives a telephone call from the postanesthesia care unit, stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
6. Assess the patency of the airway.
7. Check tubes or drains for patency.
8. Check the dressing to assess for bleeding.
9. Assess the vital signs to compare with preoperative measurements.
10. The nurse is reviewing a surgeon’s prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld?
11. Prednisone
12. Ferrous sulfate
13. Cyclobenzaprine
14. Conjugated estrogen ALLERGY
15. You are a nurse starting an IV antibiotic to a patient to treat a severe infection. During infusion, the patient is having a severe allergic reaction. Select all the appropriate interventions for this patient:
16. Slow down the antibiotic infusion
17. Call a rapid response.
18. Place the patient on oxygen
19. Prepare for the administration of Epinephrine a. 1, 2 and 3 c. 2 and 3 b. 2, 3 and 4 d. 3 and 4
20. You're assessing a patient's knowledge on how to use their EpiPen in case of an anaphylactic reaction. You're using an EpiPen trainer device to teach the patient. What demonstrated by the patient shows the patient knows how to administer the medication? Select all that apply:
21. The patient injects the medication in the subq tissue of the abdomen.
22. The patient massages the site after injection.
23. The patient administers the injection through the clothes.
24. The patient aspirates before injecting the medication. a. 1, 2 and 3 c. 2 and 3

b. 2, 3 and 4 d. 3 and 4

3. Nurse John received a patient in the ER for allergy skin testing. Which nursing interventions are most appropriate? Select all that apply.
   1. Record site, date, and time of the test.
   2. Give the client a list of potential allergens if identified.
   3. Estimate the size of the wheal and document the finding.
   4. Tell the client to return to have the site inspected only if there is a reaction. 5.Have the client wait in the waiting room for at least 1 to 2 hours after injection. a. 1, 2 and 3 c. 1 and 2 b. 2, 3 and 4 d. 3 and 4
4. A male patient was taking morphine when suddenly he had a severe anaphylactic reaction after receiving the medication. The nurse would take which actions? Select all that apply.
5. Administer oxygen.
6. Quickly assess the client’s respiratory status.
7. Document the event, interventions, and client’s response.
8. Leave the client briefly to contact a primary health care provider (PHCP).
9. Keep the client supine regardless of the blood pressure readings.
10. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus. a. 1, 2 and 4 c. 1, 2 and 3 b. 1, 2, 3, 5 and 6 d. 1, 2, 3, 4 and 5
11. While doing your rounds, you noticed that the patient in 3320 is having a sudden and severe anaphylactic reaction to a medication. The patient's blood pressure is 80/50, heart rate 125, and oxygen saturation 85%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is? a. IV Diphenhydramine c. IM Epinephrine b. IV Normal Saline Bolus d. Nebulized Albuterol
12. You received a patient in the ER due to a bee sting. The patient is in anaphylactic shock. This type of anaphylactic reaction is known as a? a. Type I Hypersensitivity Reaction b. Type II Hypersensitivity Reaction c. Type III Hypersensitivity Reaction d. Type IV Hypersensitivity Reaction
13. The patient has a severe allergy to eggs and mistakenly consumed a spiced chicken egg wrap. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have an effect on the body? a. It will prevent a recurrent attack. b. It will cause vasoconstriction and decrease the blood pressure. c. It will help dilate the airways. d. It will help block the effects of histamine in the body.
14. You're providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this condition, and if ordered the nurse should ask for an order clarification?

a. IV Diphenhydramine b. Epinephrine c. Corticosteroids d. Isotonic intravenous fluids e. IV Furosemide

9. What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient? a. Assessing, documenting, and avoiding all the patient allergies. b. Administering Epinephrine c. Administering Corticosteroids d. Establishing IV access
10. A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should take? a. Administer Epinephrine c. Stop the medication b. Call a Rapid Response d. Administer a breathing treatment
11. What is the BEST position for a patient in anaphylactic shock? a. Lateral recumbent c. High Fowler's b. Supine with legs elevated. d. Semi-Fowler’s
12. The nurse is providing teaching for a client on dietary intake and anaphylaxis. Which food should the nurse identify that trigger anaphylaxis in a sensitized individual (Select all that apply)
13. Fish 2. Coconut oil 3. Milk 4. Chocolate 5. Grains a. 4 and 5 c. 3, 4 and 5 b. 1, 2 and 3 d. 2 and 3
14. You are the nurse taking care of a patient who is on a course of oral steroids more than once a year for the treatment of asthma related to allergens. Which alternative therapy should the nurse anticipate being prescribed for the client to avoid the frequent use of steroids? a. Immunotherapy c. Plasmapheresis b. Omalizumab d. Antihistamines
15. For which allergy will the nurse teach the parents that a child with spina bifida is at increased risk? a. Drug allergy c. Latex allergy b. Contact dermatitis d. Food allergy
16. You are taking care of a patient treated for hemolytic disease. Which statement shows the nurse's understanding of the cause of the disease? a. "Neutrophils attempt to phagocytize the RBCs." b. "antibodies bound with an antigen activate the cascade destroying the RBCs." c. "Complement activation causes the release of inflammatory chemical mediators resulting in RBC destruction." d. "Endogenous antigens stimulate a type II reaction resulting in lysis of the RBC."
17. You are taking care of a patient with SLE who is being treated with immunosuppressant drugs and corticosteroids. Which precautions should you provide this client? Select all that apply.

1. Avoid large crowds.
2. Don't get a flu shot.
3. Use contraception to prevent pregnancy
4. Refrain from taking aspirin or ibuprofen.
5. Report signs of infection to the physician a. 1, 3, 4 and 5 c. 1, 2, 3 and 4 b. 3, 4 and 5 d. 1, 2 and 3

Anaphylaxis Cardio

1. You're assessing a patient's knowledge on how to use their EpiPen in case of an anaphylactic reaction. You're using an EpiPen trainer device to teach the patient. What demonstrated by the patient shows the patient knows how to administer the medication? Select all that apply:
2. The patient injects the medication in the subq tissue of the abdomen.
3. The patient massages the site after injection.
4. The patient administers the injection through the clothes.
5. The patient aspirates before injecting the medication. a. 1, 2 and 3 c. 2 and 3 b. 2, 3 and 4 d. 3 and 4
6. Nurse John received a patient in the ER for allergy skin testing. Which nursing interventions are most appropriate? Select all that apply.
   1. Record site, date, and time of the test.
   2. Give the client a list of potential allergens if identified.
   3. Estimate the size of the wheal and document the finding.
   4. Tell the client to return to have the site inspected only if there is a reaction. 5.Have the client wait in the waiting room for at least 1 to 2 hours after injection. a. 1, 2 and 3 c. 1 and 2 b. 2, 3 and 4 d. 3 and 4
7. A male patient was taking morphine when suddenly he had a severe anaphylactic reaction after receiving the medication. The nurse would take which actions? Select all that apply.
8. Administer oxygen.
9. Quickly assess the client’s respiratory status.
10. Document the event, interventions, and client’s response.
11. Leave the client briefly to contact a primary health care provider (PHCP).
12. Keep the client supine regardless of the blood pressure readings.
13. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus. a. 1, 2 and 4 c. 1, 2 and 3 b. 1, 2, 3, 5 and 6 d. 1, 2, 3, 4 and 5
14. While doing your rounds, you noticed that the patient in 3320 is having a sudden and severe anaphylactic reaction to a medication. The patient's blood pressure is 80/50, heart rate 125, and oxygen saturation 85%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is? a. IV Diphenhydramine c. IM Epinephrine

b. IV Normal Saline Bolus d. Nebulized Albuterol

5. One of the goals in the treatment of myocarditis is to prevent embolization. The nurse must emphasize which of the following? a. Application of elastic pressure stockings c. Taking anticoagulants b. ROM exercises d. All of these
6. Scott has suddenly developed shortness of breath, dyspnea, crackles, and a pink-frothy sputum. The nurse must suspect for? a. Right-sided heart failure c. Cardiac tamponade b. Left-sided heart failure d. Pericardial friction rub
7. The goal in the treatment of Scott’s myocarditis would be a. Eliminating pain c. Treatment of the underlying infection b. Prevention of thrombus formation d. Cardiac monitoring
8. Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? a. Decrease anxiety c. Administer sublingual nitroglycerin b. Enhance myocardial oxygenation d. Educate the client about his symptoms
9. Medical treatment of coronary artery disease includes which of the following procedures? a. Cardiac catheterization b. Coronary artery bypass surgery c. Oral medication therapy d. Percutaneous transluminal coronary angioplasty SLE
10. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n): A. Hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. B. Autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. C. Disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. D. Disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.
11. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes

prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? A. Institute seizure precautions. B. Reorient to time and place PRN. C. Monitor intake and output. D. Place on cardiac monitor.

3. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is: A. Activity intolerance related to fatigue and inactivity. B. Impaired skin integrity related to itching and skin sloughing. C. Social isolation related to embarrassment about the effects of SLE. D. Impaired social interaction related to lack of social skills.
4. A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of: A. Rheumatoid factor. B. Anti-Smith antibody (Anti-Sm). C. Antinuclear antibody (ANA). D. Lupus erythematosus (LE) cell prep.
5. Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says: A. "I should expect to have a low fever all the time with this disease." B. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms." C. "I should try to ignore my symptoms as much as possible and have a positive outlook." D. "I can expect a temporary improvement in my symptoms if I become pregnant."
6. A 19-year-old patient who is taking azathioprine (Imuran) for systemic lupus erythematosus has a check-up before leaving home for college. The health care provider writes all of these orders. Which one should the nurse question? A. Naproxen (Aleve) 200 mg BID B. Give measles-mumps-rubella (MMR) immunization C. Draw anti-DNA titer D. Famotidine (Pepcid) 20 mg daily

7. A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? A. Weight gain B. Subnormal temperature C. Elevated red blood cell count D. Rash on the face across the bridge of the nose
8. The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: A. A local rash that occurs as a result of allergy B. A disease caused by overexposure to sunlight C. An inflammatory disease of collagen contained in connective tissue D. A disease caused by the continuous release of histamine in the body
9. The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? A. Antibiotic B. Antidiarrheal C. Corticosteroid D. Opioid analgesic
10. A nurse is collecting data on a client who complains of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse further checks for which of the following that is also indicative of the presence of SLE? A. Emboli B. Ascites C. Two hemoglobin S genes D. Butterfly rash on cheeks and bridge of nose
11. Which client is at the highest risk for systemic lupus erythematous (SLE)? A. An Asian male B. A white female C. An African-American male D. An African-American female

12. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of the following symptoms is characteristic of this diagnosis? A. Increased T-cell count B. Scaley, inflamed rash on shoulders, neck, and face C. Swelling of the extremities D. Decreased erythrocyte sedimentation rate (ESR)
13. In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes: A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer C. Immunologic dysfunction leading to chronic inflammation in the cartilage and muscles D. The production of a variety of autoantibodies directed against components of the cell nucleus
14. A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."
15. The pathophysiology of systemic lupus erthematosus (SLE) is characterized by: A. Destruction of nucleic acids and other self-proteins by autoantibodies B. Overproduction of collagen that disrupts the functioning of internal organs C. Formation of abnormal IgG that attaches to cellular antigens, activating complement D. Increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency
16. A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is: A. You can plan to have a near-normal life since SLE rarely causes death B. It is difficult to tell because to disease is so variable in its severity and progression C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with long- term use of corticosteroids

D. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage

17. During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate: A. Increased RBCs B. Decreased ESR C. Decreased anti-DNA D. Increased complement
18. Teaching that the nurse will plan for the patient with SLE includes: A. Ways to avoid exposure to sunlight B. Increasing dietary protein and carbohydrate intake C. The necessity of genetic counseling before planning a family D. The use of no pharmacologic pain interventions instead of analgesics
19. The nurse is preparing a presentation on systemic lupus erythematosus (SLE). Which statement should the nurse include? (Select all that apply.)
20. The etiology is known to be linked to environmental factors.
21. Manifestations can be mild to fatal, with remissions and exacerbations.
22. The immune complex deposits trigger an inflammatory response.
23. SLE is a result of deposition of antigen-antibody complexes in connective tissues.
24. The inflammatory response leads to anaphylactic shock.
25. The nurse is assessing a client with systemic lupus erythematosus (SLE). Which clinical manifestation should the nurse expect to observe? (Select all that apply.)
26. Red butterfly rash on the face
27. Alopecia
28. Psoriatic lesions
29. Painful or swollen joints
30. Leg and eye edema
31. The nurse is assessing a client with systemic lupus erythematosus (SLE). Which manifestation should the nurse recognize as a result of inflammation? (Select all that apply.) Cough

Malaise Maculopapular rash Joint pain Fever

22. A client diagnosed with systemic lupus erythematosus (SLE) is experiencing pulmonary interstitial fibrosis. Which classification of lupus should the nurse suspect?
23. Systemic
24. Drug-induced
25. Discoid
26. Cutaneous
27. The nurse is caring for a client with systemic lupus erythematosus (SLE). Which system should the nurse consider as being most affected by the formation of immune complexes and tissue damage?
28. Cardiac
29. Integumentary
30. Respiratory
31. Renal
32. The laboratory results of a client with systemic lupus erythematosus (SLE) indicates anemia. Which collaborative therapy should the nurse anticipate?
33. Performing a splenectomy
34. Treating the underlying cause
35. Administering corticosteroids
36. Administering erythropoietin
37. A client with a history of systemic lupus erythematosus (SLE) anxiously states, "My chest hurts when I lie down. I think it is from coughing so much. Please sit me up." Which condition should the nurse first suspect?
38. Thrombocytopenia
39. Pericarditis
40. Myocardial infarction
41. Anemia

26. A client with a history of systemic lupus erythematosus (SLE) anxiously states, "My chest hurts when I lie down. I think it is from coughing so much. Please sit me up." Which condition should the nurse first suspect?
27. Thrombocytopenia
28. Pericarditis
29. Myocardial infarction
30. Anemia
31. The nurse is caring for a pregnant client with systemic lupus erythematosus (SLE). Which neonatal complication related to maternal lupus should the nurse anticipate the fetus to be tested for during the second trimester of pregnancy?
32. Renal anomalies
33. Congenital heart block (CHB)
34. Anemia
35. Liver involvement
36. An older adult client is experiencing an acute episode of systemic lupus erythematosus (SLE). Which primary concern should the nurse consider when administering newly prescribed medications?
37. Renal function
38. Cardiovascular function
39. Respiratory function
40. Neurological function
41. The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information should the nurse include in the client's teaching?
42. Using high-dose birth control pills
43. Using only acetaminophen for pain relief
44. Avoiding large crowds
45. Increasing daily sun exposure
46. The nurse is reviewing medications ordered for a newly admitted female client with systemic lupus erythematosus (SLE). Which medication order should the nurse question?
47. Immunosuppressive
48. Oral contraceptive
49. Antineoplastic

4. Corticosteroid
5. The nurse is caring for a client with systemic lupus erythematosus (SLE) who presents with pain and discomfort. Which treatment option should the nurse anticipate? (Select all that apply.)
6. Corticosteroids 2.Increasing sun exposure
7. Moderate exercise
8. Proper nutrition
9. NSAIDs
10. Which laboratory test is used in the diagnosis of systemic lupus erythematosus (SLE)? (Select all that apply.)
11. Urinalysis
12. Anti-DNA antibody testing
13. Erythrocyte sedimentation rate (ESR)
14. Triglyceride levels
15. Complete blood count (CBC)
16. The nurse is teaching a new colleague the effects of drugs used for clients with systemic lupus erythematosus (SLE). Which statement by the colleague indicates the need for further teaching?
17. "Thrombosis prevention is a positive side effect with aspirin therapy."
18. "Corticosteroid therapy can cause cushingoid effects."
19. "If a cytotoxic agent is prescribed, infection may occur."
20. "When the client is on aspirin therapy, I should monitor for renal toxicity."
21. A client diagnosed with systemic lupus erythematosus (SLE) presents with fatigue, joint pain, oral ulcers, and a red rash over the face and upper trunk. Which collaborative therapy should the nurse expect to implement?
22. Corticosteroid therapy
23. Antibiotic therapy
24. Surgical drainage of affected joints
25. Physical therapy to improve mobility
26. The nurse is planning care for an adolescent client with systemic lupus erythematosus (SLE). Which nursing diagnosis is a special consideration for this client?
27. Memory, Impaired
28. Fluid Volume: Imbalanced, Risk for

3. Body Image, Disturbed
4. Infection, Risk for
5. In a community setting, the nurse is providing care to a client who was recently diagnosed with systemic lupus erythematosus (SLE). Which is the goal of care for this client? (Select all that apply.)
6. Maintaining skin integrity
7. Reducing pain
8. Limiting fluid intake
9. Reducing inflammation
10. Preventing infection
11. The nurse is admitting a client with systemic lupus erythematosus (SLE) for an upper respiratory infection. Which nursing goal is the priority?
12. The client can verbalize the importance of oral care.
13. The client demonstrates proper hand hygiene.
14. The client can verbalize skin care needs to reduce the risk of altered skin integrity.
15. The client can verbalize the impact of the diagnosis to the healthcare provide
16. The nurse is providing teaching for a client diagnosed with systemic lupus erythematosus (SLE) experiencing alterations in skin integrity. Which client statement indicates effective teaching?
17. "I will apply sunscreen immediately prior to going outdoors."
18. "I will cover the lesions on my head with a wig."
19. "I will use fluorescent lighting."
20. "I will limit the use of cosmetics.
21. The nurse is caring for a client with exacerbation of systemic lupus erythematosus (SLE). Which statement by the nurse is accurate? "The client is at risk for a micronutrient deficiency."
22. The client is at risk for a micronutrient deficiency."
23. "The client is at risk for weigh gain."
24. "The client is at risk for a macronutrient deficiency."
25. "The client is at risk for weight loss." ACUTE RESPIRATORY DISTRESS SYNDROME
26. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. ■ 1. The family is coming in to visit. ■ 2. The client has increased secretions requiring frequent suctioning.

■ 3. The SpO2 and PO2 have decreased. ■ 4. The client is tachycardic with drop in blood pressure. ■ 5. The face has increased skin breakdown and edema.

2. The nurse has calculated a low PaO2 /FIO2 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? ■ 1. Supine. ■ 2. Semi-fowlers. ■ 3. Lateral side. ■ 4. Prone.
3. A client with acute respiratory distress syndrome (ARDS) has fi ne crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. ■ 1. Monitor serum creatinine and blood urea nitrogen levels. ■ 2. Administer a sedative. ■ 3. Keep the head of the bed flat. ■ 4. Administer humidified oxygen. ■ 5. Auscultate the lungs.
4. Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? ■ 1. Teaching cigarette smoking cessation. ■ 2. Maintaining adequate serum potassium levels. ■ 3. Monitoring clients for signs of hypercapnia. ■ 4. Replacing fluids adequately during hypovolemic states.
5. The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? ■ 1. Elevated carbon dioxide level. ■ 2. Hypoxia not responsive to oxygen therapy. ■ 3. Metabolic acidosis. ■ 4. Severe, unexplained electrolyte imbalance.
6. A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below.

Which fi nding should the nurse report to the physician? ■ 1. pH. ■ 2. PaCO2. ■ 3. HCO3 –. ■ 4. PaO2.

7. A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client’s peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-AssessmentRecommendation) technique for communication, the nurse calls the physician with the recommendation for: ■ 1. Initiating I.V. sedation. ■ 2. Starting a high-protein diet. ■ 3. Providing pain medication. ■ 4. Increasing the ventilator rate.
8. A client has the following arterial blood gas values: pH, 7.52; PaO2 , 50 mm Hg; PaCO2 , 28 mm Hg; HCO3 – , 24 mEq/L. Based upon the client’s PaO2 , which of the following conclusions would be accurate? ■ 1. The client is severely hypoxic. ■ 2. The oxygen level is low but poses no risk for the client. ■ 3. The client’s PaO2 level is within normal range. ■ 4. The client requires oxygen therapy with very low oxygen concentrations.
9. A client has the following arterial blood gas values: pH, 7.52; PaO2 , 50 mm Hg; PaCO2 , 28 mm Hg; HCO3 – , 24 mEq/L. The nurse determines that which of the following is a possible cause for these fi ndings? ■ 1. Chronic obstructive pulmonary disease (COPD). ■ 2. Diabetic ketoacidosis with Kussmaul’s respirations.

■ 3. Myocardial infarction. ■ 4. Pulmonary embolus.

10. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? ■ 1. Tracheostomy. ■ 2. Use of a nasal cannula. ■ 3. Mechanical ventilation. ■ 4. Insertion of a chest tube.
11. Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? ■ 1. Septic shock. ■ 2. Chronic obstructive pulmonary disease. ■ 3. Asthma. ■ 4. Heart failure.
12. Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? ■ 1. Assessing the client’s skin color. ■ 2. Monitoring the respiratory rate. ■ 3. Verifying the amount of cuff inflation. ■ 4. Auscultating breath sounds bilaterally
13. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? ■ 1. Administering oxygen every 2 hours. ■ 2. Turning the client every 4 hours. ■ 3. Administering sedatives to promote rest. ■ 4. Suctioning if cough is ineffective.
14. Which of the following complications is associated with mechanical ventilation? ■ 1. Gastrointestinal hemorrhage. ■ 2. Immunosuppression. ■ 3. Increased cardiac output.