NCLEX Practice Questions — Set 36
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider’s prescription?
Show answer and rationale
Correct answer: B. Intravenous infusion of normal saline
The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normalsaline. Regular insulin, not NPH insulin, would be administered.
An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump?
Show answer and rationale
Correct answer: D. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal
An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply.
Show answer and rationale
Correct answer: A. Elevated blood glucose level
In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul’s respirations (deep and rapid breathing pattern) would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.
Show answer and rationale
Correct answer: C. Shakiness
Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia.
A client with diabetes mellitus demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client’s anxiety?
Show answer and rationale
Correct answer: B. Convey empathy, trust, and respect toward the client.
The appropriate intervention is to address the client’s feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client’s anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.
The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?
Show answer and rationale
Correct answer: B. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."
During illness, the client should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP’s advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item?
Show answer and rationale
Correct answer: D. Intravenous fluids containing dextrose
During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin (Dilantin) is not a usual treatment measure for DKA.
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia?
Show answer and rationale
Correct answer: B. Polyuria
Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia.
The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s nostril. The nurse should take which initial action?
Show answer and rationale
Correct answer: C. Test the drainage for glucose.
After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.
After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder?
Show answer and rationale
Correct answer: A. Polydipsia
Diabetes insipidus is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur.
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?
Show answer and rationale
Correct answer: D. Maintain a patent airway.
The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement, keeping the client warm, monitoring vitalsigns, and administering thyroid hormones by the intravenous route.
A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise?
Show answer and rationale
Correct answer: B. "The best time for me to exercise is mid- to late afternoon."
A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication.
The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder?
Show answer and rationale
Correct answer: D. Polyuria
Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain).
The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately?
Show answer and rationale
Correct answer: A. Laryngeal stridor
During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngealstridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.
Show answer and rationale
Correct answer: B. Tremors
Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia.
The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing’s disease. Which statement by the student indicates an accurate understanding of this disorder?
Show answer and rationale
Correct answer: B. "Cushing’s disease results from an increased pituitary secretion of adrenocorticotropic hormone."
Cushing’s disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison’s disease is characterized by the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralocorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones.
The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101� F, pulse of 88 beats/minute, respirations of 22 breaths/minute, and blood pressure of 100/72 mm Hg. Which finding would be of most concern to the nurse?
Show answer and rationale
Correct answer: A. Temperature
An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.
The nurse is providing discharge instructions to a client who has Cushing’s syndrome. Which client statement indicates that instructions related to dietary management are understood?
Show answer and rationale
Correct answer: B. "I should eat foods that have a lot of potassium in them."
A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing’s syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.
The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client’s room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time?
Show answer and rationale
Correct answer: A. Obtain a capillary blood glucose level and perform a focused assessment.
Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client’s change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client’s condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the unlicensed assistive personnel (UAP) to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.
The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority?
Show answer and rationale
Correct answer: A. Vital signs
Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vitalsigns, particularly the blood pressure.
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply.
Show answer and rationale
Correct answer: D. Feeling cold
Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
Show answer and rationale
Correct answer: D. Respiratory distress
Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status as any swelling to the surgicalsite could cause respiratory distress. Although all the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.
A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply.
Show answer and rationale
Correct answer: D. Nausea
Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.
The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?
Show answer and rationale
Correct answer: B. Refrigerate the insulin.
Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial.
Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication?
Show answer and rationale
Correct answer: C. Alcohol
When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication.
Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client’s medical record and should question the prescription if which data is noted in the client’s history?
Show answer and rationale
Correct answer: C. Use of nitroglycerin
Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Sildenafil is not contraindicated with the use of vitamins. Insomnia and neuralgia are side effects of the medication.
The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?
Show answer and rationale
Correct answer: D. Withhold the medication and call the HCP, questioning the prescription for the client.
Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP regarding this prescription.
A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply.
Show answer and rationale
Correct answer: B. The insulin should be administered at room temperature.
Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 0.5 hour, it peaks in 2 to 5.5 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.
The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply.
Show answer and rationale
Correct answer: C. A simple sugar food item is carried and used to treat mild hypoglycemia episodes.
Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.
A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply.
Show answer and rationale
Correct answer: B. Administer methimazole with food.
Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication should be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high calorie diet. Antithyroid medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytosis and the health care provider (HCP) should be notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the risk of thyroid storm.
The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.
Show answer and rationale
Correct answer: A. Weight loss
Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.
The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and should tell the client to notify the health care provider (HCP) if which problem occurs?
Show answer and rationale
Correct answer: A. Tremors
Excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur.
The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition?
Show answer and rationale
Correct answer: A. Graves’ disease
Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves’ disease. Myxedema indicates hypothyroidism. Cushing’s syndrome and Addison’s disease are disorders related to adrenal function.
The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication?
Show answer and rationale
Correct answer: C. Runny nose
Desmopressin administered by the intranasal route can cause a runny or stuffy nose.
A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?
Show answer and rationale
Correct answer: D. Early morning
Corticosteroids (glucocorticoids) should be administered before 9 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning.
Prednisone is prescribed for a client with diabetes mellitus who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone?
Show answer and rationale
Correct answer: C. An increased amount of daily Humulin NPH insulin
Glucocorticoids can elevate blood glucose levels. Clients with diabetes mellitus may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy.
A client with diabetes mellitus visits a health care clinic. The client’s diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client’s regimen, may have contributed to the hyperglycemia?
Show answer and rationale
Correct answer: D. Prednisone
Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements.
A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client’s pain. What type of pain is consistent with this diagnosis?
Show answer and rationale
Correct answer: D. Severe and unrelenting, located in the epigastric area and radiating to the back
The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?
Show answer and rationale
Correct answer: A. Right upper quadrant, radiating to the right scapula and shoulder
During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body.
A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
Show answer and rationale
Correct answer: C. Increase intake of fluids, including juices.
Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
Show answer and rationale
Correct answer: C. Malaise
Hepatitis causes gastrointestinalsymptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.
Show answer and rationale
Correct answer: B. Encourage a high-fiber diet to promote bowel movements without straining.
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stoolsofteners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding.
The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply.
Show answer and rationale
Correct answer: A. Chocolate
Foods that decrease lower esophagealsphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client’s care plan?
Show answer and rationale
Correct answer: D. Assessing for the return of the gag reflex
The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client’s airway. The nurse also monitors the client’s vitalsigns and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client’s airway is the priority.
The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
Show answer and rationale
Correct answer: B. Hepatitis A
Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
Show answer and rationale
Correct answer: C. Document the findings.
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify?
Show answer and rationale
Correct answer: B. Irrigating the nasogastric tube
In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer?
Show answer and rationale
Correct answer: C. Pain relieved by food intake
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
Show answer and rationale
Correct answer: B. Lying recumbent following meals
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2 -receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.
The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs?
Show answer and rationale
Correct answer: B. Protruding stoma
A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?
Show answer and rationale
Correct answer: D. This is a normal, expected event.
As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Show answer and rationale
Correct answer: A. Fluid and electrolyte imbalance
A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
The nurse is doing preoperative teaching with a client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement?
Show answer and rationale
Correct answer: C. "I will need to drain the pouch regularly with a catheter."
A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool from the rectum only if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.
A client with Crohn’s disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment?
Show answer and rationale
Correct answer: D. Checking the frequency and consistency of bowel movements
The principal manifestations of Crohn’s disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea.
A client has a PRN prescription for ondansetron (Zofran). For which condition should the nurse administer this medication to the postoperative client?
Show answer and rationale
Correct answer: B. Nausea and vomiting
Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy.
A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen?
Show answer and rationale
Correct answer: C. "The medications will kill the bacteria and stop the acid production."
Triple therapy for Helicobacter pylori infection usually includes two antibacterial medications and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.
A client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition?
Show answer and rationale
Correct answer: D. Vomiting following cancer chemotherapy
Metoclopramide is a gastrointestinalstimulant and antiemetic. Because it is a gastrointestinalstimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation.
A histamine (H2 )-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2 -receptor antagonists? Select all that apply.
Show answer and rationale
Correct answer: A. Cimetidine (Tagamet)
H2 -receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client?
Show answer and rationale
Correct answer: D. Diminished breath sounds
This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply.
Show answer and rationale
Correct answer: B. Decreased oxygen saturation with mild exercise
Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.
The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome?
Show answer and rationale
Correct answer: C. Promote carbon dioxide elimination
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.
Show answer and rationale
Correct answer: B. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?
Show answer and rationale
Correct answer: B. Bronchospasm
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
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Correct answer: B. 10 seconds
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate?
Show answer and rationale
Correct answer: A. Stop the procedure and reoxygenate the client.
During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagalstimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
Show answer and rationale
Correct answer: C. Pain, especially with inspiration
Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typicalsigns and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
Show answer and rationale
Correct answer: B. Paradoxical chest movement
Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the highpressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?
Show answer and rationale
Correct answer: B. Right pneumothorax
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?
Show answer and rationale
Correct answer: D. Increased respiratory rate
The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?
Show answer and rationale
Correct answer: D. Percussion and vibration
Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus moving from smaller airways to larger ones to support expectoration of the mucus.
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care?
Show answer and rationale
Correct answer: A. Particulate respirator, gown, and gloves
The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?
Show answer and rationale
Correct answer: D. Chest pain that occurs suddenly
The most common initialsymptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?
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Correct answer: C. Positive
The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?
Show answer and rationale
Correct answer: B. Dyspnea
Histoplasmosis is an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS). The infection begins as a respiratory infection and can progress to disseminated infection. Typicalsigns and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client’s lymph nodes, liver, and spleen may occur as well.
The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?
Show answer and rationale
Correct answer: D. Shortness of breath
Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?
Show answer and rationale
Correct answer: A. Mask
Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure.
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?
Show answer and rationale
Correct answer: A. Venturi mask
The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?
Show answer and rationale
Correct answer: C. Sitting on the side of the bed and leaning on an overbed table
Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.
The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis?
Show answer and rationale
Correct answer: A. A cough with the expectoration of mucoid sputum
One of the first pulmonary manifestations of tuberculosis is a slight cough with the expectoration of mucoid sputum.
The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?
Show answer and rationale
Correct answer: B. Sputum culture
Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
Show answer and rationale
Correct answer: A. Ventilate the client manually
If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vitalsigns is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.
The nurse is preparing to administer a dose of naloxone hydrochloride intravenously to a client with an intravenous opioid overdose. Which supportive medical equipment should the nurse plan to have at the client’s bedside if needed?
Show answer and rationale
Correct answer: A. Resuscitation equipment
The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, mechanical ventilator, and vasopressors.
A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the side and adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?
Show answer and rationale
Correct answer: C. Bronchospasm
Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cellstabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.
Terbutaline is prescribed for a client with bronchitis. The nurse understands that this medication should be used with caution if which medical condition is present in the client?
Show answer and rationale
Correct answer: D. Diabetes mellitus
Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?
Show answer and rationale
Correct answer: B. Liver function tests
Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.
A client has been taking isoniazid for 11?2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?
Show answer and rationale
Correct answer: C. Peripheral neuritis
Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6 ) intake.
A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?
Show answer and rationale
Correct answer: A. Report yellow eyes or skin immediately.
Isoniazid is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcoholshould be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6 ) during the course of isoniazid therapy.
A client has been started on long-term therapy with rifampin (Rifadin). The nurse should provide which information to the client about the medication?
Show answer and rationale
Correct answer: A. Causes orange discoloration of sweat, tears, urine, and feces
Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a health care provider. The medication should be administered on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes orange-red discoloration of body secretions and willstain soft contact lenses permanently.
A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed?
Show answer and rationale
Correct answer: A. Liver enzyme levels
Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 or abuses alcohol.
The nurse has a prescription to give a client salmeterol (Serevent Diskus), two puffs, and beclomethasone dipropionate (Qvar), two puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?
Show answer and rationale
Correct answer: A. Salmeterol first and then the beclomethasone
Salmeterol (Serevent Diskus) is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side/adverse effects of the medication should the nurse monitor? Select all that apply.
Show answer and rationale
Correct answer: C. Flulike syndrome
Rifabutin (Mycobutin) may be prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side/adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flulike syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid. Ethambutol (Myambutol) causes peripheral neuritis.
A client has begun therapy with theophylline (Theo-24). The nurse should plan to teach the client to limit the intake of which items while taking this medication?
Show answer and rationale
Correct answer: A. Coffee, cola, and chocolate
Theophylline (Theo-24) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.
The nurse has just administered the first dose of omalizumab (Xolair) to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect?
Show answer and rationale
Correct answer: A. "My lips and tongue are swollen."
Omalizumab is an antiinflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an adverse reaction. The client statements in options 1, 2, and 3 are not indicative of an adverse reaction.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
Show answer and rationale
Correct answer: B. Metformin (Glucophage)
Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?
Show answer and rationale
Correct answer: A. Prepare for transcutaneous pacing.
Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client’s heart rate. Continuing to monitor the client delays necessary intervention.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply.
Show answer and rationale
Correct answer: A. Administering morphine sulfate intravenously
Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?
Show answer and rationale
Correct answer: C. Crackles
Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?
Show answer and rationale
Correct answer: D. Ventricular dysrhythmias
Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?
Show answer and rationale
Correct answer: A. Acute kidney injury
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
Show answer and rationale
Correct answer: D. Normal sinus rhythm
Normalsinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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