1. What group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?
Children
Older adults
Young adults
Middle-aged persons
2. What clinical finding should the nurse expect when assessing a client who had a splenectomy?
Lung crackles
Pain on inspiration
Shortness of breath
Excessive secretions
3. A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?
Asthma
Anemia
Endocarditis
Reye syndrome
4. A nurse uses abdominal-thoracic thrusts (Heimlich maneu-ver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx?
Tidal
Residual
Vital capacity
Inspiratory reserve
5. A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?
INR is between 2 and 3
PT is 2/2 times the control value
APTT is 2 times the control value
ACT is in the range of 70 and 120
6. A client is admitted with a higher than expected red blood cell count. What physiological alteration does the nurse expect will result from this clinical finding?
Increased serum pH
Decreased hematocrit
Increased blood viscosity
Decreased immune response
7. What is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?
Incisional pain
Pedal pulse rate
Degree of hair growth
Lower extremity color
8. What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?
Encourage frequent coughing.
Elevate the client’s lower extremities.
Prepare for modified postural drainage.
Place the client in the orthopneic position.
9. An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?
Urine output of 50 mL/hr
Blood pressure of 150/90 mm Hg
Apical heart rate of 142 beats/min
Respiratory rate of 16 breaths/min
10. What change in pressure does the nurse conclude is responsible for the lower extremity pitting edema of a client with right ventricular heart failure?
Increase in plasma hydrostatic pressure
Increase in tissue colloid osmotic pressure
Decrease in the tissue hydrostatic pressure
Decrease in the plasma colloid osmotic pressure
11. A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?
3/4 to 1 inch
1/2 to 3/4 inch
1 to 1 and 1/2 inches
2 to 2 and 1/2 inches
12. A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What response should the nurse consider the priority when assessing this client?
Acute pain
Impaired mobility
Impaired swallowing
Hematoma formation
13. While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client’s color is pale and the pulse is rapid. What should the nurse conclude about the clients condition?
Hyperventilating
Going into shock
Experiencing anxiety
Developing an infection
14. A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?
Cervical
Axillary
Inguinal
Mediastinal
15. A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume?
Exhaled after there is a normal inspiration
Exhaled forcibly after a regular expiration
Inspired forcibly above a typical inspiration
Trapped in the alveoli after a maximum expiration
16. A client who is pale and moaning is diagnosed with esophageal varices and is admitted to the hospital. The health care provider orders a blood transfusion. What nursing actions should be taken?
Take the vital signs, verify the blood product with another nurse against the client’s ID bracelet, and monitor the vital signs according to agency policy.
Since the vital signs were recorded during admission, hang the blood and monitor the client’s vital signs every 15 minutes until the transfusion is absorbed.
Record the vital signs in accordance with facility policy and check the blood product against the client’s ID bracelet in the presence of the nursing supervisor.
Take the vital signs after hanging the blood because the client is pale and moaning and is in critical condition; return in 15 minutes to monitor the vital signs.
17. A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, “Why do I have an increased tendency to develop blood clots?” Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?
Elevated blood pressure
Increased blood viscosity
Fragility of the blood cells
Immaturity of red blood cells
18. During a blood transfusion a client develops chills and a headache. What is the priority nursing action?
Cover the client.
Stop the transfusion at once.
Decrease the rate of the blood infusion.
Notify the health care provider immediately.
19. What is the most important nursing action when measuring a client’s pulmonary capillary wedge pressure (PCWP)?
Deflate the balloon as soon as the PCWP is measured.
Have the client bear down when measuring the PCWP.
Place the client in a supine position before measuring the PCWP.
Flush the catheter with a heparin solution after the PCWP is determined.
20. A client is found unconscious and unresponsive. What should the nurse do first?
Initiate a code
Check for a radial pulse.
Compress the lower sternum.
Give four full lung inflations.
21. A client with upper gastrointestinal (GI) bleeding develops mild anemia. What should the nurse expect to be prescribed for this client?
Epogen
Dextran
Iron salts
Vitamin B12
22. When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reaching the client?
Administer oxygen.
Initiate defibrillation.
Initiate cardiopulmonary resuscitation.
Administer sodium bicarbonate intravenously.
23. A client has a bone marrow aspiration performed. After the procedure, what is the first nursing action?
Position the client on the affected side.
Cleanse the site with an antiseptic solution.
Briefly apply pressure over the aspiration site.
Begin frequent monitoring of the client’s vital signs.
24. A client who is weak, dyspneic, and jaundiced has a bilirubin level greater than 2mg/100 mL blood volume. With which problem are these clinical findings consistent?
Hemolytic anemia
Pernicious anemia
Decreased rate of red blood cell destruction
Low oxygen-carrying capacity of erythrocytes
25. Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?
Aspirin to warfarin (Coumadin)
Amoxicillin to systemic infection
Protamine sulfate to parenteral heparin
Enoxaparin (Lovenox) to dalteparin (Fragmin)
26. A nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. How should the nurse respond when the client expresses fear that AIDS may develop as a result of the blood transfusion?
“The blood is treated with radiation to kill the virus.”
“Screening for the HIV antibodies has minimized this risk.”
“The ability to directly identify HIV has eliminated this concern.”
“Consideration should be given to donating your own blood for transfusion.”
27. A client is receiving Coumadin (warfarin). The nurse explains the need for careful regulation of dietary intake of vitamin K. What physiologic process does vitamin K promote that makes this instruction essential?
Platelet aggregation
Ionization of blood calcium
Fibrinogen formation by the liver
Prothrombin formation by the liver
28. What effect of anxiety makes it particularly important for the nurse to allay the anxiety of a client with heart failure?
Increases the cardiac workload
Interferes with usual respirations
Produces an elevation in temperature
Decreases the amount of oxygen used
29. What assessment of the pulse should the nurse identify when a clients on-demand pacemaker is functioning effectively?
Regular rhythm
Palpable at all pulse sites
At least at the demand rate
Equal to the pacemaker setting
30. A nurse is leading a discussion in a senior citizen center about the risk factors for developing coronary heart disease (CHD) for women versus men. What should the nurse respond when asked to identify the most significant risk factor?
Obesity
Diabetes
Elevated CRP levels
High levels of HDL-C
31. A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction?
Blowing vigorously into the mouthpiece
Getting into a chair to use the spirometer
Coughing deeply after using the spirometer
Using lips to form a seal around the mouthpiece
32. A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure?
Stability of gait
Presence of a gag reflex
Blood pressure in both arms
Symmetry of the radial pulses
33. A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricular irritability on the screen. What medication should the nurse prepare to administer?
Digoxin (Lanoxin)
Furosemide (Lasix)
Amiodarone (Cordarone)
Norepinephrine (Levophed)
34. A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent?
Pulmonary edema
Myocardial infarction
Right ventricular heart failure
Chronic obstructive lung disease
35. A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?
Hepatitis A
Rheumatic fever
Spinal meningitis
Rheumatoid arthritis
36. The family of a client with right ventricular heart failure expresses concern about the client’s increasing abdominal girth. What physiologic change should the nurse consider when explaining the client’s condition?
Loss of cellular constituents in blood
Rapid osmosis from tissue spaces to cells
Increased pressure within the circulatory system
Rapid diffusion of solutes and solvents into plasma
37. What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?
Age of the client
How long the client was anoxic
Heart rate of the client before the arrest
Emergency medications available for the client
38. A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests is ordered. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?
ALT
AST
Total LDH
Troponin T
39. A client has a splenectomy after a motor vehicle collision. What is a postoperative nursing concern specifically related to this type of surgery?
Pulmonary embolism
Prolonged immobility
Adequate lung aeration
Decreased blood volume
40. A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?
Count the pulse at another site.
Notify the health care provider.
Lower the legs to increase blood flow.
Verify the pulse by using a Doppler.
41. A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction. What statement by the client indicates to the nurse that there is a need for further teaching?
“I want to stay as pain-free as possible.”
“I am not good at remembering to take medications.”
“I should not have any problems in reducing my salt intake.”
“I wrote down my medication information for future reference.”
42. When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?
Interview the client for a health history.
Assess the client’s heart and lung sounds.
Monitor the clients pulse and temperature.
Obtain the client’s blood specimen for electrolytes.
43. A nurse is teaching a client with Hodgkin disease about responses to whole-body radiation. Which clinical indicator increase should the nurse include?
Blood viscosity
Susceptibility to infection
Red blood cell production
Tendency for pathologic fractures
44. A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?
Restrict fluids.
Elevate the legs.
Apply elastic bandages.
Do range-of-motion exercises.
45. What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted?
Instruct the client that it is better to sleep on two pillows.
Encourage the client to reduce activity from former levels.
Teach the client to keep daily accurate records of the pulse.
Inform the client that the pacemaker functions when the heart rate drops below a preset rate.
46. A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. Tbe nurse prepares for cardioversion. What nursing action is essential to avoid the potential danger of inducing ventricular fibrillation during cardioversion?
Energy level is set at its maximum level.
Synchronizer switch is in the “on” position.
Skin electrodes are applied after the T wave.
Alarm system of the cardiac monitor is functioning simultaneously.
47. A health care provider orders 1 unit of whole blood for a client after gastrointestinal surgery. What is an important nursing responsibility when administering blood?
Maintain patency of the IV catheter with dextrose solution.
Warm the blood to body temperature to prevent chilling the client.
Draw a blood sample from the client before each unit is transfused.
Run the blood at a slower rate during the first few minutes of the transfusion.
48. A nurse is caring for a client who had a splenectomy. For which complication should the nurse specifically assess in the immediate postoperative period?
Infection
Peritonitis
Intestinal obstruction
Abdominal distention
49. Two hours after a cardiac catheterization that was accessed via the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?
Call the health care provider.
Check the client’s pedal pulses.
Take the client’s blood pressure.
Recognize the response is expected.
50. A nurse is performing external cardiac compression. How should the nurse exert downward vertical pressure?
Extending the fingers over the sternum and chest with the heels of each hand side by side
Placing the fingers of one hand on the sternum and the fingers of the other hand on top of them
Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top of it
Clenching the hand into a fist and placing the fleshy part of a clenched fist on the lower sternum