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1. A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate:
1. Quadriceps setting
2. Gluteal muscle contraction
3. Moving the arms and legs in circles
4. Pushing against a footboard

Pushing against a footboard

2. The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to:
1. Observe gait
2. Put the client at ease
3. Determine activity tolerance
4. Determine range of joint motion

Put the client at ease

3. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?
1. The client keeps the cane on the left side.
2. Two points of support are kept on the floor at all times.
3. There is a slight lean to the right when the client is walking.
4. After advancing the cane, the client moves the right leg forward.

Two points of support are kept on the floor at all times.

4. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:
1. Uses a banister or wall for support when descending
2. Uses one crutch for support while going up and down
3. Advances the crutches first to ascend the stairs
4. Advances the affected leg after moving the crutches to descend the stairs

Advances the affected leg after moving the crutches to descend the stairs

5. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first:
1. Support the client and walk quickly back to the room
2. Lean the client against the wall until the episode passes
3. Lower the client gently to the floor
4. Go for help

Lower the client gently to the floor

6. A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily. Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition?
1. "It makes me stronger and healthier."
2. "It helps make all my bones stronger."
3. "Walking increases the muscle mass in my legs."
4. "Regular walking improves my stamina and endurance."

"It helps make all my bones stronger."

7. During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe:
1. A swayback and outwardly turned feet
2. A spine that is flexed and lacking anteroposterior curves
3. Widened hips and fat deposits on the thighs and buttocks
4. A stance with moderately spaced foot placement and a slightly rounded abdomen

A swayback and outwardly turned feet

8. The nurse recognizes that the older adult's tendency to take smaller steps with feet kept closer together will most likely:
1. Increase the client's risk of injury resulting from falls
2. Result in less stress on the client's knees, hips, and ankles
3. Decrease the amount of energy the client expends on movement
4. Allow for mobility in spite of the effects of aging on the client's joints

Increase the client's risk of injury resulting from falls

9. The nurse encourages a non-insulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the client's:
1. Gastric motility, thus affecting glucose digestion
2. Respiratory recovery time, thus decreasing breath load
3. Average cardiac output, thus decreasing resting heart rate
4. Use of glucose and fatty acids, thus decreasing blood glucose level

Use of glucose and fatty acids, thus decreasing blood glucose level

10. When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)
1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
5. Increased cognitive function
6. Increased musculoskeletal flexibility

1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
6. Increased musculoskeletal flexibility
Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.

11. The general goal of exercise and activity for all clients is to: (Select all that apply.)
1. Encourage weight loss
2. Improve joint flexibility
3. Minimize social isolation
4. Improve motor function
5. Foster personal independence
6. Maintain the optimal level of function

3. Minimize social isolation
5. Foster personal independence
The general goal related to exercise and activity is to improve or maintain the client's motor function and independence. While the other options are not inappropriate, they do not reflect the general goals for all clients.

12. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following?
1. The witnessing nurse completes the report.
2. Details of the incident are subjectively described.
3. An explanation of the possible cause for the incident is entered.
4. A notation is included in the medical record that an incident report was prepared.

The witnessing nurse completes the report.

13. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?
1. 1230—Client's vital signs taken.
2. 0700—Client drank adequate amount of fluids.
3. 0900—Demerol given for lower abdominal pain.
4. 0830—Increased IV fluid rate to 100 mL/hr according to protocol.

0830—Increased IV fluid rate to 100 mL/hr according to protocol.
Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating "adequate" is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the client's pain was in the lower left or lower right quadrant, or both.

14. To locate the recording of a nurse's description of the teaching provided to the client on performance of self-medication administration, one would look in a(n):
1. Kardex
2. Incident report
3. Nursing history form
4. Discharge summary form

Discharge summary form

15. The nurse has made an error and is documenting such on the client's record and notes. The action that the nurse should take is to:
1. Draw a straight line through the error and initial it.
2. Erase the error and write over the material in the same spot.
3. Use a dark color marker to cover the error and continue immediately after that point.
4. Footnote the error at the bottom of the page.

Draw a straight line through the error and initial it.

16. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written errors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record

Dates and signs all of the entries made in the record

17. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.
1. "Let me get the Registered Nurse on the phone."
2. "I am unable to take the order at this time. Please call in the morning."
3. "Please repeat the order for me so I can make sure it is written correctly."
4. "Let me have your phone number and I will have the supervisor call you back."

"Let me get the Registered Nurse on the phone."

18. Which of the following is evaluated as a legally appropriate notation?
1. "Dr. Green made an error in the amount of medication to administer."
2. "Verbalized sharp, stabbing pain along the left side of chest."
3. "Nurse Williams spoke with the client about the surgery."
4. "Client upset about the physical therapy."

"Verbalized sharp, stabbing pain along the left side of chest."
Entries should be concise, factual, and accurate. "Verbalized sharp, stabbing pain along the left side of chest" is an example of an objective description of a client's behavior. The nurse should not document "physician made error." Instead, the nurse could chart that "Dr. Green was called to clarify order for medication administration." The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the client's behavior should be recorded. For example: Client states, "I don't want physical therapy! I want to go home!"

19. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?
1. "Medicare reviews client charts to determine care given."
2. "Good charting results in good Medicare reimbursement."
3. "Our nursing salaries are paid for by the Medicare reimbursement funds."
4. "The hospital is reimbursed for the nursing care documented in the client chart."

"The hospital is reimbursed for the nursing care documented in the client chart."

20. A 45-year-old man is in the clinic for a physical. During the abdominal assessment, the nurse percusses and notes an area of dullness above the right costal margin of about 10 cm. The nurse should:
1. document the presence of hepatomegaly.
2. ask additional history questions regarding his alcohol intake.
3. describe this as an enlarged liver and refer him to a physician.
4. consider this a normal finding and proceed with the examination.

consider this a normal finding and proceed with the examination.
The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual.

21. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:
1. Secured
2. Accessible
3. Confidential
4. Documented

Confidential
Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care. The other options are primarily directed towards written records and are not ethically oriented.

22. Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?
1. "I'm pretty sure this will require the client's permission."
2. "Are you sure of the exact policy? Do you know what I should do?"
3. "The client agreed to the consultation, so I'll have the chart sent over."
4. "I think the client will need to give a verbal consent before it can be sent."

"The client agreed to the consultation, so I'll have the chart sent over."

23. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:
1. Show the unit staff proper student identification
2. Sign a confidentiality agreement when on the unit to preplan
3. Review the medical record only in the presence of unit staff
4. Obtain permission from the client to access his or her medical record

Show the unit staff proper student identification
When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.

24. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?
1. Notifying the client of the institution's privacy policy
2. Denying nonessential personal access to the client's medical records
3. Acquiring the client's verbal consent to share his or her medical record with essential personnel
4. Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form

Notifying the client of the institution's privacy policy
Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.

25. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:
1. Referral
2. Consultation
3. Transfer report
4. Multidisciplinary meeting

Referral
Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client.

26. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior.

27. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client is depressed; was observed crying while alone in room."
Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.

28. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:
1. James Thicket, NS, WVU
2. J. Jones, NS, Montclair Shores College
3. N.H, SN, Bellfield City Community College
4. Linda Mozden, SN, Fairmont State University

Linda Mozden, SN, Fairmont State University
A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as "David Jones, SN (student nurse), CMTC (Central Maine Technical College)."

29. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:
1. Shows a lack of competency
2. Displays little attention to detail
3. Contributes to serious treatment errors
4. Negatively affects the accuracy of the documentation

Contributes to serious treatment errors
Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors.

30. Just before going home, a new mother asks the nurse about the umbilical cord. The nurse would tell her:
1. it should fall off by 10 to 14 days.
2. at birth the cord is a bluish color.
3. it contains two veins and one artery.
4. skin will cover the area within 1 week.

it should fall off by 10 to 14 days.
At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.

31. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)
1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
5. Record nursing opinion
6. Identify client outcomes

1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
6. Identify client outcomes
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions.

32. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)
1. Safe nursing practice
2. Continuity of client care
3. Positive client outcomes
4. Efficient time management
5. Cost-conscious nursing care
6. Effective nurse-client relationships

1. Safe nursing practice
2. Continuity of client care
4. Efficient time management
Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. While important, the remaining options are not criteria for effective nursing documentation.

33. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse will conduct which of the following to assess for this condition?
1. Obturator test
2. Murphy's sign
3. Assess for rebound tenderness
4. Iliopsoas muscle test

Murphy's sign
Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration. The person feels sharp pain and abruptly stops inspiration midway.

34. Which of the following statements is true regarding the arterial system?
1. Arteries are large-diameter vessels.
2. The arterial system is a high-pressure system.
3. The walls of arteries are thinner than those of veins.
4. Arteries can expand greatly to accommodate a large blood volume increase.

The arterial system is a high-pressure system.
The pumping heart makes the arterial system a high-pressure system.

35. The major artery supplying the arm is the:
1. ulnar artery.
2. radial artery.
3. brachial artery.
4. deep palmar artery.

brachial artery.
The major artery supplying the arm is the brachial artery.

36. To assess the dorsalis pedis artery, the nurse would palpate:
1. behind the knee.
2. over the lateral malleolus.
3. in the groove behind the medial malleolus.
4. lateral to the extensor tendon of the great toe.

lateral to the extensor tendon of the great toe.
The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.

37. A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with:
1. venous obstruction of the left leg.
2. claudication due to venous abnormalities in the left leg.
3. ischemia caused by partial blockage of an artery supplying the left leg.
4. ischemia caused by complete blockage of an artery supplying the left leg.

ischemia caused by partial blockage of an artery supplying the left leg.
Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only at exercise, when oxygen needs increase.

38. Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart?
1. Intraluminal valves ensure unidirectional flow toward the heart.
2. Contracting skeletal muscles milk blood distally toward the veins.
3. The high-pressure system of the heart helps to facilitate venous return.
4. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

Intraluminal valves ensure unidirectional flow toward the heart.
Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow.

39. Which of the following veins are responsible for most of the venous return in the arm?
1. Deep veins
2. Ulnar veins
3. Subclavian veins
4. Superficial veins

Superficial veins
The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

40. A 70-year-old patient is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply:
1. "Venous insufficiency is a common problem after this type of surgery."
2. "Oh, we have lots of veins—you won't even notice that it has been removed."
3. "You will probably experience decreased circulation after the veins are removed."
4. "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

"Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."
As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation.

41. Which of the following situations best describes a person at risk for development of venous disease?
1. A woman in her fifth month of pregnancy
2. A person who has been on bed rest for 4 days
3. A person with a 30-year, 1 pack per day smoking history
4. An elderly person taking anticoagulant medication

A person who has been on bed rest for 4 days
At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable states and vein wall trauma also place the person at risk for venous disease.

42. Which of the following statements regarding the lymphatic system is true?
1. Lymph flow is propelled by the contraction of the heart.
2. The flow of lymph is slow compared with that of the blood.
3. One of the functions of the lymph is to absorb lipids from the biliary tract.
4. Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream and back again.

The flow of lymph is slow compared with that of the blood.
The flow of lymph is slow compared with that of the blood.

43. When performing an assessment of a patient, the nurse notes the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
1. Assess the patient's abdomen, noting any tenderness.
2. Carefully assess the cervical lymph nodes, checking for any enlargement.
3. Ask additional history questions regarding any recent ear infections or sore throats.
4. Examine the patient's lower arm and hand, checking for the presence of infection or lesions.

Examine the patient's lower arm and hand, checking for the presence of infection or lesions.
The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm.

44. A 35-year-old man is seen in the clinic for an "infection in my left foot." Which of the following would the nurse expect to find during an assessment of this patient?
1. Hard and fixed cervical nodes
2. Enlarged and tender inguinal nodes
3. Bilateral enlargement of the popliteal nodes
4. "Pellet-like" nodes in the supraclavicular region

Enlarged and tender inguinal nodes
The inguinal nodes in the groin drain most of the lymph of the lower extremity. With local inflammation, the nodes in that area become swollen and tender.

45. The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding would the nurse expect to note?
1. Excessive swelling of the lymph nodes
2. The presence of palpable lymph nodes
3. No nodes palpable because of the immature immune system of a child
4. Fewer numbers and a decrease in size of lymph nodes compared with those of an adult

The presence of palpable lymph nodes
Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

46. The nurse recognizes that which of the following is a normal physiologic change associated with the aging process?
1. Hormonal changes causing vasodilation and a resulting drop in blood pressure.
2. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency.
3. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure.
4. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities.

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure.
Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure.

47. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
1. 1 minute.
2. 5 minutes.
3. 10 minutes.
4. 2 minutes in each quadrant.

5 minutes.
Absent bowel sounds are rare. The nurse must listen for 5 minutes by the watch before deciding bowel sounds are completely absent.

48. A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated, which disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the patient is most likely experiencing:
1. pain related to lymphatic abnormalities.
2. problems related to arterial insufficiency.
3. problems related to venous insufficiency.
4. pain related to musculoskeletal abnormalities.

problems related to arterial insufficiency.
Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

49. A patient is complaining of tenderness along the costovertebral angles. The nurse knows that this symptom is most often indicative of:
1. ovary infection.
2. liver enlargement.
3. kidney inflammation.
4. spleen enlargement.

kidney inflammation.
Tenderness along the costovertebral angles occurs with inflammation of the kidney or paranephric area.

50. A nurse notes that a patient has ascites, which indicates that which of the following is present?
1. Fluid
2. Feces
3. Flatus
4. Fibroid tumors

Fluid
Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

51. The nurse knows that during an abdominal assessment, deep palpation is used to determine:
1. bowel motility.
2. enlarged organs.
3. superficial tenderness.
4. overall impression of skin surface and superficial musculature.

enlarged organs.
With deep palpation, note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

52. Tenderness on light palpation in the right lower quadrant could indicate a disorder of which of the following structures?
1. Spleen
2. Sigmoid
3. Appendix
4. Gallbladder

Appendix
The appendix is located in the right lower quadrant and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant.

53. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by:
1. projectile vomiting.
2. hypoactive bowel activity.
3. palpable olive-sized mass in right lower quadrant.
4. pronounced peristaltic waves crossing from right to left.

projectile vomiting.
Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

54. Which of the following statements is true regarding an aortic aneurysm?
1. A bruit is absent.
2. Femoral pulses are increased.
3. A pulsating mass is usually present.
4. Most are located below the umbilicus.

A pulsating mass is usually present.
Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

55. A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe?
1. A unilateral cool foot
2. Thin, shiny, atrophic skin
3. Pallor of the toes and cyanosis of the nailbeds
4. A brownish discoloration to the skin of the lower leg

A brownish discoloration to the skin of the lower leg
A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a byproduct of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

56. A patient has hard, nonpitting edema of the left lower leg and ankle. The nurse knows that:
1. nonpitting, hard edema occurs with lymphatic obstruction.
2. alterations in arterial function will cause this edema.
3. phlebitis of a superficial vein will cause bilateral edema.
4. long-standing arterial obstruction will cause pitting edema.

nonpitting, hard edema occurs with lymphatic obstruction.
Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, it is nonpitting and feels hard to the touch.

57. The nurse is performing a peripheral vascular assessment on a bedridden patient, and notes the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign. The nurse would:
1. reevaluate the patient in a few hours.
2. consider this a normal finding for a bedridden patient.
3. seek emergency referral because of the risk of pulmonary embolism.
4. ask the patient to raise his leg off of the bed and check for pain on elevation.

seek emergency referral because of the risk of pulmonary embolism.
Increased warmth, swelling, redness, and tenderness require emergency referral because of the risk of pulmonary embolism.

58. A patient has bilateral pitting edema of the feet. In the assessment of the peripheral vascular system, the nurse's primary focus should be:
1. oxygenation of the lower extremities.
2. arterial function of the lower extremities.
3. venous function of the lower extremities.
4. possible thrombophlebitis of the lower extremities.

venous function of the lower extremities.
Bilateral pitting edema of the lower extremities occurs with heart failure, venous disease, or lymphatic obstruction.

59. During an assessment, the nurse notes that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy 1 year ago. The nurse suspects which problem?
1. Venous stasis
2. Lymphedema
3. Arteriosclerosis
4. Deep vein thrombosis

Lymphedema
Chronic lymphedema is unilateral swelling, nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer and can impede drainage of lymph.

60. The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His past medical history is unremarkable, and he received immunizations 1 week ago. Which of the following findings would be considered normal in this situation?
1. Enlarged, warm, tender nodes
2. Lymphadenopathy of the cervical nodes
3. Palpable firm, small, shotty, mobile, nontender lymph nodes
4. Firm, rubbery, large nodes, somewhat fixed to the underlying tissue

Palpable firm, small, shotty, mobile, nontender lymph nodes
Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

61. When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?
1. A low humming sound
2. A regular "lub, dub" pattern
3. A swishing, whooshing sound
4. A steady, even, flowing sound

A swishing, whooshing sound
When using the Doppler ultrasonic stethoscope, the pulse site is noted when one hears a swishing, whooshing sound.

62. A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate:
1. Quadriceps setting
2. Gluteal muscle contraction
3. Moving the arms and legs in circles
4. Pushing against a footboard

Pushing against a footboard
Resistive isometric exercises are those in which the individual contracts the muscle while pushing against a stationary object or resisting the movement of an object. An example of a resistive isometric exercise is pushing against a footboard. Quadriceps setting is an example of an isometric exercise. Gluteal muscle contraction is an example of an isometric exercise. Moving the arms and legs in a circle is an example of isotonic exercise.

63. Which of the following statements is true regarding the arterial system?
1. Arteries are large-diameter vessels.
2. The arterial system is a high-pressure system.
3. The walls of arteries are thinner than those of veins.
4. Arteries can expand greatly to accommodate a large blood volume increase.

The arterial system is a high-pressure system
The pumping heart makes the arterial system a high-pressure system.

64. The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to:
1. Observe gait
2. Put the client at ease
3. Determine activity tolerance
4. Determine range of joint motion

Put the client at ease
The first step in assessing body alignment is to put the client at ease so unnatural or rigid positions are not assumed. When assessing body alignment, the first action of the nurse is to put the client at ease. Later, the nurse may assess the client's gait to observe the client's balance, posture, and ability to walk without assistance.

65. The major artery supplying the arm is the:
1. ulnar artery.
2. radial artery.
3. brachial artery.
4. deep palmar artery.

brachial artery.
The major artery supplying the arm is the brachial artery.

66. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?
1. The client keeps the cane on the left side.
2. Two points of support are kept on the floor at all times.
3. There is a slight lean to the right when the client is walking.
4. After advancing the cane, the client moves the right leg forward.

Two points of support are kept on the floor at all times.
Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the client's right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg

67. To assess the dorsalis pedis artery, the nurse would palpate:
1. behind the knee.
2. over the lateral malleolus.
3. in the groove behind the medial malleolus.
4. lateral to the extensor tendon of the great toe.

lateral to the extensor tendon of the great toe.
The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.

68. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:
1. Uses a banister or wall for support when descending
2. Uses one crutch for support while going up and down
3. Advances the crutches first to ascend the stairs
4. Advances the affected leg after moving the crutches to descend the stairs

Advances the affected leg after moving the crutches to descend the stairs
To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.

69. A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with:
1. venous obstruction of the left leg.
2. claudication due to venous abnormalities in the left leg.
3. ischemia caused by partial blockage of an artery supplying the left leg.
4. ischemia caused by complete blockage of an artery supplying the left leg.

ischemia caused by partial blockage of an artery supplying the left leg.
Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only at exercise, when oxygen needs increase.

70. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first:
1. Support the client and walk quickly back to the room
2. Lean the client against the wall until the episode passes
3. Lower the client gently to the floor
4. Go for help

Lower the client gently to the floor
If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the client's weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the client's head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help.

71. Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart?
1. Intraluminal valves ensure unidirectional flow toward the heart.
2. Contracting skeletal muscles milk blood distally toward the veins.
3. The high-pressure system of the heart helps to facilitate venous return.
4. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

Intraluminal valves ensure unidirectional flow toward the heart.
Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow.

72. A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily. Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition?
1. "It makes me stronger and healthier."
2. "It helps make all my bones stronger."
3. "Walking increases the muscle mass in my legs."
4. "Regular walking improves my stamina and endurance."

"It helps make all my bones stronger."
Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Osteopenia, the precursor of osteoporosis, results in weakened bones that are easily damaged. Walking helps stimulate bone cell production, which in turns helps produce stronger bones. While the other options are not incorrect, they do not address the issue of osteopenia.

73. Which of the following veins are responsible for most of the venous return in the arm?
1. Deep veins
2. Ulnar veins
3. Subclavian veins
4. Superficial veins

Superficial veins
The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

74. During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe:
1. A swayback and outwardly turned feet
2. A spine that is flexed and lacking anteroposterior curves
3. Widened hips and fat deposits on the thighs and buttocks
4. A stance with moderately spaced foot placement and a slightly rounded abdomen

A swayback and outwardly turned feet
The toddler's posture is awkward because of the slight swayback and protruding abdomen. As the child walks, the legs and feet are usually far apart and the feet are slightly everted (turned outward).

75. A 70-year-old patient is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply:
1. "Venous insufficiency is a common problem after this type of surgery."
2. "Oh, we have lots of veins—you won't even notice that it has been removed."
3. "You will probably experience decreased circulation after the veins are removed."
4. "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

"Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."
As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation.

76. The nurse recognizes that the older adult's tendency to take smaller steps with feet kept closer together will most likely:
1. Increase the client's risk of injury resulting from falls
2. Result in less stress on the client's knees, hips, and ankles
3. Decrease the amount of energy the client expends on movement
4. Allow for mobility in spite of the effects of aging on the client's joints

Increase the client's risk of injury resulting from falls
The older adult may take smaller steps, keeping their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries. The remaining options are not necessarily true.

77. Which of the following situations best describes a person at risk for development of venous disease?
1. A woman in her fifth month of pregnancy
2. A person who has been on bed rest for 4 days
3. A person with a 30-year, 1 pack per day smoking history
4. An elderly person taking anticoagulant medication

A person who has been on bed rest for 4 days
At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable states and vein wall trauma also place the person at risk for venous disease.

78. The nurse encourages a non-insulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the client's:
1. Gastric motility, thus affecting glucose digestion
2. Respiratory recovery time, thus decreasing breath load
3. Average cardiac output, thus decreasing resting heart rate
4. Use of glucose and fatty acids, thus decreasing blood glucose level

Use of glucose and fatty acids, thus decreasing blood glucose level
While all the options are correct, regular exercise does tend to increase effective use of glucose and fatty acids; this would be the primary benefit for the diabetic client.

79. Which of the following statements regarding the lymphatic system is true?
1. Lymph flow is propelled by the contraction of the heart.
2. The flow of lymph is slow compared with that of the blood.
3. One of the functions of the lymph is to absorb lipids from the biliary tract.
4. Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream and back again.

The flow of lymph is slow compared with that of the blood.
The flow of lymph is slow compared with that of the blood.

80. When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)
1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
5. Increased cognitive function
6. Increased musculoskeletal flexibility

1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
6. Increased musculoskeletal flexibility
Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.

81. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following?
1. The witnessing nurse completes the report.
2. Details of the incident are subjectively described.
3. An explanation of the possible cause for the incident is entered.
4. A notation is included in the medical record that an incident report was prepared.

The witnessing nurse completes the report.
The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written.

82. The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding would the nurse expect to note?
1. Excessive swelling of the lymph nodes
2. The presence of palpable lymph nodes
3. No nodes palpable because of the immature immune system of a child
4. Fewer numbers and a decrease in size of lymph nodes compared with those of an adult

The presence of palpable lymph nodes
Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

83. To locate the recording of a nurse's description of the teaching provided to the client on performance of self-medication administration, one would look in a(n):
1. Kardex
2. Incident report
3. Nursing history form
4. Discharge summary form

Discharge summary form

84. The nurse recognizes that which of the following is a normal physiologic change associated with the aging process?
1. Hormonal changes causing vasodilation and a resulting drop in blood pressure.
2. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency.
3. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure.
4. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities.

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure.
Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure.

85. The nurse has made an error and is documenting such on the client's record and notes. The action that the nurse should take is to:
1. Draw a straight line through the error and initial it.
2. Erase the error and write over the material in the same spot.
3. Use a dark color marker to cover the error and continue immediately after that point.
4. Footnote the error at the bottom of the page.

Draw a straight line through the error and initial it.
If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible

86. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written errors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record

Dates and signs all of the entries made in the record
Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased.

87. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse would next:
1. check for the presence of claudication.
2. refer the individual for further evaluation.
3. consider this a normal finding and proceed with the peripheral vascular evaluation.
4. ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

consider this a normal finding and proceed with the peripheral vascular evaluation.
It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable.

88. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.
1. "Let me get the Registered Nurse on the phone."
2. "I am unable to take the order at this time. Please call in the morning."
3. "Please repeat the order for me so I can make sure it is written correctly."
4. "Let me have your phone number and I will have the supervisor call you back."

"Let me get the Registered Nurse on the phone."
A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse.

89. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?
1. "Medicare reviews client charts to determine care given."
2. "Good charting results in good Medicare reimbursement."
3. "Our nursing salaries are paid for by the Medicare reimbursement funds."
4. "The hospital is reimbursed for the nursing care documented in the client chart."

"The hospital is reimbursed for the nursing care documented in the client chart."
Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs.

90. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment:
1. Secured
2. Accessible
3. Confidential
4. Documented

Confidential
Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care. The other options are primarily directed towards written records and are not ethically oriented.

91. Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?
1. "I'm pretty sure this will require the client's permission."
2. "Are you sure of the exact policy? Do you know what I should do?"
3. "The client agreed to the consultation, so I'll have the chart sent over."
4. "I think the client will need to give a verbal consent before it can be sent."

"The client agreed to the consultation, so I'll have the chart sent over."
Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information.

92. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to:
1. Show the unit staff proper student identification
2. Sign a confidentiality agreement when on the unit to preplan
3. Review the medical record only in the presence of unit staff
4. Obtain permission from the client to access his or her medical record

Show the unit staff proper student identification
When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.

93. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?
1. Notifying the client of the institution's privacy policy
2. Denying nonessential personal access to the client's medical records
3. Acquiring the client's verbal consent to share his or her medical record with essential personnel
4. Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form

Notifying the client of the institution's privacy policy
Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.

94. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a:
1. Referral
2. Consultation
3. Transfer report
4. Multidisciplinary meeting

Referral
Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client.

95. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior.

96. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's continued attempts to smoke in the bathroom."

"Client is depressed; was observed crying while alone in room."
Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.

97. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:
1. James Thicket, NS, WVU
2. J. Jones, NS, Montclair Shores College
3. N.H, SN, Bellfield City Community College
4. Dale Emmett, SN, Fortis College

Dale Emmett, SN, Fortis College
A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as "David Jones, SN (student nurse), CMTC (Central Maine Technical College)."

98. The nurse realizes that the incorrect spelling of terms in the medical record most importantly:
1. Shows a lack of competency
2. Displays little attention to detail
3. Contributes to serious treatment errors
4. Negatively affects the accuracy of the documentation

Contributes to serious treatment errors
Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors.

99. Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom unassisted
3. Client continues to report periods of dizziness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing

Risk for injury related to falling due to dizziness
The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the client's objective or subjective response to the nursing intervention.

100. Nursing documentation should fulfill which of the following criteria? (Select all that apply.)
1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
5. Record nursing opinion
6. Identify client outcomes

1. Accurate
2. Inclusive
3. Well organized
4. Show continuity of care
6. Identify client outcomes
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions.

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