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COTAC Final Exam Practice - ATI Dynamic Quizzes + Rationales - Ameritech

Terms in this set (360)

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?

Respiratory alkalosis

Respiratory acidosis

Metabolic alkalosis

Metabolic acidosis
Respiratory acidosis

(Rationale: Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication.
Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. Excessive vomiting also places a client at risk for development of metabolic alkalosis.Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk for the development of metabolic acidosis.)
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

Hallucinations

Pruritus

Hand and foot syndrome

Tinnitus
Tinnitus

(Rationale:An adverse effect of cisplatin is ototoxicity, which can cause tinnitus..Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemia.Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis.Hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic medication used to treat breast and colorectal cancer.)
A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take?

Hyperventilate the client with 100% oxygen prior to obtaining the specimen.

Apply ice to the site after obtaining the specimen.

Perform an Allen's test prior to obtaining the specimen.

Release pressure applied to the puncture site 1 min after the needle is withdrawn.
Perform an Allen's test prior to obtaining the specimen.

(Rationale: The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery....The nurse should not administer oxygen prior to the blood draw, because the test measures the client's arterial blood gases when breathing room air...The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site...The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.)
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following?

Increases oxygen intake

Promotes carbon dioxide elimination

Uses the intercostal muscles

Strengthens the diaphragm
Promotes carbon dioxide elimination

(Rationale:The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently..)
A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client?

Lying flat on the affected side

Prone with the arms raised over the head

Supine with the head of the bed elevated

Sitting while leaning forward over the bedside table
Sitting while leaning forward over the bedside table

(Rationale:When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.)
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism?

Sudden onset of dyspnea

Tracheal deviation

Bradycardia

Difficulty swallowing
Sudden onset of dyspnea

(Rationale:Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.)
A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

Eat high-calorie foods first.

Increase intake of water at meal times.

Perform active range-of-motion exercises before meals.

Keep saltine crackers nearby for snacking.
Eat high-calorie foods first.

(Rationale: The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.)
A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first?

How to eliminate environmental triggers that precipitate attacks

The client's perception of the disease process and what might have triggered past attacks

The client's medication regimen

Manifestations of respiratory infections
The client's perception of the disease process and what might have triggered past attacks

(Rationale:The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.)
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

Pericardial friction rub

Weight gain

Night sweats

Cyanosis of the fingertips
Night sweats

(Rationale: Night sweats and fevers are clinical manifestations of tuberculosis.)
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?

Clamp the chest tube if there is continuous bubbling in the water seal chamber.

Keep the chest tube drainage system at the level of the right atrium.

Tape all connections between the chest tube and drainage system.

Empty the collection chamber and record the amount of drainage every 8 hr.
Tape all connections between the chest tube and drainage system.

(Rationale: The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.)
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by a non-rebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)?

Tympanic temperature 38° C (100.4° F)

PaO2 50 mm Hg

Rhonchi

Hypopnea
PaO2 50 mm Hg

(Rationale:The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.)
A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

Total lung capacity

Vital lung capacity

Functional residual capacity

Residual volume
Total lung capacity

(Rationale:Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.)
measures the amount of air the client can exhale after maximum inhalation.
Vital lung capacity
measures the amount of air in the lungs after normal expiration.
Functional residual capacity
measures the amount of air in the lungs after forced expiration.
Residual volume
A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include?

"Apply warm compresses to the face."

"Take aspirin 650 milligrams by mouth for mild pain."

"Close your mouth when sneezing."

"Lie on your back with your head elevated 30° when resting."
"Lie on your back with your head elevated 30° when resting."

(Rationale: The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.)
A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?

Absence of breath sounds

Expiratory wheezing

Inspiratory stridor

Rhonchi
Absence of breath sounds

(Rationale:A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.)
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

"If the test is positive, it means you have an active case of tuberculosis."

"If the test is positive, you should have another tuberculin skin test in 3 weeks."

"You must return to the clinic to have the test read in 2 or 3 days."

"A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
"You must return to the clinic to have the test read in 2 or 3 days."

(Rationale:The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.)
A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that which of the following is the purpose of the treatments?

To encourage deep breaths

To mobilize secretions in the airways

To dilate the bronchioles

To stimulate the cough reflex
To mobilize secretions in the airways

(Rationale:The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.)
A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

Dry cough

Rhinitis

Sore throat

Swollen lymph nodes
Dry cough

(Rationale: A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.)
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

The client is unable to speak.

The client's airway secretions were last suctioned 2 hr ago.

The client coughs and expectorates a large mucous plug.

The nurse auscultates coarse crackles in the lung fields.
The nurse auscultates coarse crackles in the lung fields.

(Rationale:The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.)
A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is appropriate?

"After the surgeon removes the lung, you will not need to cough."

"I'll make sure you get a cough suppressant to keep you from straining the incision when you cough."

"Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain."

"I will show you how to splint your incision while coughing."
"I will show you how to splint your incision while coughing."

(Rationale:The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.)
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following?

Friction rub

Crackles

Crepitus

Tactile fremitus
Crepitus

(Rationale: Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.)
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

Weight gain 1 kg (2.2 lb) in 1 day

Pitting edema +1

Client report of nocturnal cough

B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
Weight gain 1 kg (2.2 lb) in 1 day

(Rationale:A weight gain of 1 kg (2.2 lb) in 1 day alerts the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.)
A BNP level above 100 pg/mL is indicative of
heart failure
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?

Midsternal chest pain

Thrill

Pitting edema in lower extremities

Lower back discomfort
Lower back discomfort

(Rationale: Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicates that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.)
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions?

0.45% sodium chloride

Dextrose 5% in 0.9% sodium chloride

Dextrose 10% in water

0.9% sodium chloride
0.9% sodium chloride

(Rationale:Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products.)
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan?

Administer ferrous sulfate supplementation.

Increase dietary intake of folic acid.

Initiate weekly injections of vitamin B12.

Initiate a blood transfusion.
Initiate weekly injections of vitamin B12.

(Rationale:The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.)
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?

Maintain the IV access with 0.9% sodium chloride.

Stop the infusion of blood.

Send the blood container and tubing to the blood bank.

Obtain a urine sample.
Stop the infusion of blood.

(Rationale:The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.)
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?

Coarse crackles

Wheezes

Rhonchi

Friction rub
Coarse crackles

(Rationale:A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.)
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.)

Jugular vein distension

Moist crackles

Postural hypotension

Increased heart rate

Fever
Jugular vein distension
Moist crackles
Increased heart rate

(Rationale: The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. This is an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses.)
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Decreased capillary refill

Dyspnea

Orthopnea

Dependent edema
Dependent edema

(Rationale:Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of dependent edema.)
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?

Hospitalization is required when administering each treatment.

The maximum effect of the medication will occur in 6 months.

Hypertension is a common adverse effect of this medication.

Blood transfusions are needed with each treatment.
Hypertension is a common adverse effect of this medication.

(Rationale:The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.)
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?

Prothrombin time

WBC count

Platelet count

Hematocrit
Prothrombin time

(Rationale:The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.)
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter?

P waves occurring at 0.16 seconds before each QRS complex

Atrial rate of 300/min with QRS complex of 80/min

Ventricular rate of 82/min with an atrial rate of 80/min

An irregular ventricular rate of 125/min with a wide QRS pattern
Atrial rate of 300/min with QRS complex of 80/min

(Rationale:The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.)
A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care?

Instruct the client on a long-term cardiac conditioning program.

Administer scheduled doses of acetaminophen.

Check for peak laboratory markers of myocardial damage.

Monitor for bleeding.
Monitor for bleeding.

(Rationale:Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client remains on bed rest until hemostasis is assured.)
A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has anemia. Which of the following actions should the nurse take first?

Hang an IV infusion of 0.9% sodium chloride with the blood.

Check the client's identification number with the number on the blood.

Witness the informed consent.

Obtain pretransfusion vital signs.
Witness the informed consent.

(Rationale: Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion to a client.)
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take?

Obtain blood samples to test platelet function.

Prepare for replacement of the missing clotting factor.

Administer aspirin for the client's pain.

Place the bleeding joint in the dependent position.
Prepare for replacement of the missing clotting factor.


(Rationale:Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.)
A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client?


Omega-3 fatty acids

Antioxidants

Vitamins A, D, and C

Beta-carotene
Omega-3 fatty acids

(Rationale: Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.)
A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect?

Bradycardia with S-T segment depression

Relief of chest pain with deep inspiration

Dyspnea with hiccups

Chest pain that increases when sitting upright
Dyspnea with hiccups

(Rationale: The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.)
A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take?

Check for hypertension.

Auscultate for loud, bounding heart sounds.

Auscultate blood pressure for pulsus paradoxus.

Check for a pulse deficit.
Auscultate blood pressure for pulsus paradoxus.

(Rationale:The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.)
A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

"I should eat foods high in saturated fat."

"Before taking my medication, I will count my radial pulse rate."

"I will exercise once per week for an hour at the health club."

"I will stop taking my medication when my blood pressure is within a normal range."
"Before taking my medication, I will count my radial pulse rate."

(Rationale: A beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration.)
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect?

Chest pain is relieved soon after resting.

Nitroglycerin relieves chest pain.

Physical exertion does not precipitate chest pain.

Chest pain lasts longer than 15 min.
Chest pain lasts longer than 15 min.

(Rationale: The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.)
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?

Position the client supine with his legs elevated when in bed.

Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr.

Tell the client to sit with his legs dependent after ambulating.

Instruct the client to wear knee-length socks for 2 weeks after surgery.
Position the client supine with his legs elevated when in bed.

(Rationale: The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.)
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect?

Pitting edema

Areas of reddish-brown pigmentation

Dry, pale skin with minimal body hair

Sunburned appearance with desquamation
Dry, pale skin with minimal body hair

(Rationale: A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.)
A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change?

Potassium 2.8 mEq/L

Digoxin level 0.7 ng/mL

Hemoglobin 9.8 g/dL

Calcium 8.0 mg
Potassium 2.8 mEq/L

(Rationale: A flattened T wave or the development of U waves is indicative of a low potassium level.)
A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor?

Hypokalemia

Lead poisoning

Hypercalcemia

Iron toxicity
Iron toxicity

(Rationale: The client who has received several blood transfusions is at risk for development of hemosiderosis, which is excess storage of iron in the body. The excessive iron can come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia.)
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr?

Infective endocarditis

Pericarditis

Ventricular dysrhythmias

Pulmonary emboli
Ventricular dysrhythmias

(Rationale: After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.)
A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take?

Continue to monitor for manifestations of a transfusion reaction.

Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

Continue the transfusion and repeat the type and crossmatch.

Prepare to administer a dose of diphenhydramine IV.
Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

(Rationale:A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.)
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10 gtt/min
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect?

Increased cardiac output

Increased pulmonary congestion

Decreased left atria pressure

Decreased pulmonary artery pressure
Increased pulmonary congestion

(Rationale: Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.)
A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?

Administer antihypertensive medication for blood pressure.

Monitor that urinary output is 20 mL/hr.

Withhold pain medication to prepare for surgery.

Take vital signs every 2 hr.
Administer antihypertensive medication for blood pressure.

(Rationale:The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.)
A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect?

Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes.

The client is experiencing premature ventricular complexes at 12/min.

Telemetry monitoring shows pacing spikes with no QRS complexes.

The client is experiencing hiccups.
Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes.

(Rationale: The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.)
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect?

Plethoric appearance of facial skin

Glossitis and weight loss

Jaundice with an enlarged liver

Petechiae and ecchymosis
Petechiae and ecchymosis

(The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.)
The client who has _____ _____ will have a plethoric (dark, flushed) manifestation of the facial skin and mucous membranes.
polycythemia vera
The client who has ___ ____ ____ will have manifestations of jaundice with an enlarged liver and spleen.
sickle cell anemia
The client who has ___ ___ will have manifestation of glossitis (smooth, beefy-red tongue) and weight loss.
pernicious anemia
A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate?

Basal cell carcinomas

Melanomas

Actinic keratoses

Squamous cell carcinomas
Melanomas

(Rationale:Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.)
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?

Hyponatremia

Leukopenia

Hyperchloremia

Elevated BUN
Leukopenia

(Rationale:Transient leukopenia is an adverse effect of silver sulfadiazine.)
A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?

First-degree frostbite

Second-degree frostbite

Third-degree frostbite

Fourth-degree frostbite
Third-degree frostbite

(Rationale: When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch.)
A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?

IV
I
III
II
II

(Rationale: With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.)
with a ____ ____ there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.
stage II
With a ___ ___ pressure ulcer, there is full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer might extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
stage III
With a ___ ___ pressure ulcer, the skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence, that might feel warm or cool when touched. The tissue is swollen and congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can appear blue or purple and different from other skin areas.
stage I
With a ___ ___ pressure ulcer, the client has full-thickness tissue loss, with destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection, tunneling, and undermining can occur.
stage IV
A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions?

Papules

Macules

Wheals

Vesicles
Papules

(Rationale: A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.)
A ____ is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. ____ are common lesions of warts and elevated moles.
papule
A ____ is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A ____ is a change in the color of the skin. Freckles and the rash associated with rubella are types of ____.
macule
____ , also known as hives, are transient, elevated, irregularly shaped lesions caused by localized edema. ___are a common manifestation of an allergic reaction.
Wheals
A ____ is a circumscribed, elevated lesion or blister containing serous fluid. _____ typically arise with herpes simplex, poison ivy, and chickenpox.
vesicle
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources?


Cadaver skin

Pig skin

Amniotic membranes

Beef collagen
Pig skin

(Rationale: Heterografts are obtained from an animal, usually a pig.)
A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?

Zoster vaccine

Acyclovir

Amoxicillin

Infliximab
Acyclovir

(Rationale: The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.)
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include?

"Move between the bed and the wheelchair once every 2 hours."

"Make sure that your caregiver massages your skin daily."

"Use a rubber ring when sitting at the bedside."

"Shift your weight in the wheelchair every 15 minutes."
"Shift your weight in the wheelchair every 15 minutes."
A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma?

Brown eyes

Light skin

Black hair

Dark skin
Light skin
A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole?

Ulceration

Blanching of surrounding skin

Dimpling

Fading of color
Ulceration

(Rationale: Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.)
A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a malignant melanoma?

Rough, dry, scaly lesion

Firm nodule with crust

Pearly papule with ulcerated center

Irregularly shaped lesion with blue tones
Irregularly shaped lesion with blue tones

(Rationale: Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.)
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?

Hemoglobin 10 g/dL

Sodium 132 mEq/L

Albumin 3.6 g/dL

Potassium 4.0 mEq/dL
Sodium 132 mEq/L

(Rationale:his laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.)
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider?

Edema in the burned extremities

Severe pain at the burn sites

Urine output of 30 mL/hr

Temperature of 39.1° C (102.4° F)
Temperature of 39.1° C (102.4° F)

(Rationale
A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures?

Curettage

External radiation therapy

Regional chemotherapy

Surgical excision
Surgical excision

(Rationale: The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.)
A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement?

Immobilize the limb at the level of the heart.

Apply a tourniquet to the affected limb.

Use a sterile scapula to incise the wound.

Apply ice to the skin over the snakebite wound.
Immobilize the limb at the level of the heart.

(Rationale: The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.)
A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?

"I will be on a special shower table."

"The water temperature will be very cool to ease my pain."

"The nurse will use a firm-bristled brush to remove loose skin."

"The nurse will use scissors to open small blisters."
"I will be on a special shower table."

(Rationale: The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection.)
A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention?

Partial-thickness burn

Stage III pressure ulcer

Surgical incision

Dehisced sternal wound
Surgical incision

(Rationale: With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.)
A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing?

Vitamin B1

Calcium

Vitamin C

Potassium
Vitamin C

(Rationale: A diet high in protein and vitamin C is recommended because these nutrients promote wound healing._
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?

"May I go with my family to the visitor's lounge?"

"I'll see my friends when I get home."

"My dad is coming to visit. Can you fix my hair for me?"

"I told my cousins I'm in protective isolation."
"May I go with my family to the visitor's lounge?"

(Rationale: This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.)
A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include?

Apply a broad-spectrum sunscreen 5 min before sun exposure.

Wear a sun visor instead of a hat when outside in the sun.

Avoid exposure to the midday sun.

Use a tanning booth instead of sunbathing outdoors.
Avoid exposure to the midday sun.

(Rationale: The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.)
A nurse is caring for a client who is postoperative following a bilateral adrenalectomy. The nurse should expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic effects?

Compensate for decrease in cortisol levels

Inhibit glucose metabolism

Act as a diuretic to maintain urine output

Decrease susceptibility to infection
Compensate for decrease in cortisol levels

(Rationale: The client who has an adrenalectomy requires glucocorticoids before, during, and after surgery to prevent an adrenal crisis caused by a sudden drop in cortisol levels. One of the hormones produced by the adrenal glands is cortisol, a glucocorticoid. Loss of glucocorticoid secretion leads to a state of altered metabolism and an inability to deal with stressors which, if untreated, is fatal.)
A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following clients should the nurse include in the screening?

Men who smoke

Men and women who are obese

Women who have hepatitis

Men and women who consume high-protein and low-carbohydrate foods
Men and women who are obese

(Rationale: There is a high correlation between obesity and type 2 diabetes mellitus. Obesity plays a major role in the development of type 2 diabetes mellitus by decreasing the number of available insulin receptors in skeletal muscles and fat cells. This is referred to as peripheral insulin resistance. A reduced-calorie diet for obese clients tends to reverse the phenomenon of peripheral insulin resistance.)
A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

Shakiness

Urinary frequency

Dry mucous membranes

Excess thirst
Shakiness

(Rationale: The client who has hypoglycemia can experience early manifestations of shakiness. Other early manifestations include fatigue, headache, difficulty thinking, sweating, and nausea.)
A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Hunger

Increased urination

Cold, clammy skin

Tremors
Increased urination

(Rationale: Increased urination, or polyuria, is a manifestation of hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis.)
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. The nurse should understand that which of the following laboratory values is consistent with diabetic ketoacidosis?

Blood glucose 30 mg/dL

Negative urine ketones

Blood pH 7.38

Bicarbonate level 12 mEq/L
Bicarbonate level 12 mEq/L

(Rationale: The client who has diabetic ketoacidosis should have a bicarbonate level less than 15 mEq/L because the client has an increased production of counter-regulatory hormones that lead to metabolic acidosis.)
A nurse is preparing a 24-hour urine specimen for a client who is suspected to have pheochromocytoma. Which of the following laboratory tests from the 24-hour urine specimen should the nurse use to determine the client's condition?

Creatinine clearance

Vanillylmandelic acid (VMA)

17-hydroxycorticosteroids (17-OHCS)

Protein
Vanillylmandelic acid (VMA)

(Rationale: The nurse should expect the 24-hr urine specimen to test for VMA. This test is used to determine if the client has pheochromocytoma, which measures the level of catecholamine metabolites in a 24-hr urine sample. Pheochromocytoma is a tumor of the adrenal gland that causes excess release of the catecholamines epinephrine and norepinephrine, which are hormones that regulate blood pressure and heart rate.)
A nurse is providing teaching to a client who has type 1 diabetes mellitus about exercise. Which of the following statements should the nurse include in the teaching?

"You should exercise during a peak insulin time."

"Wear a medical alert identification tag when you exercise."

"Exercise can decrease the effects of insulin and cause the blood glucose levels to increase."

"You will get the most benefit from exercise when your glucose levels are higher than normal."
"Wear a medical alert identification tag when you exercise."

(Rationale: The client should wear a medical alert identification tag in the event of a hypoglycemic response, because exercise can potentiate the effects of insulin and cause the blood glucose levels to decrease.)
A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure?

Calcium

Sodium

Potassium

Phosphorous
Calcium

(Rationale: The parathyroid hormone regulates calcium, phosphorus, and magnesium balance within the client's blood and bone by maintaining a balance between the mineral levels in the blood and the bone. Hyperparathyroidism is associated with hypercalcemia; therefore, a decrease in the calcium level indicates an improvement in