Question: The recovery room nurse is admitting a client from the OR following the client’s successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?
Answer Options:
A. Core body temperature
B. Heart rate and rhythm
C. Skin integrity
D. Airway patency
Answer: D — Airway patency
Question: A client’s most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
Answer Options:
A. Ineffective tissue perfusion related to low albumin
B. Risk for imbalanced fluid volume related to low albumin
C. Impaired skin integrity related to low albumin
D. Risk for infection related to low albumin
Answer: B — Risk for imbalanced fluid volume related to low albumin
Question: A 23-year-old client comes to the free clinic stating, “I think I have a lump in my breast. Do I have cancer?” The nurse instructs the client that a diagnosis of breast cancer is confirmed by what method?
Answer Options:
A. Supervised breast self-examination
B. Fine-needle aspiration
C. Serial chest x-rays
D. Mammography
Answer: B — Fine-needle aspiration
Question: The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT:
Answer Options:
A. Malnutrition
B. Progressive dyspnea
C. Multiple comorbidities
D. Advanced age
Answer: B — Progressive dyspnea
Question: An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?
Answer Options:
A. The location of burned skin surfaces
B. The total body surface area (TBSA) affected by the burn
C. The source of the burn
D. The length of time since the burn
Answer: B — The total body surface area (TBSA) affected by the burn
Question: A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client’s complete blood count, the nurse will expect which of the following results?
Answer Options:
A. An increased hemoglobin and decreased hematocrit
B. A decreased hemoglobin and hematocrit
C. A decreased MCV and RDW
D. An increased MCV and RDW
Answer: B — A decreased hemoglobin and hematocrit
Question: A client has been admitted to the intensive care unit (ICU) after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP?
Answer Options:
A. Left-sided heart failure
B. Hypovolemia
C. Aortic valve regurgitation
D. Myocardial infarction (MI)
Answer: B — Hypovolemia
Question: The nurse is performing a preoperative assessment on a client going to surgery. The client reports drinking two bottles of wine each day for years. What postoperative difficulty should the nurse anticipate?
Answer Options:
A. Increased risk for postoperative complications
B. Nonadherence to prescribed treatment after surgery
C. Increased risk for allergic reactions
D. Alcohol withdrawal syndrome upon administration of general anesthesia
Answer: D — Alcohol withdrawal syndrome upon administration of general anesthesia
Question: Which age-related physiologic change contributes to heart disease being the leading cause of death in older adults?
Answer Options:
A. Atrial-septal defects develop with age
B. Heart muscle and arteries lose their elasticity
C. Resting heart rate decreases with age
D. Diastolic blood pressure decreases
Answer: B — Heart muscle and arteries lose their elasticity
Question: Identify the part of the ECG that represents ventricular repolarization.
Answer Options:
(From Image)
A. T wave
B. P wave
C. QRS complex
D. U wave
Answer: A — T wave
Question: A nurse describes the heart’s pumping action. What term describes the phase where the heart ejects blood?
Answer Options:
A. Diastole
B. Ejection fraction
C. Repolarization
D. Systole
Answer: D — Systole
Question: The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client’s mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse’s most appropriate action?
Answer Options:
A. Position the client in high Fowler position as tolerated
B. Prepare the client for craniotomy
C. Participate in interventions to increase cerebral perfusion pressure (CPP)
D. Administer osmotic diuretics as prescribed
Answer: C — Participate in interventions to increase cerebral perfusion pressure (CPP)
Question: A client with a large venous leg ulcer needs care. What intervention helps promote healing and prevent infection?
Answer Options:
A. Apply antibiotic ointment to surrounding skin
B. Abstain from wearing graduated compression stockings
C. Apply a clean occlusive dressing daily
D. Provide a high-calorie, high-protein diet
Answer: D — Provide a high-calorie, high-protein diet
Question: The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG?
Answer Options:
A. U wave
B. T wave
C. P wave
D. QRS complex
Answer: D — QRS complex
Question: The nurse is caring for a post-craniotomy client. Which of the following assessments would be the nurse’s priority?
Answer Options:
A. Closely monitoring neurologic status
B. Monitoring pain
C. Monitoring temperature
D. Assessing for infection
Answer: A — Closely monitoring neurologic status
Question: A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to which area of the heart?
Answer Options:
A. Endocardium
B. Myocardium
C. Visceral pericardium
D. Pericardium
Answer: B — Myocardium
Question: A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication?
Answer Options:
A. Raynaud disease
B. Deep vein thrombosis
C. Thoracic aortic aneurysm
D. Aortitis
Answer: B — Deep vein thrombosis
Question: The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often?
Answer Options:
A. At least once every 5 years
B. At least once every 10 years
C. At least once every 2 years
D. At least monthly
Answer: C — At least once every 2 years