Fundamentals
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Sanguineous exudate
Serous exudate
Serosanguineous exudate
Purulent exudate
Correct Answer: D.
Purulent exudate
Purulent exudate drainage on the client's dressings is thick yellow, green, and brown drainage and usually indicates wound sloughing or infection.
A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor?
Magnesium 2.0 mEq/L
Hgb 6.5 g/dL
WBC count 9.6/mm^3
Creatinine 0.8 mg/dL
Correct Answer: B.
Hgb 6.5 g/dL
The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore, a client who has an Hgb level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.
A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects?
Hyponatremia
Leukopenia
Hyperchloremia
Elevated BUN
Correct Answer: B.
Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine; therefore, the nurse should monitor the client for an allergic reaction that is causing a decrease in the client's WBC count.
A nurse is assisting with the plan of care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan?
Restrict the client's fluid intake
Restrict the client's calcium intake
Decrease the client's fat intake
Decrease the client's potassium intake
Correct Answer: C.
Decrease the client's fat intake
The nurse should decrease the client's fat intake to reduce the occurrence of biliary colic
A nurse is assisting with preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure instructions? (Select all that apply.)
"I will have to drink a radioactive solution before the test begins."
"A special camera will scan the bones in my entire body."
"There will be better absorption of the radiation in healthy bone."
"I'll have to drink a lot of water to help get the radiation out of my body."
"I understand the radiation is harmless, and I don't have to worry about it."
Correct Answers: B.
"A special camera will scan the bones in my entire body."
D.
"I'll have to drink a lot of water to help get the radiation out of my body."
E.
"I understand the radiation is harmless, and I don't have to worry about it."
A nurse is monitoring a client who is receiving lactated Ringer’s 500 mL IV infused over 4 hours. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should make sure the manual IV infusion is delivering how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
Correct Answer:
31
A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect?
Decreased albumin
Elevated hemoglobin
Elevated lymphocytes
Decreased cortisol
Correct Answer: A.
Decreased albumin
A decreased albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.
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 should the nurse make?
Basal cell carcinomas
Melanomas
Actinic keratoses
Squamous cell carcinomas
Correct Answer: B.
Melanomas
Melanomas are malignant neoplasms with atypical melanocytes in the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases to the bone, liver, lungs, spleen, the CNS, and lymph nodes.
nurse is collecting data from a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect?
Emesis with a coffee-ground appearance
Increased blood pressure
Decreased heart rate
Bright green stools
Correct Answer: A.
Emesis with a coffee-ground appearance
The nurse should expect a client who has a bleeding duodenal ulcer to have emesis that resembles coffee grounds or is bright red in color. Hematemesis indicates upper gastrointestinal bleeding, occurring at or above the duodenojejunal junction.
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should examine the client for which of the following manifestations of dislocation of the hip prosthesis?
Bulging in the area over the surgical incision
Shortening of the right leg
Sensation of warmth over the surgical incision
Pallor following elevation of the right leg
Correct Answer: B.
Shortening of the right leg
The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip or buttock pain, limping, and rotation of the hip internally.
A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure?
142/85 mmHg
116/70 mmHg
130/76 mmHg
124/82 mmHg
Correct Answer: B.
116/70 mmHg
This blood pressure is within the expected reference range, which is any value less than 120 mmHg systolic and 80 mmHg diastolic.
A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of 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.
Correct Answer: C.
Hypertension is a common adverse effect of this medication.
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 assisting with the development of a program to educate clients about measures to reduce the risk of skin cancer. Which of the following instructions should the nurse include?
Re-apply sunscreen every 4 hr during 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
Correct Answer: C.
Avoid exposure to the midday sun
The nurse should instruct clients to avoid skin exposure to the sun between 1100 and 1500 when sun rays are the strongest.
A nurse is reinforcing teaching with the parents of a child who has celiac disease. Which of the following foods should the nurse instruct the parents to omit from the child's diet?
Cornflakes
Reduced fat milk
Canned fruits
Wheat bread
Correct Answer: D.
Wheat bread
Clients who have celiac disease should eliminate as much gluten as possible from their diets. Wheat, rye, and barley contain gluten and should be eliminated from the diet of a child who has celiac diseas
A nurse is reinforcing nutrition education to a client who has osteomalacia. The nurse should identify that osteomalacia is caused by a deficiency of which of the following nutrients?
Fluoride
Vitamin A
Vitamin D
Phosphorus
Correct Answer: C.
Vitamin D
Osteomalacia, a softening of the bones due to defective bone mineralization, results from a deficiency of vitamin D.
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
Incontinence
Mental state
Nutrition
General physical condition
Correct Answer: C.
Nutrition
Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters of the Braden scale for determining a client's risk for developing pressure ulcers.
A nurse is reinforcing teaching with a client about dietary modifications to help control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions?
Onion soup and salad
Vegetarian wrap with potato chips
Grilled chicken salad with fresh tomatoes
Chicken bouillon and crackers
Correct Answer: C.
Grilled chicken salad with fresh tomatoes
Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are fresh food items that are likely to be low in sodium. However, the client should make sure the food preparer has not added salt generously to the meal.
A nurse is caring for a client who has regular occupational exposure to sunlight and presents to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?
A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder
Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose
A raised, circumscribed lesion on the face that contains yellow-white purulent material
An irregularly shaped brown lesion with light blue areas on the neck
Correct Answer: D.
An irregularly shaped brown lesion with light blue areas on the neck
Malignant melanoma, the leading cause of skin cancer death, is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at the greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion and irregular borders in hues of tan, black, or blue.
A nurse is collecting data from a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?
Jaundice
Anorexia
Dark urine
Pale feces
Correct Answer: B.
Anorexia
Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.
A nurse is reinforcing preoperative teaching with a client who is scheduled for total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?
"I will begin using a continuous movement machine on my knee a day after surgery."
"I should avoid taking NSAID medications for pain."
"I should wear elastic stockings on both of my legs."
"I will have a small weight attached to my leg to hold the joint in place after surgery."
Correct Answer: C.
"I should wear elastic stockings on both of my legs."
The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as indicating an understanding of the teaching.
A nurse is collecting data about a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?
Vesicular
Bronchial
Rhonchi
Bronchovesicular
Correct Answer: A.
Vesicular
The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched.
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?
Wheezes
Coarse crackles
Rhonchi
Friction rub
Correct Answer: B.
Coarse crackles
A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by the movement of air through airways partially or intermittently occluded with fluid. These sounds are associated with heart failure and frothy sputum, are heard at the end of inspiration, and are not cleared by coughing.
A nurse in a dermatology clinic is using the ABCDE method while screening several of a client's skin lesions for skin cancer. Which of the following findings should the nurse report to the provider?
Symmetric shape
Border regularity
Color variation within a lesion
Diameter >4 mm
Correct Answer: C.
Color variation within a lesion
The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of the lesion.
A nurse is reinforcing discharge teaching with a client who has a newly placed ileostomy about ostomy care while at home. Which of the following instructions should the nurse include in the teaching?
"Empty your ostomy pouch when it gets half full."
"Place an aspirin in the ostomy pouch to eliminate odor."
"Change the ostomy appliance every week."
"Cleanse the site around the stoma with hydrogen peroxide and water."
Correct Answer: A.
"Empty your ostomy pouch when it gets half full."
The nurse should instruct the client to empty the ostomy pouch when it is a third to half full. This prevents the ostomy from becoming too full of stool or gas and exploding.
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly hired nurse. Which of the following pieces of information should the nurse include about osteoarthritis?
"Osteoarthritis is caused by autoimmune processes."
"Osteoarthritis causes joints to become red and hot."
"Osteoarthritis affects other organ systems."
"Osteoarthritis can impair a joint on a single side of the body."
Correct Answer: D.
"Osteoarthritis can impair a joint on a single side of the body."
The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment.