UWorld Medical-Surgical Nursing Test Questions and Answers (Verified 2021)

UWorld Medical-Surgical Nursing Test Test Id: Question Id: 32803 () The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? Unordered Options Ordered Response 1. Give the client gentle reminders that the client has already eaten 2. Say that the client can have a snack in a couple of hours 3. Serve the client half of the meal initially and offer the other half later 4. Take a picture of the client having a meal and show it when the client becomes upset Explanation Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. (Option 1) Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the client's reality. (Option 2) Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration. (Option 4) Showing a picture of the client having a meal is confrontational and will have no meaning to the client. Educational objective: Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Test Id: Question Id: 33389 () The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up? Unordered Options Ordered Response 1. Abdomen is soft, nondistended, and tender to touch 2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min 3. Client rates pain as 4 on a scale of 0-10 4. Green bile is draining from the nasogastric tube Explanation Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm with synthetic graft placement. The client must be monitored postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate. (Option 1) Following surgery, the client will experience abdominal tenderness. The abdomen should remain soft and nondistended. A rigid, distended abdomen would indicate possible blood (graft leakage) in the cavity. (Option 3) Pain is an expected finding following abdominal surgery. However, increasing pain that is not relieved by medication can indicate possible graft leakage and should be investigated. (Option 4) During abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate postoperative period. Green bile-colored drainage would be expected. Bloody drainage would cause concern. Educational objective: Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify graft leakage. Test Id: Question Id: 30627 () The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg. Which rhythm strip would indicate that the medication achieved the desired outcome? Unorder ed Options Ordered Response . . . Explanation Atropine is given to the client experiencing symptomatic bradycardia. In symptomatic bradycardia, the heart rate is <60/min and is inadequate for the client's condition, causing symptoms such as hypotension, chest pain, or syncope. Atropine acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal sinus rhythm and reversal of clinical symptoms indicate that the medication has had the desired effect. (Option 1) A continuation of sinus bradycardia would not indicate that the atropine had been effective. (Option 3) Sinus tachycardia would be an undesirable effect of atropine as the heart rate would be >100/min. (Option 4) The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular conduction time is prolonged. Educational objective: Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increase in heart rate, evidence of normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia. Test Id: Question Id: 32111 () The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction? Unordered Options Ordered Response 1. "I can expect pink-tinged urine for at least 24 hours." 2. "I can take a warm bath and acetaminophen if I have discomfort or bladder spasms." 3. "I should expect frequency and burning when I urinate." 4. "I should expect to see blood clots in my urine for up to 24 hours." Explanation A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder (Option 4). (Options 1 and 3) Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. (Option 2) Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Educational objective: Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48 hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability to void, gross hematuria, blood clots, fever, chills, or severe pain. Test Id: Question Id: 31884 () A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Atrial fibrillation 2. Atrial flutter 3. Mobitz II 4. Torsades de pointes Explanation Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective: In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia). Copyright © UWorld. All rights reserved. Test Id: Question Id: 31083 () An elderly client with oxygen-dependent chronic obstructive pulmonary disease is admitted for pneumonia. The client is do not resuscitate, and the nurse is concerned that the client will soon develop respiratory failure as breathing is becoming shallow and the client is looking exhausted. Which is the most appropriate intervention to include in the plan of care? Unordered Options Ordered Response 1. Administer morphine to decrease air hunger 2. Call the health care provider for possible intubation 3. Promote relaxation through music and distraction 4. Titrate oxygen to maintain an oxygen saturation ≥94% Explanation A client with oxygen-dependent chronic obstructive pulmonary disease (COPD) and pneumonia who is showing signs of shallow breathing and fatigue may stop breathing. This client is do not resuscitate (DNR), which makes comfort the goal of care. Interventions should be used to promote comfort, such as relaxation, music, and distraction. Anxiety can be alleviated by being present and talking calmly to the client. Interventions that may compromise breathing and hasten death should be avoided. (Option 1) Morphine is not appropriate in this client with respiratory failure as it may cause respiratory depression, hastening death. (Option 2) Intubation is not appropriate in this client with respiratory failure who is DNR. However, calling the health care provider is appropriate as the client can be offered noninvasive positive pressure ventilation (eg, bilevel positive airway pressure). (Option 4) The oxygen saturation goal in a client with COPD is typically 90%-93%. Educational objective: The nurse should integrate the advance directive into the plan of care for the client. In a client who is DNR, this includes a focus on comfort when the clinical situation is declining. Test Id: Question Id: 30086 () The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? Unordered Options Ordered Response 1. Food poisoning 2. Influenza 3. Myocardial infarction 4. Stroke Explanation Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels. Educational objective: Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome. Test Id: Question Id: 30086 () The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? Unordered Options Ordered Response 1. Food poisoning 2. Influenza 3. Myocardial infarction 4. Stroke Explanation Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels. Educational objective: Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome. Test Id: Question Id: 33789 () The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? Unordered Options Ordered Response 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate client for pain and document the findings 4. Notify the health care provider immediately Explanation Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective: A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. Test Id: Question Id: 33789 () The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? Unordered Options Ordered Response 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate client for pain and document the findings 4. Notify the health care provider immediately Explanation Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective: A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. Test Id: Question Id: 30147 () A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. Unordered Options Ordered Response 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline Explanation The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2). (Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA. Educational objective: DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin and should be treated first with rehydration (normal saline) and then insulin administration. Copyright © UWorld. All rights reserved Test Id: Question Id: 30316 () A client is being discharged today following a partial gastrectomy. Instructions for recuperating at home would include which of the following? Select all that apply. Unordered Options Ordered Response 1. Avoid high fiber foods 2. Avoid intake of fluids with meals 3. Consume low-carbohydrate meals 4. Have small, frequent meals 5. Maintain a sitting-up position after eating Explanation Up to 50% of clients with partial gastrectomy may experience dumping syndrome. Dumping syndrome occurs when gastric contents are emptied too rapidly into the duodenum and cause a fluid shift into the small intestine. This fluid shift results in hypotension, abdominal pain, diarrhea, nausea, vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. Dietary recommendations are aimed at delaying gastric emptying and include the following: • Small, frequent meals reduce the amount of food in the stomach at any one time. Eat slowly in a relaxed environment. • Avoid meals high in simple carbohydrates, as these may trigger dumping syndrome as the carbohydrates are broken down into simple sugars. Instead, consume meals high in protein, fat, and fiber, as these take longer to digest and will remain in the stomach longer than carbohydrates (Option 1). • Separate fluids from meals. If fluids are taken with meals, stomach contents pass more easily into the jejunum and worsen symptoms. Fluid intake should be only after or between meals, separated from solid intake by at least 30 minutes. • Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after meals slows down the gastric emptying and is preferred (Option 5). Educational objective: Dumping syndrome is a complication of gastrectomy. Measures that delay gastric emptying can reduce the risk of dumping syndrome. Clients should eat meals low in carbohydrates and high in fiber, proteins, and fats. Fluids should not be taken with meals. Symptoms usually diminish over time. Test Id: Question Id: 33795 () The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision. Unordered Options Ordered Response 1. 2. 3. 4. Explanation Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated. (Option 1) Retinal detachment is separation of the retina from the underlying epithelium that allows fluid to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters, cloudy vision, or a curtain appearing in the vision. (Option 2) Age-related macular degeneration is a degenerative eye disease that brings about the gradual loss of central vision, leaving peripheral vision intact. (Option 4) A cataract is cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception. Educational objective: Primary open-angle glaucoma is characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). Test Id: Question Id: 31223 () A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas? Unordered Options Ordered Response 1. Metabolic acidosis and hyperventilation 2. Metabolic alkalosis and hypoventilation 3. Respiratory acidosis and hypoventilation 4. Respiratory alkalosis and hyperventilation Explanation The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory acidosis. Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression (eg, opioids, benzodiazepines, alcohol, sedating antihistamines). (Option 1) Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating. (Option 2) Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating. (Option 4) Hypoxia, anxiety, and pain are common causes of respiratory alkalosis, which is due to alveolar hyperventilation (rapid breathing). Educational objective: Over-sedation, sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis. Test Id: Question Id: 32324 () The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply. Unordered Options Ordered Response 1. Avoid raw, unpeeled fruits or vegetables 2. Limit contact with infected pets 3. Use insect (mosquito) repellent 4. Wash all bedding in hot water 5. Wear long-sleeved, light-colored clothes Explanation West Nile virus is a mosquito-borne disease (encephalitis) that occurs mainly during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and using an insect repellent. Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and dusk when mosquitoes are most active (Options 3 and 5). (Option 1) Food and water precautions are emphasized for infectious diseases contracted through contaminated water or food, such as hepatitis A or typhoid (enteric) fever. (Option 2) Limiting contact with infected pets is classic advice for avoiding ringworm, a superficial fungal skin infection. (Option 4) Washing bedding in hot water is a classic instruction to help reduce allergies/asthma (eg, commonly from mites) or scabies (a contagious skin infection caused by mites). Educational objective: West Nile virus is transmitted by an infected mosquito bite. Prevention focuses on avoiding mosquitoes and using a mosquito repellent. Prevention also includes keeping arms and legs covered with light-colored clothing and avoiding outdoor activities at dawn and dusk. Test Id: Question Id: 30846 () The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)? Unordered Options Ordered Response 1. Lansoprazole 2. Metronidazole 3. Prednisone 4. Sulfasalazine Explanation Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP. (Option 1) Lansoprazole (Prevacid) is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. It does not convert LTBI to active disease. (Option 2) Metronidazole (Flagyl) is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease. (Option 4) Sulfasalazine (Azulfidine) is a gastrointestinal anti-inflammatory medication used to treat IBD and does not convert LTBI to active disease. Educational objective: A client with LTBI has a positive TST, is asymptomatic, and cannot transmit the disease to others. Malignancy, immunosuppressant medications, chemotherapy, and prolonged debilitating disease Test Id: Question Id: 31341 () The nurse is monitoring a client who has been on clopidogrel therapy. What assessments are essential? Select all that apply. Unordered Options Ordered Response 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets Explanation Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases the risk of bleeding. The client should be assessed for bruising, tarry stools, and other signs of bleeding. In addition, there is a chance that the clopidogrel can cause thrombotic thrombocytopenia purpura (Options 1, 2, and 5). (Option 3) Monitoring intake and output is indicated while the client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis), but not for clopidogrel. Educational objective: Any antiplatelet drug (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. The nurse should teach the client what to assess for potential bleeding (eg, stool, urine, gums) and bruising. Test Id: Question Id: 31316 () A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. Unordered Options Ordered Response 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020 Explanation This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change. Educational objective: Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration. Test Id: Question Id: 30428 () The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. Unordered Options Ordered Response 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia Explanation A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: 1. A brief disruption in level of consciousness 2. Amnesia regarding the event (retrograde amnesia) 3. Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1–2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: • Worsening headaches and vomiting (indicate high intracranial pressure) • Sleepiness and/or confusion (indicate high intracranial pressure) • Visual changes • Weakness or numbness of part of the body Educational objective: Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1–2 days. Test Id: Question Id: 30185 () The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? Unordered Options Ordered Response 1. Carpal tunnel syndrome 2. Diabetes mellitus 3. Sciatica 4. Small cell lung cancer Explanation SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH. Educational objective: ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia. Test Id: Question Id: 30789 () A nurse on the medical surgical unit has just received report. Which client should be seen first? Unordered Options Ordered Response 1. Client 1 day post femoral-popliteal bypass grafting who has an intravenous (IV) antibiotic due now 2. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough 3. Client with hypertension and blood pressure of 180/92 mm Hg who reports a headache 4. Client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately Explanation The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings. (Option 1) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with DVT. (Option 3) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess this client after the client with DVT and administer any antihypertensives needed. (Option 4) This client can be delegated to unlicensed assistive personnel who can go to the room immediately. Educational objective: The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE. Test Id: Question Id: 30603 () A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect to assess? Select all that apply. Unordered Options Ordered Response 1. Bronchial breath sounds 2. Decreased fremitus 3. Diminished lung sounds 4. Hyperresonance on percussion 5. Wheezing Explanation A pleural effusion is an abnormal collection of fluid (>15-20 mL) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully. This results in decreased lung volume, atelectasis, and ineffective gas exchange. Clients commonly have dyspnea on exertion and non-productive cough. Examination shows diminished breath sounds, dullness to percussion, and decreased tactile fremitus. If the effusion is large, the trachea (mediastinum) is deviated to the opposite side. Palpable vibration felt on the chest wall is known as fremitus. Sound travels faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. The presence of egophony, bronchophony, or whispered pectoriloquy also suggests a consolidative process. Fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in pleural effusion and pneumothorax (Option 2). (Option 1) Bronchial breath sounds are normally present over the trachea, and vesicular breath sounds are present over the lung parenchyma. However, in consolidation (lobar pneumonia), bronchial breath sounds are present over the lung parenchyma due to over-transmission of sound. Over-transmission is due to airway patency leading to the affected area. Breath sounds are diminished or absent over a pleural effusion or pneumothorax. (Option 4) Percussion shows hyperresonance in clients with pneumothorax and dullness in those with pleural effusions or pneumonia. (Option 5) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion. Educational objective: A pleural effusion is an abnormal collection of fluid (>15-20 mL) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Examination shows diminished breath sounds, dullness to percussion, and decreased tactile fremitus. Copyright © UWorld. All rights reserved. Test Id: Question Id: 30639 () A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? Unordered Options Ordered Response 1. "I must visit my health care provider (HCP) to check my drug levels." 2. "I should report to my HCP if I develop nausea and vomiting." 3. "I should tell my HCP if I feel my heart skip a beat." 4. "I will need to increase my potassium intake." Explanation Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: 1. Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2) 2. Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) 3. Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness 4. Cardiac arrhythmias – most dangerous (Option 1) Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia). (Option 3) Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the HCP if it is low or has skipped beats. Educational objective: Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized Test Id: Question Id: 30356 () A client is admitted to the emergency department after a fall with dizziness and light- headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Complete heart block 2. 1st-degree heart block 3. Sinus bradycardia 4. Sinus rhythm Explanation Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest pain, and hypotension. The clinical significance of SB depends on how the client tolerates it. The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage. (Option 1) Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm. (Option 2) In 1st-degree AV block, every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. (Option 4) Sinus rhythm has a rate of 60-100/min. Educational objective: The nurse should be able to recognize SB on the ECG and assess for clinical significance (eg, chest pain, syncope, hypotension) in the client. Initial expected treatment for symptomatic clients includes atropine and transcutaneous pacing. Copyright © UWorld. All rights reserved. Test Id: Question Id: 32256 () The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? Unordered Options Ordered Response 1. Insert a Foley catheter into the existing tract and inflate the balloon 2. Insert a small-bore nasointestinal tube to administer feedings and medications 3. Notify the health care provider who inserted the PEG tube 4. Reinsert the PEG tube into the existing tract immediately Explanation A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long- term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective: A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis. Test Id: Question Id: 30186 () A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse? Unordered Options Ordered Response 1. "It is common for critically ill clients to develop type II diabetes. We give insulin to keep the glucose level under control (<140 mg/dL [7.8 mmol/L])." "The client was diabetic before, but you just didn't know it. We give insulin 2. to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." 3. "The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL (7.8-10.0 mmol/L)." "This increase is common in critically ill clients and affects their ability to 4. fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." Explanation Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care- associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended. (Option 1) Hospital hyperglycemia is not a direct cause of type II diabetes mellitus. In the non-diabetic client, the glucose level usually returns to normal after resolution of the disease process and/or discontinuation of steroid medications. A target glucose range of <140 mg/dL [7.8 mmol/L) is not recommended for this client. (Option 2) The prevalence of diabetes in hospitalized clients is high (about 1 in 4) and may be an undiagnosed pre-existing condition. A normal-range glucose level (70-110 mg/dL [3.9-6.1 mmol/L]) is not the recommended target range in this client due to the risk of hypoglycemia (with aggressive control) and worse outcomes. (Option 4) Although hyperglycemia does affect the ability to fight infection, 70-110 mg/dL [3.9-6.1 mmol/L] is not the recommended target range for this client. Educational objective: Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended. Test Id: Question Id: 30154 () The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? Unordered Options Ordered Response 1. "Half of my vision looks like it’s being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don’t seem as bright as they used to." Explanation Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option 1 indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness. (Option 2) The need for reading glasses is associated with presbyopia and is a common, nonemergency, age-related visual disorder. (Option 3) Cloudy vision with a glare is associated with a cataract, a nonemergency, age-related visual disorder. (Option 4) Although decreased vibrancy of colors is a sign of diabetic retinopathy and requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency. Educational objective: Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. Test Id: Question Id: 30431 () A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? Unordered Options Ordered Response 1. "I am very tired, and it's hard for me to keep my eyes open." 2. "I don't feel good, and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life." Explanation A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options 1, 2, and 3) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency. Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency. Test Id: Question Id: 30220 () The nurse in an outpatient clinic receives a blood test report of moderately elevated thyroid-stimulating hormone (TSH) and markedly decreased T3 and T4 levels. Which signs and/or symptoms should be expected in the client's evaluation? Select all that apply Unordered Options Ordered Response 1. Cold intolerance 2. Constipation 3. Forgetfulness 4. Hair loss 5. Warm, moist skin 6. Weight loss Explanation Hypothyroidism is a thyroid disorder characterized by thyroid hormone deficit (low T3 and T4). TSH is elevated due to compensatory increase from pituitary. Hypothyroidism affects almost every body system and is predominately associated with a slow metabolic rate. Some common manifestations include the following: 1. Decreased gut motility leading to constipation 2. Cool and pale skin due to decreased blood flow; hyperkeratosis results in dry and rough skin 3. Brittle nails and hair; hair loss due to poor blood supply 4. Bradycardia from low metabolic state 5. Joint pains and muscle aches are common 6. Clients can develop dementia and depression due to mental slowing 7. Cold intolerance characteristic 8. Modest weight gain (Options 5 and 6) Weight loss; heat intolerance; shakiness; diarrhea; and warm, moist skin are symptoms associated with hyperthyroidism or an increased metabolic rate. Educational objective: Signs and symptoms of hypothyroidism (a thyroid hormone deficit) are associated with a low metabolic rate. Weight gain, constipation, dry skin, hair loss, cold intolerance, bradycardia, mental slowing (dementia and depression), and anemia are some of the most common manifestations. Test Id: Question Id: 30219 () An elderly client with hypothyroidism is brought to the emergency department for depressed mental status. The client lives alone but has not taken medications for several months or seen a health care provider. Which action should the nurse take first? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Administer IV levothyroxine 2. Check serum thyroid-stimulating hormone, T3 and T4 3. Place a warming blanket on the client 4. Prepare for endotracheal intubation Explanation Myxedema coma is a complication associated with progression of symptoms of hypothyroidism from lethargy and mental sluggishness to a coma state. This client has hypothermia, bradycardia, hypotension, and depressed mental status. Hypothyroidism can also cause hypoventilation due to central depression of respiratory drive, respiratory muscle fatigue, and mechanical obstruction by a large tongue. This client exhibits signs of acute respiratory distress (increased respirations, very low oxygen saturation). Therefore, life-saving measures to facilitate respiratory support, such as mechanical ventilation, must be implemented first. Other treatments include thyroid hormone replacement with levothyroxine (Synthroid) IV push (Option 1), heating warming the client with a warming blanket (Option 3), and frequent diagnostics of the thyroid, including a serum thyroid panel (Option 2). Educational objective: Myxedema coma is a complication associated with progression of hypothyroidism symptoms. The highest-priority intervention is respiratory support for the client exhibiting signs of acute respiratory distress. Test Id: Question Id: 30747 () The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. Unordered Options Ordered Response 1. Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction You answered this question correctly. Explanation In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective: The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown. Test Id: Question Id: 30818 () A previously healthy client is hospitalized with left lower lobe (LLL) bacterial pneumonia. The nurse assesses chest pain with inspiration, productive cough of thick rusty sputum, and LLL fine inspiratory crackles and low-pitched expiratory wheezing. Which of the medications that the health care provider prescribes should the nurse question? Unordered Options Ordered Response 1. Furosemide 20 mg intravenous (IV) push every day 2. Guaifenesin ER 600 mg PO every 12 hours 3. Ibuprofen 600 mg PO every 6 hours PRN 4. Levofloxacin 500 mg IV every day Explanation Medications commonly prescribed to treat bacterial pneumonia include antibiotics, expectorants, mucolytics, antipyretics, analgesics, and anti-inflammatories. Furosemide (Lasix) is a diuretic and is not appropriate for treating the fine crackles associated with pneumonia. The crackles result from alveolar filling and atelectasis, not from heart failure or pulmonary edema. (Option 2) Extended-release guaifenesin (Mucinex) is an expectorant medication that increases respiratory fluids and thins secretions to facilitate mobilization and expectoration. It is appropriate to prescribe in clients who have pneumonia with a productive cough and low-pitched wheezing (rhonchi). (Option 3) Ibuprofen is an anti-inflammatory medication administered to relieve pleuritic chest pain associated with pneumonia and is appropriate to prescribe in clients with pneumonia. (Option 4) Recommended antibiotic therapy for hospitalized clients with community- acquired streptococcal pneumonia includes monotherapy with a fluoroquinolone or combined therapy with a macrolide (eg, azithromycin [Zithromax]) plus a beta-lactam (eg, a cephalosporin [ceftriaxone]) for 1-2 days before transitioning to oral antibiotics. Educational objective: Medications prescribed to treat hospitalized clients with community-acquired bacterial pneumonia include IV antibiotics, expectorants, mucolytics, antipyretics, analgesics, and anti-inflammatories. Copyright © UWorld. All rights reserved. Test Id: Question Id: 30856 () Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria? Unordered Options Ordered Response 1. Family risk factors 2. Industrial chemical exposure 3. Tobacco use 4. Usual diet Explanation The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use (Option 3). Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. (Option 1) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option 2) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). (Option 4) Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause. Educational objective: Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor. Test Id: Question Id: 33759 () The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question? Unordered Options Ordered Response 0.45% sodium chloride (NaCl) solution prescribed for a client with 1. syndrome of inappropriate antidiuretic hormone secretion who has a sodium level of 120 mEq/L (120 mmol/L) 2. 0.9% NaCl solution prescribed for a client with gastrointestinal bleeding who has a hemoglobin level of 8.9 g/dL (89 g/L) 3. 1,000 mL bolus of 0.9% NaCl solution prescribed for a client with septic shock who has a white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Lactated Ringer's solution prescribed for a male client with hypovolemic shock and a thermal burn who has a hematocrit level of 56% (0.56) Explanation Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia. (Option 2) Isotonic fluids (eg, normal saline) are appropriate for clients with volume deficit such as those with gastroi