Detailed Answer Key
NUR220 Exam 1 Prep
1. A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
A. Positive Western blot test
Rationale: The client is already identified as HIV positive. Therefore, another value is the priority.
B. CD4-T-cell count 180 cells/mm3
Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the priority for the
nurse to report to the provider.
C. Platelets 150,000/mm3
Rationale: The client's platelet count is within the expected reference range. Therefore, another value is the
priority.
D. WBC 5,000/mm3
Rationale: The client's WBC count is within the expected reference range. Therefore, another value is the
priority.
2. A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of
the following findings should the nurse expect?
A. Hyperpigmentation
Rationale: Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce
enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is
characterized by weight loss, muscle weakness, fatigue, low blood pressure, and
hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.
B. Intention tremors
Rationale: Intention tremors may be seen in multiple sclerosis, a neuromuscular disorder that primarily
affects the central nervous system.
C. Hirsutism
Rationale: Addison's disease results in loss of body hair, called vitiligo.
D. Purple striations
Rationale: Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation in
Cushing's syndrome. Hyperpigmentation can be seen as well.
3. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a
tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should
the nurse assess the client?
Created on:02/03/2023 Page 1
, Detailed Answer Key
NUR220 Exam 1 Prep
A. Chvostek's sign
Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following
subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the
hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after
surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and
in front of the ear. A positive response would be twitching of the ipsilateral (same side only)
facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
B. Babinski's sign
Rationale: Babinski's sign is a diagnostic test for brain damage or upper motor neuron damage. It is
positive if the toes flare up when the nurse strokes the plantar aspect of the foot.
C. Brudzinski's sign
Rationale: Brudzinski's sign is an indication of meningeal irritation, such as in clients who have meningitis.
With the client supine, the nurse should place one hand behind his head and places her other
hand on his chest. The nurse then raises the client's head with her hand behind his head, while
the hand on his chest restrains him and prevents him from rising. Flexion of the client's lower
extremities constitutes a positive sign.
D. Kernig's sign
Rationale: Kernig's sign is an indication of meningeal irritation, such as in clients who have meningitis. The
nurse performs the maneuver with the client supine with his hips and knees in flexion. The
inability to extend the client's knees fully without causing pain constitutes a positive test.
4. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the
following values should give the nurse the best indication of the client's renal function?
A. Serum creatinine
Rationale: A renal function disorder reduces the excretion of creatinine, resulting in increased levels of
blood creatinine. Creatinine is a specific and sensitive indicator of renal function.
B. Blood urea nitrogen (BUN)
Rationale: The BUN is used as a gross index of glomerular function and the production and excretion of
urea. High-protein diets, rapid-protein catabolism, and dehydration are conditions that will cause
an elevation in the BUN. This is not the best indication of the client's renal function.
C. Serum sodium
Rationale: Serum sodium is affected by urinary output but may also be falsely affected by hemodilution and
hemoconcentration. This is not the best indication of the client's renal function.
D. Urine-specific gravity
Rationale: Due to the body's compensatory mechanisms and ability to maintain glomerular filtration rate
(GFR) until 75% of renal function is lost, this is not the best indication of the client's renal
function.
Created on:02/03/2023 Page 2
, Detailed Answer Key
NUR220 Exam 1 Prep
5. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The
nurse should anticipate that the client will report that her earliest manifestation was
A. dysphagia.
Rationale: Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the
tumor grows in size and impedes the esophagus.
B. hoarseness.
Rationale: Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest
manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords
during speech. The voice may sound harsh and lower in pitch than normal.
C. dyspnea.
Rationale: Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the tumor
grows in size and impedes the airway opening.
D. weight loss.
Rationale: Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
6. A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse
should recognize that the client is at risk for developing which of the following infectious oral conditions?
A. Halitosis
Rationale: Halitosis (foul-smelling breath) is not an infectious oral condition and is frequently the result of
poor dental health, poor oral hygiene, or gastrointestinal problems.
B. Gingivitis
Rationale: Gingivitis is inflammation of the gum or gingiva and is typically caused by irritation from dental
plaque and poor oral hygiene.
C. Xerostomia
Rationale: Xerostomia (dry mouth) is typically an adverse effect of medications that have anticholinergic
properties. It is not an infectious oral condition.
D. Candidiasis
Rationale: Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older
adults, and clients whose immune systems have been compromised by illness, such as AIDS, or
medications.
7. A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast
Created on:02/03/2023 Page 3
, Detailed Answer Key
NUR220 Exam 1 Prep
cancer. Which of the following findings should the nurse report to the provider?
A. WBC 2300/mm3
Rationale: This WBC finding is below the expected reference range. Chemotherapy treatment can cause
leukopenia; the nurse should report this finding to the provider and implement precautions to
protect the client from infection.
B. RBC 5 million/mm3
Rationale: This finding is within the expected reference range.
C. Hemoglobin 12 g/dL
Rationale: This finding is within the expected reference range.
D. Platelets 155,000/mm3
Rationale: This finding is within the expected reference range.
8. A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP).
The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following
actions should the nurse take first?
A. Notify the provider.
Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if
the output is bright rad and thick; however, the nurse should attempt a different intervention first.
B. Check the tubing for kinks.
Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore,
the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the
bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting,
which could occlude the catheter lumen.
C. Adjust the rate of the bladder irrigant.
Rationale: The nurse may need to increase the rate of bladder irrigant to stimulate removal of urine and
clots; however, the nurse should use a less restrictive intervention first.
D. Irrigate the catheter.
Rationale: The nurse may need to irrigate the catheter to check for an internal obstruction; however, the
nurse should use a less restrictive intervention first.
9. A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following
actions should the nurse plan to take?
A. Tell the client to expect dark stools following chemotherapy.
Rationale:
Created on:02/03/2023 Page 4
NUR220 Exam 1 Prep
1. A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
A. Positive Western blot test
Rationale: The client is already identified as HIV positive. Therefore, another value is the priority.
B. CD4-T-cell count 180 cells/mm3
Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the priority for the
nurse to report to the provider.
C. Platelets 150,000/mm3
Rationale: The client's platelet count is within the expected reference range. Therefore, another value is the
priority.
D. WBC 5,000/mm3
Rationale: The client's WBC count is within the expected reference range. Therefore, another value is the
priority.
2. A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of
the following findings should the nurse expect?
A. Hyperpigmentation
Rationale: Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce
enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is
characterized by weight loss, muscle weakness, fatigue, low blood pressure, and
hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.
B. Intention tremors
Rationale: Intention tremors may be seen in multiple sclerosis, a neuromuscular disorder that primarily
affects the central nervous system.
C. Hirsutism
Rationale: Addison's disease results in loss of body hair, called vitiligo.
D. Purple striations
Rationale: Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation in
Cushing's syndrome. Hyperpigmentation can be seen as well.
3. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a
tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should
the nurse assess the client?
Created on:02/03/2023 Page 1
, Detailed Answer Key
NUR220 Exam 1 Prep
A. Chvostek's sign
Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following
subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the
hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after
surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and
in front of the ear. A positive response would be twitching of the ipsilateral (same side only)
facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
B. Babinski's sign
Rationale: Babinski's sign is a diagnostic test for brain damage or upper motor neuron damage. It is
positive if the toes flare up when the nurse strokes the plantar aspect of the foot.
C. Brudzinski's sign
Rationale: Brudzinski's sign is an indication of meningeal irritation, such as in clients who have meningitis.
With the client supine, the nurse should place one hand behind his head and places her other
hand on his chest. The nurse then raises the client's head with her hand behind his head, while
the hand on his chest restrains him and prevents him from rising. Flexion of the client's lower
extremities constitutes a positive sign.
D. Kernig's sign
Rationale: Kernig's sign is an indication of meningeal irritation, such as in clients who have meningitis. The
nurse performs the maneuver with the client supine with his hips and knees in flexion. The
inability to extend the client's knees fully without causing pain constitutes a positive test.
4. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the
following values should give the nurse the best indication of the client's renal function?
A. Serum creatinine
Rationale: A renal function disorder reduces the excretion of creatinine, resulting in increased levels of
blood creatinine. Creatinine is a specific and sensitive indicator of renal function.
B. Blood urea nitrogen (BUN)
Rationale: The BUN is used as a gross index of glomerular function and the production and excretion of
urea. High-protein diets, rapid-protein catabolism, and dehydration are conditions that will cause
an elevation in the BUN. This is not the best indication of the client's renal function.
C. Serum sodium
Rationale: Serum sodium is affected by urinary output but may also be falsely affected by hemodilution and
hemoconcentration. This is not the best indication of the client's renal function.
D. Urine-specific gravity
Rationale: Due to the body's compensatory mechanisms and ability to maintain glomerular filtration rate
(GFR) until 75% of renal function is lost, this is not the best indication of the client's renal
function.
Created on:02/03/2023 Page 2
, Detailed Answer Key
NUR220 Exam 1 Prep
5. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The
nurse should anticipate that the client will report that her earliest manifestation was
A. dysphagia.
Rationale: Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the
tumor grows in size and impedes the esophagus.
B. hoarseness.
Rationale: Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest
manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords
during speech. The voice may sound harsh and lower in pitch than normal.
C. dyspnea.
Rationale: Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the tumor
grows in size and impedes the airway opening.
D. weight loss.
Rationale: Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
6. A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse
should recognize that the client is at risk for developing which of the following infectious oral conditions?
A. Halitosis
Rationale: Halitosis (foul-smelling breath) is not an infectious oral condition and is frequently the result of
poor dental health, poor oral hygiene, or gastrointestinal problems.
B. Gingivitis
Rationale: Gingivitis is inflammation of the gum or gingiva and is typically caused by irritation from dental
plaque and poor oral hygiene.
C. Xerostomia
Rationale: Xerostomia (dry mouth) is typically an adverse effect of medications that have anticholinergic
properties. It is not an infectious oral condition.
D. Candidiasis
Rationale: Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older
adults, and clients whose immune systems have been compromised by illness, such as AIDS, or
medications.
7. A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast
Created on:02/03/2023 Page 3
, Detailed Answer Key
NUR220 Exam 1 Prep
cancer. Which of the following findings should the nurse report to the provider?
A. WBC 2300/mm3
Rationale: This WBC finding is below the expected reference range. Chemotherapy treatment can cause
leukopenia; the nurse should report this finding to the provider and implement precautions to
protect the client from infection.
B. RBC 5 million/mm3
Rationale: This finding is within the expected reference range.
C. Hemoglobin 12 g/dL
Rationale: This finding is within the expected reference range.
D. Platelets 155,000/mm3
Rationale: This finding is within the expected reference range.
8. A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP).
The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following
actions should the nurse take first?
A. Notify the provider.
Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if
the output is bright rad and thick; however, the nurse should attempt a different intervention first.
B. Check the tubing for kinks.
Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore,
the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the
bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting,
which could occlude the catheter lumen.
C. Adjust the rate of the bladder irrigant.
Rationale: The nurse may need to increase the rate of bladder irrigant to stimulate removal of urine and
clots; however, the nurse should use a less restrictive intervention first.
D. Irrigate the catheter.
Rationale: The nurse may need to irrigate the catheter to check for an internal obstruction; however, the
nurse should use a less restrictive intervention first.
9. A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following
actions should the nurse plan to take?
A. Tell the client to expect dark stools following chemotherapy.
Rationale:
Created on:02/03/2023 Page 4
