A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse take?
A. Place the affected leg in external rotation.
B. Encourage the client to use the incentive spirometer every shift.
C. Instruct the client to lean forward when rising from a chair.
D. Maintain abduction of the affected extremity. - ANSWER D. Maintain abduction of
the affected extremity.
The nurse should ensure that the affected extremity is in a position of abduction to prevent
hip dislocation. The nurse should place an abductor pillow or several pillows between the
client's legs to keep the affected extremity in abduction while the client is in bed
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the
following findings should indicate to the nurse that the medication has been effective?
A. The client's daily peak expiratory flow (PEF) measures 85% above personal best.
B. The client's ABGs shows a pH level of 7.32.
C. The client's forced expiratory volume is decreased after treatment with medication.
D. The client's wheezing is limited to expiratory. - ANSWER A. The client's daily peak
expiratory flow (PEF) measures 85% above personal best.
A client who has asthma should use a peak flow meter twice daily to monitor asthma
control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness
of medication therapy
1
,A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone
ointment. The nurse should assess the client to monitor for which of the following adverse
effects?
A. Increased pigmentation
B. Localized hair loss
C. Thinning of the hair
D. Increased sensitivity to the sun - ANSWER C. Thinning of the hair
Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid
preparations. The client should only apply the ointment to dry patches of the skin because
topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning
of the skin
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema
B. Jugular distention
C. Weight Gain
D/ Frothy sputum - ANSWER D. Frothy sputum
The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of
left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload
and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of
pulmonary edema and can be life-threatening. Therefore, the nurse should notify the
provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of
the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3 - 24 mEq/L, PaO2
85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the
client is experiencing?
A.Respiratory alkalosis
2
,B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis - ANSWER A. Respiratory Alkalosis
This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar
hyperventilation and resultant respiratory alkalosis.
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect?
A. Vitiligo
B. Osteoporosis
C. Myxedema
D. Heat intolerance - ANSWER B. Osteoporosis
Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a
result of mineral loss and nitrogen depletion, and the risk for fractures increases
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should
identify which of the following lesion characteristics on the client's skin?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
C. A firm, nodular, crusty, or ulcerated lesion
D. A weeping vesicle - ANSWER A. A pearly, waxy nodule
A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a
pearly or waxy appearance, resulting from overexposure to the sun, especially on the face,
head, and neck
A nurse is assessing a client who has hypocalcemia. In which of the following areas should
the nurse tap on the client's face to detect the presence of Chvostek's sign? (You will find hot
spots to select in the artwork below. Select only the hot spot that corresponds to your
answer.) - ANSWER A is correct. The nurse should tap the client's cheek just in front of
the ear and below the zygomatic arch. The client who has hypocalcemia will display a
Chvostek's sign, which is a twitching of the facial muscle
3
, A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the nurse expect?
a. High lipase
B. Low urine specific gravity
C. Low Hemoglobin
D. High creatine kinase-MB (CK-MB) - ANSWER B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity.
The increased excretion of water alters the ratio of particulate matter, which affects the
specific gravity
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from room and hallways
B. Place a monthly calendar in the client's room
C. Use confrontation to manage the client's behavior
D. Review the daily schedule with the client every morning - ANSWER D. Review the
daily schedule with the client every morning
The nurse should instruct the family member to use short, simple sentences when
explaining an activity to the client. The explanation should be done immediately before the
activity to aid the client's memory and ability to follow directions.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse identify as a manifestation of this
syndrome?
A. An audile pleural friction rub
B. Tracheal deviation from the midline
C. Refractory hypoxemia
D. Bloody expectorant when coughing - ANSWER C. Refractory hypoxemia
4
Which of the following actions should the nurse take?
A. Place the affected leg in external rotation.
B. Encourage the client to use the incentive spirometer every shift.
C. Instruct the client to lean forward when rising from a chair.
D. Maintain abduction of the affected extremity. - ANSWER D. Maintain abduction of
the affected extremity.
The nurse should ensure that the affected extremity is in a position of abduction to prevent
hip dislocation. The nurse should place an abductor pillow or several pillows between the
client's legs to keep the affected extremity in abduction while the client is in bed
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the
following findings should indicate to the nurse that the medication has been effective?
A. The client's daily peak expiratory flow (PEF) measures 85% above personal best.
B. The client's ABGs shows a pH level of 7.32.
C. The client's forced expiratory volume is decreased after treatment with medication.
D. The client's wheezing is limited to expiratory. - ANSWER A. The client's daily peak
expiratory flow (PEF) measures 85% above personal best.
A client who has asthma should use a peak flow meter twice daily to monitor asthma
control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness
of medication therapy
1
,A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone
ointment. The nurse should assess the client to monitor for which of the following adverse
effects?
A. Increased pigmentation
B. Localized hair loss
C. Thinning of the hair
D. Increased sensitivity to the sun - ANSWER C. Thinning of the hair
Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid
preparations. The client should only apply the ointment to dry patches of the skin because
topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning
of the skin
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema
B. Jugular distention
C. Weight Gain
D/ Frothy sputum - ANSWER D. Frothy sputum
The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of
left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload
and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of
pulmonary edema and can be life-threatening. Therefore, the nurse should notify the
provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of
the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3 - 24 mEq/L, PaO2
85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the
client is experiencing?
A.Respiratory alkalosis
2
,B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis - ANSWER A. Respiratory Alkalosis
This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar
hyperventilation and resultant respiratory alkalosis.
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect?
A. Vitiligo
B. Osteoporosis
C. Myxedema
D. Heat intolerance - ANSWER B. Osteoporosis
Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a
result of mineral loss and nitrogen depletion, and the risk for fractures increases
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should
identify which of the following lesion characteristics on the client's skin?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
C. A firm, nodular, crusty, or ulcerated lesion
D. A weeping vesicle - ANSWER A. A pearly, waxy nodule
A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a
pearly or waxy appearance, resulting from overexposure to the sun, especially on the face,
head, and neck
A nurse is assessing a client who has hypocalcemia. In which of the following areas should
the nurse tap on the client's face to detect the presence of Chvostek's sign? (You will find hot
spots to select in the artwork below. Select only the hot spot that corresponds to your
answer.) - ANSWER A is correct. The nurse should tap the client's cheek just in front of
the ear and below the zygomatic arch. The client who has hypocalcemia will display a
Chvostek's sign, which is a twitching of the facial muscle
3
, A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the nurse expect?
a. High lipase
B. Low urine specific gravity
C. Low Hemoglobin
D. High creatine kinase-MB (CK-MB) - ANSWER B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity.
The increased excretion of water alters the ratio of particulate matter, which affects the
specific gravity
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from room and hallways
B. Place a monthly calendar in the client's room
C. Use confrontation to manage the client's behavior
D. Review the daily schedule with the client every morning - ANSWER D. Review the
daily schedule with the client every morning
The nurse should instruct the family member to use short, simple sentences when
explaining an activity to the client. The explanation should be done immediately before the
activity to aid the client's memory and ability to follow directions.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse identify as a manifestation of this
syndrome?
A. An audile pleural friction rub
B. Tracheal deviation from the midline
C. Refractory hypoxemia
D. Bloody expectorant when coughing - ANSWER C. Refractory hypoxemia
4
