Med-Surg HESI Practice Test Questions with correct Answers

Med-Surg HESI Practice Test Questions with correct Answers A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? A. "Diagnosis of AIDS is made when you have 2 positive ELISA test results." B. "Diagnosis is made when both the ELISA and the Western Blot tests are positive." C. "I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister?" D. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual." D. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual." -AIDS is diagnosed when one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas) and/or a CD4+ T cell countless than 200 (normal count 1,000) A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? A. Release the traction q4h to provide skin care. B. Turn the client for back care while suspending traction. C. Provide back and skin care while maintaining the traction. D. Give back care after the client is released from traction. C. Provide back and skin care while maintaining the traction. -Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed and is the correct intervention to maintain the client's skin integrity A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Jewish European ancestry. B. H. pylori bowel infection. C. Family history of irritable bowel syndrome. D. Age between 25 and 55 years. A. Jewish European ancestry. -Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? A. Lung tissue biopsy. B. Positive blood cultures. C. MRI D. CT of the thorax. A. Lung tissue biopsy. -Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary primary site -Although chest radiography identifies sarcoidosis, lung tissue biopsy obtained by bronchoscopy or bronchoalveolar lavage provides definitive confirmation During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A. This is a normal auscultatory finding. B. May indicate pneumothorax. C. May indicate pneumonia. D. May indicate severe emphysema. C. May indicate pneumonia. -This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation -Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word -Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A. Stage II. B. Invasive infiltrating ductal carcinoma. C. T1N0M0. D. Inflammatory with peau d'orange. D. Inflammatory with peau d'orange. -Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies -It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender Small bowel obstruction is a condition characterized by which finding? A. Severe fluid and electrolyte imbalances. B. Metabolic acidosis. C. Ribbon-like stools. D. Intermittent lower abdominal cramping. A. Severe fluid and electrolyte imbalances. A client who is sexual active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? A. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). B. Getting pregnant while using an IUD is common and is not the best contraceptive choice. C. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. D. Selecting a contraceptive device should consider choosing a successful method used in the past. A. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client A. have her own teeth or dentures?" B. take aspirin and if so, how much?" C. take nitroglycerin?" D. take digitalis?" D. take digitalis?" -The symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly -Elderly persons are particularly susceptible to digitalis intoxication which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A. He visits his diabetic brother who just had surgery to amputate an infected foot. B. He is provided with the most current information about the dangers of untreated diabetes. C. He comments on the community service announcements about preventing complications associated with diabetes. D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. A. He visits his diabetic brother who just had surgery to amputate an infected foot. -The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A. Prevention of deformities. B. Avoidance of joint trauma. C. Relief of joint inflammation. D. Improvement in joint strength. A. Prevention of deformities. -Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures Which milestone indicates to the nurse successful achievement of young adulthood? A. Demonstrates a conceptualization of death and dying. B. Completes education and becomes self-supporting. C. Creates a new definition of self and roles with others. D. Develops a strong need for parental support and approval. B. Completes education and becomes self-supporting. The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. She sustained an insect bite to her left arm yesterday. B. She has lost twenty pounds since the surgery. C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano. A. She sustained an insect bite to her left arm yesterday. -A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? A. Pain in the calf awakening him from a sound sleep. B. Calf pain on exertion which stops when standing in one place. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D. Pain upon arising in the morning which is relieved after some stretching and exercise. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. -Thrombophlebitis pain is relieved by rest and elevation of the extremity -It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) -Remove the diaphragm immediately after intercourse -Wash the diaphragm with an alcohol solution. -Use the diaphragm to prevent conception during the menstrual cycle. -Do not leave the diaphragm in place longer than 8 hours after intercourse. -Replace the old diaphragm every 3 months. -Do not leave the diaphragm in place longer than 8 hours after intercourse. -Replace the old diaphragm every 3 months. -The diaphragm needs to remain against the cervix for 6-8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS -The diaphragm should be replaced every 3 months to maintain integrity. Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. Hematuria. B. 2 pounds weight gain. C. 3+ bacteria in urine. D. Steady, dull flank pain. C. 3+ bacteria in urine. -UTI for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine is the most significant finding at this time In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate an increased serum level of which substance? A. Sodium. B. Antidiuretic hormone. C. Potassium. D. Glucose. A. Sodium. -Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign -ADH is decreased with diabetes insipidus -Glucose is not affected by primary aldosteronism A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Dyspnea. B. Nocturia. C. Confusion. D. Stomatitis. B. Nocturia. -As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood -In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? A. Facial flushing. B. Fever. C. Pounding headache. D. Feelings of dizziness. D. Feelings of dizziness. -Feelings of dizziness may occur as the result of a decreased heart rate, leading to a decreased cardiac output which may be an indication of pacemaker failure The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment. C. Willingness of the client to learn the injection sites. -If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea. A. Lower left quadrant pain and a low-grade fever. -LLQ pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A. The dosage of the diuretic will be decreased. B. The diuretic will be discontinued. C. A potassium supplement will be prescribed. D. The dosage of the diuretic will be increased. C. A potassium supplement will be prescribed. -This client's potassium level is too low (normal is 3.5 to 5) -Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward. A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. -Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate -The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? A. Instruct the client to look at examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. -The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to the side of his/her line of vision. -The examiner should hold the ophthalmoscope firmly against his/her face and then direct it at the client's pupil Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A. Breasts feel lumpy when palpated. B. History of white nipple discharge. C. Episodes of vaginal bleeding. D. Excessive diaphoresis occurs at night. C. Episodes of vaginal bleeding. -Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the HCP A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? A. Start an IV nitroglycerin infusion. B. Nasogastric lavage with cool saline. C. Increase the vasopressin infusion. D. Prepare for endotracheal intubation. A. Start an IV nitroglycerin infusion. -Vasopressin is used to promote vasoconstriction, thereby reducing bleeding from the esophageal varice Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? A. A history of obesity. B. An allergy to sulfa drugs. C. Cessation of smoking three years ago. D. Numbness in the soles of the feet. B. An allergy to sulfa drugs. -An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas) Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties. B. Sudden, stabbing, severe pain over the lip and chin. C. Facial weakness and paralysis. D. Difficulty in chewing, talking, and swallowing. B. Sudden, stabbing, severe pain over the lip and chin. -Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) -Women are more often afflicted with this condition and generally occurs in clients over the age of 50 years old A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A. Frequent urinary tract infections. B. Inability to get pregnant. C. Premenstrual syndrome. D. Chronic use of laxatives. B. Inability to get pregnant. -Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum -A history of infertility is another common finding associated with endometriosis After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A. 15 minutes before and 15 minutes after the next dose. B. One hour before and one hour after the next dose. C. 5 minutes before and 30 minutes after the next dose. D. 30 minutes before and 30 minutes after the next dose. C. 5 minutes before and 30 minutes after the next dose. -Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin sulfate -The best time to draw a trough is the closest time to the next administration The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound. B. If the family would prefer a private or semi-private room. C. null D. If the client's wound is infected. D. If the client's wound is infected. -Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess -The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected -To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to this client? A. Apply sequential compression devices (SCDs) bilaterally. B. Assess for a positive Homan's sign in each leg. C. Pad all bony prominences on the affected leg. D. Advise the client to remain in bed with the leg elevated. D. Advise the client to remain in bed with the leg elevated. -The client is exhibiting symptoms of DVT, a complication of immobility -The initial care includes bedrest and elevation of the extremity In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) -Set the infusion pump to infuse the albumin within four hours. -Compare the client's blood type with the label on the albumin. -Assign a UAP to monitor blood pressure q15 minutes. -Administer through a large gauge catheter. -Monitor hemoglobin and hematocrit levels. -Assess for increased bleeding after administration. -Set the infusion pump to infuse the albumin within four hours. -Administer through a large gauge catheter. -Monitor hemoglobin and hematocrit levels. -Assess for increased bleeding after administration. -Albumin should be infused within four hours because it does not contain any preservatives -Any fluid remaining after four hours should be discarded -Vital signs should be monitored periodically to assess for fluid volume overload -A large gauge catheter allows for fast infusion rate, which may be necessary -Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored -While monitoring for bleeding because of the increased blood volume and blood pressure The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A. A decreased total lung capacity. B. Normal arterial blood gases. C. Normal skin coloring. D. An absence of sputum. C. Normal skin coloring. -The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations) A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? A. "Check it again in one month, and if it is still there schedule an appointment." B. "Most lumps are benign, but it is always best to come in for an examination." C. "Try not to worry too much about it, because usually, most lumps are benign." D. "If you are in your menstrual period it is not a good time to check for lumps." B. "Most lumps are benign, but it is always best to come in for an examination." -The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? A. Osteoporosis is a progressive genetic disease with no effective treatment. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. C. Estrogen replacement therapy should be started to prevent the progression osteoporosis. D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. -Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Increased WBC, decreased RBC. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased protein in the urine, slightly increased serum glucose levels. D. Decreased serum sodium, an increased urine specific gravity. C. Increased protein in the urine, slightly increased serum glucose levels. -As older adults aged, the protein found in urine slightly rises as a result of kidney changes and the serum glucose increases slightly, also due to changes in the kidney -The specific gravity declines by age 80 from 1.032 to 1.024 A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's A. pulse rate, both apically and radially. B. blood pressure, both standing and sitting. C. temperature. D. skin color and turgor. C. temperature. -Long term use of steroids use COPD clients is effective in suppressing inflammation in their airways making it easier for them to breath, but at the same time suppresses the immune system, placing the client at risk for infection What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? A. Vasodilators and hormones. B. Analgesics and sedatives. C. Anticoagulants and expectorants. D. Bronchodilators and steroids. D. Bronchodilators and steroids. -Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A. Propanolol (Inderal). B. Captopril (Capoten). C. Furosemide (Lasix). D. Dobutamine (Dobutrex). A. Propanolol (Inderal). A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? A. "What dose of medication are you taking?" B. "Are you eating foods rich in potassium?" C. "Have you lost weight recently?" D. "At what time do you take your medication?" D. "At what time do you take your medication?" Which information about mammograms is most important to provide a post-menopausal female client? A. Breast self-examinations are not needed if annual mammograms are obtained. B. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. C. Yearly mammograms should be done regardless of previous normal x-rays. D. Women at high risk should have annual routine and ultrasound mammograms. C. Yearly mammograms should be done regardless of previous normal x-rays. -The American Cancer Society new guidelines recommend starting at the age of 45 and thereafter till the age of 54 years old, then every two years -The US Preventive Services Task Force Services (USPSTS) recommends starting at the age of 50 years old and screenings every two years thereafte A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to notify the healthcare provider for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside. C. Advise the client to notify the healthcare provider for immediate medical attention. -Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? A. Ask the client what he means by "heart trouble." B. Call for an ECG to be performed immediately. C. Notify surgery that the ECG is over two years old. D. Notify the client's surgeon immediately. B. Call for an ECG to be performed immediately. -According to the hospital policy, clients over the age of 50 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before -The nurse needs to first arrange for an ECG to be performed immediately prior to surgery A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? A. Determine the client is anxious and allow him to sleep. B. Evaluate his blood pressure, pulse, and respiratory status. C. Review the client's pre-operative history for alcohol abuse. D. Continue to monitor the client for reactivity to anesthesia. B. Evaluate his blood pressure, pulse, and respiratory status. -Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs will provide information about possible cardiovascular complications, such as stroke A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A. Serum creatinine. B. Blood Urea Nitrogen (BUN). C. Sedimentation rate. D. Urine specific gravity. A. Serum creatinine. -Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake -An elevated creatinine strongly indicates nephron loss, reducing filtration A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? A. The vaccine is given annually before the flu season to those over 50 years of age. B. The immunization is administered once to older adults or persons with a history of chronic illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. B. The immunization is administered once to older adults or persons with a history of chronic illness. -It is recommended by the CDC that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit? A. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. B. Shuffling gait, masklike facial expression, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Numbness of the extremities, loss of balance, and visual disturbances. B. Shuffling gait, masklike facial expression, and tremors of the head. In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? A. Genetic counseling. B. Twelve-step recovery program. C. Clinical nutritionist. D. Smoking cessation program. D. Smoking cessation program. -Buerger's disease is strongly related to smoking or the use of some other form of tobacco which affects the circulation in the arms and legs leading to infection and gangrene and sometimes amputation of the affected area -The most effective means of controlling symptoms and disease progression is through smoking cessation The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? A. Two weeks before menstruation. B. Vaginal mucous discharge is thick. C. Low basal temperature. D. First thing in the morning. A. Two weeks before menstruation. -Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle -Sexual intercourse should occur within 24 hours of ovulation for an increase chance of conception to occur -High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment. B. Renal osteodystrophy resulting from chronic renal failure. C. Osteoporosis resulting from hormonal changes. D. Cardiovascular changes resulting in small strokes which impair mental acuity. C. Osteoporosis resulting from hormonal changes. -The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in later life A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication. D. Give an antihypertensive medication. -Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake -Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A. Serum PTT of 10 seconds. B. Serum calcium of 5 mg/dl. C. Oxygen saturation of 90%. D. Hemoglobin of 10 g/dl. B. Serum calcium of 5 mg/dl. -TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain. A. Sweating, trembling, tachycardia. The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement? A. Administer 30 minutes before eating. B. Evaluate the effectiveness 1 hour after administration. C. Instruct the client to swallow the tablet whole. D. Question the healthcare provider's prescription. D. Question the healthcare provider's prescription. -Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? A. An increase in abdominal girth. B. Hypertension and a bounding pulse. C. Decreased bowel sounds. D. Difficulty in handwriting. D. Difficulty in handwriting. -A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? A. K. B. B12. C. B6. D. C. A. K -This drug is administered to help lower the triglycerides levels -One of the side effects clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency -These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K due to the drug effects on the liver The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? A. Increase the amount of calcium intake in the diet. B. Apply alternating heat and cold therapies. C. Initiate a weight-reduction diet to achieve a healthy body weight. D. Use a walker for ambulation to lessen weight-bearing on the hips. C. Initiate a weight-reduction diet to achieve a healthy body weight. -Achieving a healthy weight is critical to protect the joints of clients with OA -Weight loss for obese clients will take off the excess pressure that weight bearing joints such as the hips and knees are exposed to and reduce the wear and tear of the joints A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) -Marijuana cigarettes do not affect sperm count. -Alcohol consumption can cause erectile dysfunction. -Low testosterone levels affect sperm production. -Cessation of smoking improves general health and fertility. -Obesity has no effect on sperm production. -Alcohol consumption can cause erectile dysfunction. -Low testosterone levels affect sperm production. -Cessation of smoking improves general health and fertility. Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? A. Describe proper administration of vaginal suppositories and cream. B. Encourage the client to perform Kegel exercises 10 times daily. C. Explain the importance of using condoms when having sexual intercourse. D. Discuss the importance of keeping a diary of daily temperature and menstrual cycle events. B. Encourage the client to perform Kegel exercises 10 times daily. -Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis -Kegel exercises helps strengthen the surrounding muscles The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor. A. Potassium 6.0 mEq. -Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? A. Place a chair at a right angle to the bedside. B. Encourage deep breathing prior to standing. C. Help the client to sit and dangle legs on the side of the bed. D. Allow the client to sit with the bed in a high Fowler's position. D. Allow the client to sit with the bed in a high Fowler's position. -The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to compensate from lying flat and the vasodilation effects of perioperative drugs -This helps prevent the client from becoming light-headed and decreases the chance of a client fall The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include? A. Safety precautions during activity. B. Assess for changes in size of lymph nodes. C. Maintain a fluid intake of 3 to 4 L per day. D. Administer narcotic analgesic around the clock. C. Maintain a fluid intake of 3 to 4 L per day. -Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum calcium -Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight bearing should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal complications Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? A. Newly retracted nipple. B. A thickened area where the skin folds under the breast. C. Whitish nipple discharge. D. Tender lumpiness noted bilaterally throughout the breasts. A. Newly retracted nipple. -A newly retracted nipple, compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A. A diet low in phosphates. B. Skin inspection for bruising. C. Exercise regimen, including swimming. D. Elimination of hazards to home safety. D. Elimination of hazards to home safety. -Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures in the home should be done such as the elimination of throw rugs and proper lighting to minimize trip hazards and falls A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement? A. Notify social services immediately of suspected elderly abuse. B. Discuss the need for mental health counseling with the daughter. C. Explain to the client that she needs to take better care of herself. D. Collect further data to determine whether self-neglect is occurring. D. Collect further data to determine whether self-neglect is occurring. -Changes in weight and hygiene may be indicators of self-neglect or neglect by family members -Further assessment is needed before notifying social services or discussing a need for counseling A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A. they occur in the lower lobe alveoli which are more sensitive to infection. B. gram-negative organisms are more resistant to antibiotic therapy. C. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. gram-negative pneumonias usually affect infants and small children. B. gram-negative organisms are more resistant to antibiotic therapy. -The gram-negative organisms are very resistant to drug therapy which makes recovery very difficult and has become a world-wide concern in which The Who is keeping a very close surveillance on these occurrences