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20. The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon? a. The fecal matter is brown and has a solid consistency b. There are no bowel sounds in the left lower quadrant c. The stoma mucosa is purple in color d. The stoma has streaks of bright red blood Ans. C 21. The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? a. Skull radiography b. Computerized tomography (CT) scan Ans. D c. Magnetic resonance imaging (MRI) d. Lumbar puncture 22. A young adult male client has a leg cast following an open reduction for fractured tibia. He is in skeletal traction with 10 lbs of weight. Approximately two hours after returning to the unit, he reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse promote first? a. Release the traction and notify the healthcare provider b. Administer PRN pain medication routinely as prescribed c. Notify the healthcare provider of the assessment findings d. Record the observations and check the limb every 15 minutes. Ans. C 23. A client is receiving combination chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment findings warrants intervention by the nurse? a. Polycythemia b. Leukopenia c. Ascites d. Nystagmus Ans. B 24. The nurse is planning care for an older adult male who experienced a cerebrovascular accident several weeks ago. Because of expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage client’s use of picture charts b. Ask the client simple questions c. Teach the client use of basic sign language d. Speak slowly to the client Ans. A 25. The nurse has determined that a client with trigeminal neuralgia has the nursing problem, “imbalanced nutrition, less than body requirements”. Which cause is contributing to the problem? a. Altered taste sensation b. Nausea c. Fatigue d. Pain when eating Ans. D 26. A client with Cushing’s syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Irregular apical pulse b. Purple marks on skin of the abdomen c. Pitting ankle edema d. Quarter size blood spot on dressing Ans. A 27. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? a. Has everyone at home already had varicella? b. Do you have any dry patches on your feet and hands? c. Do your family members share combs and brushes? d. Have the antifungal creams been effective? Ans. A 28. The healthcare provider prescribed D5W 1800 mL IV to infuse in 24 hours. The IV administration set delivers 60 microdroplets. The nurse should program the ANS 75 29. A client with COPD arrives at the emergency department reporting of shortness of breath upon exertion and weakness. The client tells the nurse of normally receiving dialysis three times a week but missed the last treatment. The client’s serum potassium is 4.8 mEq/L and creatinine is 1.4, accompanied with a blood pressure of 200/120 mmHg. The client has salt crystals present on the skin. Which finding is most important for the nurse to bring to the attention of the healthcare provider? a. Potassium level b. Blood pressure c. Uremic frost d. Creatinine results. Ans. B 30. The nurse determines that an adult client who is admitted to the post anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6 F (34.8 C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement? a. Take the clients temperature using another method b. Check the blood pressure every five minutes for one hour c. Ask the client to cough and deep breathe d. Raise the head of the bed to 60 to 90 degrees Ans. A 31. An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes sulfate 300 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Platelet count and hematocrit c. Serum iron and ferritin d. Neutrophils and eosinophils Ans. C 32. To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (SATA) a. Encourage use of incentive spirometer b. Establish a regular bladder routine c. Perform chest physiotherapy d. Initiate passive range of motion exercises e. Teach the client breathing exercises Ans. A, C, E 33. A client with ureterolithiasis is preparing for discharge after a ureteroscopy removal. Which instruction should the nurse include in this client’s postoperative discharge teaching? a. Use incentive spirometer b. Report when hematuria becomes pink triggered c. Monitor urinary stream for decreased output d. Restrict physical activities Ans. C 34. After assessing in a left lateral thoracentesis for a client with pleural effusion, the nurse takes the pleural fluid samples and sends them to the lab procedure, which finding warrants immediate intervention by the nurse? a. Oxygen saturation 90% on 4 liters nasal cannula Ans. D b. Left-sided pain on inhalation c. Subcutaneous emphysema around insertion site d. Decreased left lung breath sounds 35. During a preoperative assessment phone call, a client states taking several “pills” every day. Which response should the office nurse provide? a. “Obtain a copy of your medication records from your healthcare provider” b. “Bring all your pill containers to your preoperative appointment” c. “Discuss with your healthcare provider which medications to take before surgery” d. “Bring copies of all your prescriptions to your preoperative appointment” Ans. A 36. Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Fortified milk and cereals b. Citrus fruits and juices c. Red meats and eggs d. Green leafy vegetables Ans. A 37. The healthcare provider prescribes metoclopramide 7.5 mg/mL IM every 3 hours PRN vomiting for a client who is receiving chemotherapy. The nurse prepares using a 2 mL prefilled syringe cartridge labeled, “metoclopramide 5 mg/mL” How many mL should the nurse administer? ANS: 1.3 38. The nurse is assessing a client’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function? a. Ecchymotic area b. Enlarged vein c. Pulselessness d. redness Ans. B 39. Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Encourage the client to lie down and rest after meals Ans. C b. Remind the client to avoid high-fiber foods c. Teach the client to elevate the head of the bed on blocks d. Instruct the client to use antacids only as a last resort 40. The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PERF is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? a. Albuterol 2.5 to 5 mg per nebulization b. Epinephrine auto-injector 0.15mg c. Salmeterol 2 puffs per measured- dose inhaled d. Oxygen at 6 liters. Minute by nasal cannula